Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River City Post Acute during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when an argument between two residents escalated into one resident standing and repeatedly punching another resident who was seated and attempting to block the blows. One resident, with muscle weakness and mobility difficulties but intact cognition, sustained a small laceration near the eye and a hematoma on the back of the head, with mild tenderness reported. The other resident, who also had intact cognition and diagnoses including a bone infection and anxiety disorder, was documented as the aggressor. An LN responded after hearing a staff call for help and witnessed the ongoing assault. The DON later confirmed the incident, and facility policy in place prohibited abuse and defined physical abuse as willful infliction of injury such as hitting.
A resident with a PICC line and a history of MRSA infection had an IV central line dressing that was not changed on the ordered weekly schedule. Surveyors observed that the dressing was dated more than a week earlier, and an LPN acknowledged it should have been changed and confirmed she did not perform the dressing change as ordered. The DON stated that PICC dressings must be changed per physician orders and that failure to do so places the resident at risk for infection, and facility policy required at least weekly transparent dressing changes.
A resident with multiple chronic conditions and moderate cognitive impairment, whose paid caregiver was also the responsible party, was subjected to repeated episodes of verbal and physical aggression by that caregiver, including yelling, use of profanity, slamming doors and furniture, kicking walls and furniture, and throwing a cup of water that missed. The roommate, also cognitively impaired, reported these behaviors and expressed concern, and CNAs observed the caregiver’s escalating anger and aggressive actions in the room and identified them as potential abuse. An RN documented one incident but did not treat it as abuse because the resident minimized it and the roommate was viewed as unreliable, despite the facility’s abuse prohibition policy defining intimidation and mental abuse through verbal or nonverbal conduct as abuse.
A resident with multiple chronic conditions and moderate cognitive impairment, whose paid caregiver also served as responsible party, was the subject of alleged verbal and potential physical abuse reported by the roommate and CNAs. Staff observed the caregiver becoming angry over missing personal items, yelling, speaking aggressively, and kicking furniture and fixtures, and CNAs reported these concerns to an RN/LVN the same day. The nurse documented the incident but did not initiate required abuse reporting because she had not witnessed it herself and questioned the reliability of the roommate, and the administrator was not informed until two days later. As a result, the formal abuse report to the state agency, ombudsman, and law enforcement was not submitted within the facility’s policy and regulatory timeframes, which required immediate reporting and no later than two hours for alleged abuse.
Surveyors found that staff did not follow enhanced barrier precautions for two residents with indwelling urinary catheters. One CNA adjusted a resident’s urine drainage bag, removed gloves, then obtained new gloves and provided care to another resident without performing hand hygiene, despite the resident’s care plan requiring hand hygiene and PPE use between residents. Another CNA adjusted a different resident’s urine drainage bag without wearing gloves, contrary to the resident’s care plan and facility policy requiring gowns and gloves for device care. Facility leadership and the IPN confirmed that residents with indwelling devices are on enhanced barrier precautions and that staff are required to use PPE and perform hand hygiene between residents.
A resident with hemiplegia, hemiparesis, depression, and intact cognition was care planned to smoke with supervision and valued engaging in meaningful daily routines. During a scheduled smoke break, an LPN cursed at the resident, yelled at him to leave the smoking area, and prevented him from smoking, as later corroborated by another resident. The resident reported feeling humiliated, intimidated, and singled out, subsequently isolating in his room and avoiding usual exercise and socialization to avoid encountering the LPN. Facility leadership and social services staff acknowledged that the LPN verbally abused the resident, and an internal investigation substantiated the abuse despite an existing abuse-prohibition policy.
A resident on hospice with a history of cardiovascular and cerebrovascular disease was found unresponsive, and the ADON administered two doses of intranasal naloxone at the request of a relative but did not document these doses on the MAR or ensure a signed physician telephone order was placed in the medical record or on the physician order summary. Facility policy requiring immediate transcription and maintenance of telephone orders in the chart was not followed, and the ADON also did not call 911 or follow the full opioid overdose response protocol, which required emergency activation and repeated naloxone dosing with rescue measures until EMS arrival.
A resident with dementia, epilepsy, and major depressive disorder was discharged, and their representative repeatedly requested the return of the resident's personal belongings. Facility staff received the request but did not respond or provide updates, and the belongings could not be located in storage. There was no documentation that the items were returned, and required grievance and property return procedures were not followed.
Two residents with significant physical and cognitive impairments were found without accessible call lights, as one had the device blocked by a pillow and the other had it stored in a drawer. Staff and care plans confirmed that call lights should be within reach, but observations and interviews revealed this was not consistently maintained.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not consistently answer call lights promptly, as reported by three residents who experienced significant delays—sometimes up to 30 minutes—when requesting assistance for incontinence care, toileting, and mobility. Observations confirmed multiple unanswered call lights, and interviews with leadership acknowledged that these response times did not meet facility expectations or policy.
A resident with a right humerus fracture and shoulder dislocation did not receive care according to physician orders, as the immobilizer sling was not properly applied and supplemental oxygen was not administered or updated as needed. Nursing staff continued to document that these interventions were provided, despite observations and interviews confirming otherwise.
A resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for self-care was found with a call light not within reach while in bed, despite care plan and facility policy requiring accessibility. Staff confirmed the call light was not accessible at the time of observation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with diabetes and severe cognitive impairment had a physician's order requiring notification if blood sugar exceeded a certain level. When the resident's blood sugar was above this threshold, a nurse administered insulin but did not notify the physician as required, and there was no documentation of physician contact. The facility could not provide a policy on following physician orders.
A resident with schizophrenia and moderate cognitive impairment, who required assistance with personal care and was known to remove her wander guard, left the facility unsupervised after staff failed to complete an elopement risk assessment upon admission and did not adequately monitor the resident as required by policy. The resident's care plan noted a tendency to wander and a desire to leave, but these risks were not sufficiently addressed, resulting in the resident's exit without staff knowledge.
A resident with autonomic neuropathy and recent burn injuries was able to leave the facility unsupervised when a staff member failed to secure an exit door. The resident was not found during routine medication rounds, prompting a facility-wide search and code green. The resident later returned to collect belongings and signed out AMA. Facility policy required supervision and safety measures, but these were not effectively followed.
Multiple shower rooms were found with unsanitary conditions, including mold, mildew, and a resident cup left on a sink. Staff interviews confirmed these issues had been ongoing and were known to management, despite facility policies requiring daily cleaning and infection prevention measures.
Staff did not follow physician orders for two residents, including not applying prescribed wound care and not ensuring protective boots were worn as ordered for a resident with diabetes, and pre-pouring and mis-timing medication administration for another resident. These actions were confirmed by staff interviews and were not in accordance with facility policy.
A resident with cognitive impairment sustained a finger fracture after a fall. Swelling and discoloration were noted, and an X-ray confirmed the fracture, but no immediate intervention to stabilize the injury was provided. The PA reviewed the X-ray but did not inform nursing staff or arrange treatment, and there was no documentation of the resident refusing hospital transfer. The fracture was only addressed days later when the resident was sent to the ED and received a splint.
A resident with severe cognitive impairment was struck on the head twice by another resident in an unprovoked incident witnessed by an LPN. The altercation occurred in a hallway near the nursing station, and documentation confirmed the victim did not provoke the aggression. Staff interviews and facility policies affirmed the expectation and right for all residents to be free from abuse.
A resident with moderate cognitive impairment was moved to a different room without the responsible party receiving prior written notification, as required by both federal regulations and facility policy. The DON confirmed that the responsible party was not notified until after the move had occurred, and documentation showed the notification was made by phone with a voicemail left.
A resident with schizoaffective disorder and substance abuse eloped from the facility on two occasions due to staff failing to consistently implement Q 15-minute safety checks as required by the care plan. Documentation of the checks was inconsistent with the resident's actual whereabouts, and the facility was unaware of the resident's location during these incidents.
A resident with a history of heart disease and a deep tissue injury was not provided with soft heel lift boots as ordered by the physician and outlined in the care plan. Observations and staff interviews confirmed the absence of the required pressure-relieving device, despite facility policy and the resident's dependence on staff for mobility and wound prevention. The DON confirmed that physician orders for such devices were not followed.
Staff failed to properly dispose of used disposable razors and allowed a sharps container to become overfilled in a resident shower room, with the door left open and accessible to residents. Both nursing and CNA staff confirmed the issue, and the Infection Preventionist and DON acknowledged that the facility's policy for timely replacement of sharps containers was not followed, resulting in a breach of infection control practices.
A resident did not receive care in accordance with a physician's order for fluid restriction, as the facility failed to limit the resident's daily fluid intake as prescribed.
A resident was not provided with adequate supervision, resulting in a failure to prevent elopement. This deficiency was identified through observation, interview, and record review.
Two residents received IV care without physician orders for IV flushes, as required to maintain IV line patency and ensure proper medication administration.
Two residents receiving IV antibiotics for infections had PICC line dressings that were not changed within the required timeframe and IV tubing that was not labeled with the date or time. Facility policy required timely dressing changes and proper labeling of IV tubing, but these procedures were not followed, as confirmed by nursing staff and leadership.
A resident with chronic kidney disease and muscle weakness experienced a delay in call light response, leading to an accident. The CNA assisting the resident spoke rudely and threw a disposable brief at the resident, compromising her dignity. Witnesses confirmed the CNA's inappropriate behavior, which was acknowledged by the DON and Administrator as contrary to the facility's policy on resident dignity.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with multidrug-resistant organisms, as required. One resident with acute pyelonephritis and another with ESBL resistance did not have EBP signage or PPE outside their rooms. Additionally, a CNA provided care to a resident without using gown and gloves, despite EBP signage. The facility also failed to sanitize a blood pressure cuff between resident uses, contrary to its policy.
The facility failed to develop comprehensive care plans for two residents on anticoagulation therapy. One resident was on Clopidogrel for DVT prophylaxis without a care plan until it was created later. Another resident on Ticagrelor lacked a care plan and monitoring orders for bleeding, despite the medication's black box warning. Facility policies requiring comprehensive care plans and specific protocols for anticoagulation therapy were not followed.
A resident with End Stage Renal Disease did not receive dialysis as prescribed, resulting in an ER transfer. The facility failed to arrange transportation for dialysis appointments, and there was no documentation of dialysis during a hospital visit. The DON and SSD could not provide reasons for the missed appointments, despite the facility's policy requiring them to arrange dialysis care and transportation.
The facility did not complete annual performance evaluations for two CNAs, increasing the risk of poor-quality care. CNA 1, hired in 2007, last had an evaluation in 2019, and CNA 2, hired in 2015, last had one in 2022. The Regional HR Manager cited staff turnover as a reason for the lapse, despite the facility's policy requiring annual evaluations to provide feedback and identify areas for improvement.
The facility failed to follow infection control practices when a cook did not wear a beard restraint while preparing food for 165 residents. This was confirmed during an observation and interview with the Dietary Manager, who acknowledged the requirement for beard restraints to prevent foodborne illness and hair contamination. The facility's policies mandate the use of hair restraints to prevent hair from contacting food.
The facility failed to maintain the walk-in freezer in safe condition, with ice buildup observed on the ceiling and back wall. This was confirmed by the Dietary Manager and Maintenance Director, who acknowledged the potential impact on food quality for 165 residents. The facility's policy and FDA Food Code 2022 emphasize the importance of maintaining equipment to prevent health risks.
The facility did not meet the minimum space requirement of 80 square feet per resident in 13 rooms, each housing three occupants. Despite the deficiency, residents and staff reported adequate space for personal effects and care delivery. The facility had a room waiver and requested its continuation, with the Department recommending the waiver's continuation.
A resident with a history of violent behavior physically abused another resident by yanking and shaking their hair, causing harm and emotional distress. The incident occurred due to inadequate supervision, despite the facility's policy emphasizing the need for prevention and supervision in cases of potential resident-to-resident altercations.
The facility failed to maintain a sanitary environment for food preparation, as rodent droppings were found in the kitchen and dry food storage area. The Dietary Supervisor acknowledged the droppings after lunch service, despite recent pest control services. Missing rodent traps were noted in pest control reports, and the Maintenance Director was unaware of their absence. The Dietary Aide reported past sightings of droppings, and the Director of Nursing recognized the hazard posed by rodents in the kitchen.
The facility failed to properly dispose of trash and garbage, with uncovered dumpsters and an open compactor bin observed during a survey. The Maintenance Director acknowledged the issue, citing that the garbage service did not cover the bins and staff improperly disposed of garbage into the open compactor bin. Interviews with the DON and VPO confirmed the dumpsters should be covered, aligning with facility policies.
A facility failed to provide necessary communication means for a Spanish-speaking resident with limited English proficiency. Despite policies requiring translation services, staff were unaware of how to use the Language Line and relied on finding Spanish-speaking staff. A communication board was also missing from the resident's room, leading to unmet communication needs and potential care risks.
A resident's room was found to be unsanitary, with a brown crusted stain on the privacy curtain and insect fragments in the top drawer of the bedside dresser. The resident, who was moderately cognitively impaired, did not use the locked drawer. Facility staff confirmed the unsanitary conditions, which were not in line with the facility's housekeeping procedures and policies for maintaining a clean and homelike environment.
A resident's care plan in an LTC facility was not revised to accurately reflect her feeding assistance needs. Despite being able to feed herself and refusing assistance, the care plan indicated she required total assistance. Observations and interviews confirmed the resident's independence, but the care plan remained misleading, highlighting a failure in updating the care plan according to the resident's current status.
Two residents were involved in a physical altercation when one hit the other to retrieve a hat, leading to the second resident throwing coffee in retaliation. Despite a care plan for increased behaviors and frequent monitoring, the incident occurred, highlighting a failure to protect residents from abuse.
A resident's hearing aids were inoperable, leading to communication difficulties and frustration. Staff were unaware of the hearing aids' status, and the facility failed to maintain them as per policy, impacting the resident's ability to communicate effectively.
The facility failed to follow food safety and infection control standards. A dietary aide used non-sterile gloves to handle a food thermometer, and a resident was served a meal from a discarded tray. Additionally, a trash can without a lid and a dirty sink were observed in the kitchen. The facility could not provide relevant policies and procedures.
The facility failed to serve meals at safe and appetizing temperatures, as observed during a survey. The RD found that food temperatures did not meet the required 120 degrees Fahrenheit, with residents frequently complaining about cold meals. Interviews with staff confirmed that this issue had been ongoing, potentially affecting residents' nutritional intake.
A facility failed to follow infection control practices by storing unlabeled and uncleaned bedpans and a bedside commode bucket under a sink in a resident's bathroom. The resident required assistance for toileting due to medical conditions. The Infection Preventionist confirmed that these devices should be labeled, cleaned, and stored properly to prevent cross-contamination.
The facility failed to provide food at an appetizing temperature, with multiple residents consistently receiving cold hot foods. Despite complaints and staff awareness, the issue remained unresolved, leading to resident dissatisfaction.
The facility failed to provide a functioning call light system for two residents, compromising their ability to communicate with staff for assistance. The issue was confirmed by a Licensed Nurse and the Maintenance Assistant, who noted that the facility had old wiring. The Director of Nursing confirmed that the call light system should always be operational, as residents relied on it to communicate with staff.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when one resident punched another in the face and head. Resident 1, admitted in early 2026 with muscle weakness and difficulty with mobility and assessed with a BIMS score of 15/15 indicating no cognitive impairment, was seated in a chair when Resident 2 began throwing punches. Resident 2, also admitted in early 2026 with diagnoses including a bone infection of the right foot and an anxiety disorder and a BIMS score of 14/15 indicating no cognitive impairment, engaged in an argument with Resident 1 that escalated into a physical attack. A progress note for Resident 1 documented that he was struck in the face and back of the head, resulting in a small laceration at the outer corner of his right eye, a small hematoma on the back of his head, and complaints of mild tenderness. A progress note for Resident 2 documented that he attacked Resident 1 by throwing punches while Resident 1 was seated and Resident 2 was standing. A licensed nurse reported hearing another staff member yell for help and, upon arriving at the scene, observed Resident 2 throwing punches at Resident 1, with several punches making contact as Resident 1 attempted to block them while seated. The DON confirmed that the incident occurred between the two residents and stated that her expectation was for residents to be free from any abuse. The facility’s Abuse Prohibition Policy and Procedures, dated 2/21, states that the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation, and defines abuse as the willful infliction of injury, including physical abuse such as hitting and slapping. Despite this policy, the incident of resident-to-resident physical abuse occurred, resulting in documented injuries to Resident 1.
Failure to Perform Weekly PICC Dressing Change per Orders and Policy
Penalty
Summary
The facility failed to ensure services met professional standards of quality when nursing staff did not change a resident’s peripherally inserted central catheter (PICC) dressing according to physician orders and facility policy. The resident was admitted in April 2026 with diagnoses including a methicillin-resistant Staphylococcus aureus (MRSA) infection. Physician orders dated 4/14/26 directed that the resident’s IV central line dressing be changed every seven days and as needed, specifically on the evening shift every Sunday. On 4/22/26 at 12:41 p.m., during an observation with a licensed nurse, the resident’s PICC dressing was found labeled with the date 4/13, and the nurse confirmed it should have been replaced on the evening of 4/19/26 and that the dressing should be changed weekly due to the risk of infection. In a subsequent interview on 4/22/26 at 2:42 p.m., another licensed nurse confirmed she did not change the resident’s PICC dressing on 4/19/26 as ordered by the physician. During an interview at 2:47 p.m. the same day, the Director of Nursing stated that PICC line dressings should be changed per physician orders and that failure to do so places the resident at risk for infection. Review of the facility’s policy and procedure titled “PICC DRESSING CHANGE,” dated 6/18, indicated that dressing changes using transparent dressings are to be performed at least weekly. The observed failure to change the PICC dressing as ordered and as required by policy constituted the deficiency.
Failure to Protect Resident From Mental and Emotional Abuse by Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from mental and emotional abuse by his visitor/caregiver. The resident was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, protein calorie malnutrition, dysphagia, and congestive heart failure, and had a BIMS score indicating moderate cognitive impairment. An order documented that the resident did not have capacity to make decisions, and the visitor/caregiver was identified as the responsible party and healthcare decision maker. On one occasion, the resident’s roommate reported to a CNA that the responsible party was physically abusing the resident. When a licensed nurse spoke with the resident, he laughed and said they were just fooling around. Another CNA reported that the responsible party became violent after discovering that a pair of scissors had been removed from the resident’s drawer, kicking the wall and the bedside drawer. Subsequent documentation and interviews described a pattern of verbally and physically aggressive behavior by the caregiver in the resident’s room. A nurse’s note indicated that a Report of Suspected Dependent Adult/Elder Abuse was completed for alleged verbal abuse, and the resident stated that the caregiver had never been physical but did yell and was an angry person. A social worker’s note documented that the caregiver denied physical abuse but admitted to verbal abuse toward the resident, describing frequent arguments and profanity as normal between them. The resident also told the social worker that he did not view their interactions as abuse, although the social worker explained that such conduct in this setting is considered abuse when witnessed as verbally or physically abusive toward a resident. Interviews with staff and the roommate further detailed the caregiver’s conduct. The resident reported that the caregiver became angry when shaving cream was missing, yelled, and slammed the door. The roommate, who also had moderate cognitive impairment, stated that the caregiver had anger issues, yelled when the resident did not do things right or fast enough, pounded on the wall, threw a cup of water at the resident but missed, and slammed the bedside table, and that he was worried about the resident. A CNA described an incident where the caregiver became angry about a missing razor, talked loudly, kicked the closet door and trash can, and appeared to be losing control, which the CNA viewed as potential abuse. The licensed nurse who received the report from the CNA did not recognize the incident as abuse because the resident did not indicate he was being abused and the roommate was considered not always reliable, and she only documented the incident in the chart. These actions and inactions occurred despite a facility abuse prohibition policy that defines abuse to include intimidation and mental abuse through verbal or nonverbal conduct that causes or has the potential to cause mental anguish.
Failure to Timely Report Alleged Verbal Abuse by Resident’s Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse of a resident to the state agency within the required regulatory timeframe. The resident was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, protein calorie malnutrition, dysphagia, and congestive heart failure, and had a BIMS score indicating moderate cognitive impairment. The resident had an order stating he did not have capacity to make decisions, and his visitor/caregiver was identified as his responsible party and healthcare decision maker. On one date, the resident’s roommate reported to a CNA that the responsible party was physically abusing the resident. Nursing documentation indicated that when the nurse spoke with the resident, he laughed and said they were just fooling around. Another CNA reported that the responsible party was violent, having kicked the wall and bedside drawer after discovering that a pair of scissors had been removed from the drawer. A CNA later described that the caregiver became angry when a razor was missing, talked loudly, became aggressive, and kicked the closet door and trash can while the roommate was present, and stated she was afraid the caregiver was losing control and believed the behavior was potential abuse. The roommate also reported to another CNA that the caregiver was becoming verbally aggressive to the resident. Staff interviews showed that CNAs reported the incident to a licensed nurse on the day it occurred, and CNAs understood that suspected abuse should be reported the same day to the nurse and then to the state, though they were not all familiar with exact timeframes. The licensed nurse who received the reports did not complete or file the abuse report at that time, stating she did not witness the incident, the resident did not indicate he was being abused, and she considered the roommate unreliable, so she only documented the incident in the chart. The administrator later acknowledged that the incident occurred on that earlier date but was not brought to her attention until two days later, at which time the abuse reporting form was completed and sent to the Department, ombudsman, and law enforcement. The facility’s policies required that alleged violations involving abuse be reported immediately, and not later than two hours after the allegation is made, but the report for this incident was not submitted until two days after the initial allegation.
Noncompliance With Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters
Penalty
Summary
Surveyors identified a failure to follow the facility’s infection prevention and control practices, specifically enhanced barrier precautions, for residents with indwelling urinary catheters. Resident 1, admitted with urinary retention and a personal history of infectious disease, had a care plan requiring enhanced standard/barrier precautions, including changing gowns and gloves and performing hand hygiene when moving from contact with one resident to another. During observation, CNA 1 adjusted Resident 1’s urine drainage bag, then removed his gloves, went to another room to obtain new gloves, and proceeded to provide care to another resident without performing hand hygiene in between. In a subsequent interview, CNA 1 acknowledged that he should have washed his hands before putting on new gloves. Resident 2, re-admitted after hospitalization for sepsis, urinary tract infection, and acute kidney failure, also had a care plan requiring enhanced barrier precautions, including wearing gowns and gloves for device care such as urinary catheter care. During observation, CNA 2 adjusted Resident 2’s urine drainage bag without wearing gloves. In an interview, CNA 2 confirmed she did not wear gloves and stated she should have worn them. Review of the facility’s enhanced barrier precautions policy showed that residents with indwelling medical devices, including urinary catheters, were to be on enhanced barrier precautions, and staff were required to wear gowns and gloves and perform hand hygiene between residents. The Infection Preventionist Nurse and the Assistant Director of Nursing both stated that staff were required to wear PPE and perform hand hygiene for residents on enhanced barrier precautions.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a licensed nurse. The resident was admitted with hemiplegia, hemiparesis, and depression, and had a BIMS score of 13/15, indicating he was cognitively intact. His care plan allowed him to smoke with supervision per smoking assessment and facility policy, and he reported that engaging in meaningful daily routines was important to him. During an evening smoke break, the resident went to the designated smoking area as scheduled, but when the licensed nurse saw him approaching the group of smokers, the nurse cursed and yelled at him, telling him to “get the fuck out of here,” and did not allow him to smoke in the designated area. The resident reported this as an alleged verbal abuse incident, and another resident later reported witnessing the nurse cursing, yelling, and preventing him from smoking. Following the incident, the resident stated he felt intimidated, humiliated, scared, discriminated against, and singled out by the nurse. He avoided the evening smoke break so he would not have to deal with the same staff member, and he began staying in his room instead of participating in activities or socializing. Observations showed him lying in bed in a curled-up position in a dark room, and he became agitated and paced while recalling the incident, stating in garbled speech that the facility was his home. Facility staff, including the Administrator and Social Services Director, confirmed that the licensed nurse verbally abused the resident and that the incident affected him mentally and emotionally, leading him to stop walking around the building, exercising, and visiting friends in another hall because he would have to pass the hall where the nurse worked. A completed facility investigation substantiated the alleged verbal abuse incident, despite the facility’s written abuse prohibition policy that states staff must do all within their control to prevent occurrences of abuse and mistreatment.
Failure to Properly Order, Document, and Administer Naloxone During Change in Condition
Penalty
Summary
The facility failed to ensure services met professional standards of quality for one resident related to the ordering, documentation, and administration of naloxone. The resident had a history of hypertension, heart failure, and cerebrovascular disease and was on hospice care. A telephone order for naloxone was reportedly obtained from the physician, but there was no signed physician order in the resident’s medical record, and the order was not entered on the Physician’s Order Summary Report. The Assistant Director of Nursing (ADON) stated that a copy of the telephone order was in her office and acknowledged it had not been recorded in the resident’s chart. Facility policy required that telephone orders be transcribed onto the physician’s order form at the time the order was taken, mailed promptly to the physician for signature, and that a copy be maintained in the medical record until the signed form was returned. The facility also failed to document the administration of naloxone on the resident’s Medication Administration Record (MAR) and did not follow the facility’s opioid overdose response policy. The ADON reported that, upon finding the resident unresponsive with a relative present, she administered naloxone 4 mg nasal spray at 8:32 a.m. and a second 4 mg dose at 8:34 a.m. at the relative’s request, but did not document these doses on the MAR. Progress notes later reflected that naloxone was administered twice with no change in status and described agonal breathing and shallow respirations. The ADON further acknowledged that she did not call 911 as required by the facility’s naloxone policy, which directed staff to call 911, assess for pulse and respirations, initiate rescue breathing or CPR as indicated, and administer additional naloxone doses every two to three minutes until emergency personnel arrived.
Failure to Timely Respond to Request for Resident's Personal Belongings After Discharge
Penalty
Summary
The facility failed to accommodate the exercise of a resident representative's rights by not responding in a timely manner to a request for the resident's personal belongings after discharge. The resident in question had diagnoses including dementia, epilepsy, and major depressive disorder, and was discharged from the facility. Despite multiple requests from the resident's sister for the return of personal belongings, there was no documented response or update provided by facility staff. The Social Services Director (SSD) acknowledged that the request was received but had not contacted the family or confirmed the whereabouts of the belongings. A search of the storage area did not locate the items, and there was no documentation in the resident's record indicating the belongings were returned or received by the family. Interviews with facility staff, including the SSD, Business Office Manager (BOM), and administrator, confirmed that the request for the resident's belongings was communicated internally but not acted upon or followed up with the family. Facility policy requires that grievances be acknowledged and updates provided within 72 hours, and that personal property be returned and documented at discharge. These procedures were not followed, resulting in the resident's representative not receiving the requested belongings or communication regarding their status.
Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of five sampled residents, resulting in the potential for unmet care needs. One resident, admitted with multiple sclerosis, muscle weakness, and moderate cognitive impairment, was observed unable to access her call light due to it being blocked by a pillow. Despite attempts to reach it, she was unsuccessful, and both a CNA and a licensed nurse confirmed the call light was out of reach. The resident expressed a desire to have the call light accessible. The care plan for this resident specifically indicated that the call light should be within reach due to her risk for falls and limited mobility. Another resident, with a history of cerebral infarction, muscle weakness, dysphagia, and severe cognitive impairment, was found with the call light stored in a drawer, out of reach. When asked to use the call light, the resident was unaware of its location. Both a licensed nurse and a CNA confirmed the call light was not accessible and stated it should be within reach. The care plan for this resident also required the call light to be accessible due to high fall risk. The facility's policy stated that call lights must be accessible to residents in bed, on the toilet, or in bathing areas. Interviews with staff and the administrator confirmed the expectation that call lights should always be within reach unless staff are present and assisting the resident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
Staff failed to answer call lights in a timely manner for three of four sampled residents. One resident, admitted with acute respiratory failure and protein calorie malnutrition, reported having to wait a long time to be changed after using the call light for incontinence care. This resident was observed to be on continuous oxygen and unable to walk, and stated that delays occurred whenever she needed assistance after incontinence episodes. Another resident, with encephalopathy and cerebrovascular disease, stated that it sometimes took 30 minutes for her call light to be answered, depending on staff busyness. This resident was dependent on staff for toileting, personal hygiene, dressing, and bed mobility. A third resident, with a right humerus fracture and shoulder dislocation, reported that her call light was ignored for 15 minutes late at night before staff responded. This resident required substantial assistance for bed mobility, toileting, and dressing. Observations on the unit revealed multiple unanswered call lights. Interviews with facility leadership confirmed that the expectation was for call lights to be answered within 2 to 3 minutes, and that 30 minutes was considered too long. The facility's policy required timely responses to resident requests, with staff expected to communicate estimated response times and seek assistance if needed. Despite these policies, staff did not consistently respond to call lights promptly, as evidenced by resident reports and direct observation.
Failure to Follow Physician Orders for Immobilizer Sling and Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident admitted with a right humerus fracture and shoulder dislocation. Physician orders were in place for the resident to have a non-weight bearing right upper extremity, use an immobilizer sling on the shoulder, and receive continuous supplemental oxygen at 2L/min via nasal cannula. Despite these orders, observations revealed that the resident was not wearing the immobilizer sling as ordered, with her wrist out of the immobilizer, and was not receiving supplemental oxygen. The resident reported feeling unwell and in pain, and stated that the immobilizer was not effective and that she had only used oxygen a few times. Record reviews showed that licensed nurses had been signing off on the administration of both the immobilizer sling and oxygen orders, even though these interventions were not being provided as ordered. Interviews with nursing staff confirmed that the oxygen order should have been updated and that the immobilizer was not being used as directed. The physical therapist and assistant director of nursing also confirmed the lack of compliance with the physician's orders. Facility policy required that supplies and medications needed to carry out physician orders be provided, but this was not followed in this case.
Call Light Not Accessible to Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for self-care and bed mobility was found to have a call light that was not within reach while lying in bed. The resident's care plan specifically indicated that the call light should be placed within reach due to her risk for falls and self-injury related to impaired balance, limited mobility, and generalized weakness. During an observation, the call light was seen hanging from the side of the bed, out of the resident's reach. This finding was confirmed by both a Certified Nursing Assistant and a Licensed Nurse, who acknowledged that the call light was not accessible and that this was not acceptable practice. The facility's policy, revised in October 2024, requires that the call light be accessible to residents when in bed. The deficiency was identified through observation, interview, and record review, and it was noted that the resident was still able to use her call light despite episodes of confusion.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Elevated Blood Sugar per Order
Penalty
Summary
A physician's order for a resident with diabetes, schizophrenia, dementia, and psychotic disturbance was not followed as required by professional standards. The resident had a physician's order for insulin Lispro to be administered according to a sliding scale, with instructions to notify the physician if the blood sugar value exceeded 401. On review of the electronic medication administration record, it was found that the resident's blood sugar was recorded at 411, and the nurse administered six units of Lispro insulin but did not notify the physician as directed in the order. During an interview and record review, a licensed nurse confirmed that the physician was not notified of the elevated blood sugar value, and acknowledged that the nurse did not follow the physician's order. No documentation was found in the nursing progress notes or medication administration record indicating that the physician was contacted. Additionally, when a policy and procedure on following physician orders was requested, the facility was unable to provide one.
Failure to Monitor and Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for a resident with schizophrenia and moderate cognitive impairment, resulting in the resident leaving the facility without staff knowledge. The resident was admitted with a diagnosis that included the need for assistance with personal care and was determined to lack capacity to make healthcare decisions. Orders indicated the use of a wander guard device due to poor safety awareness, with instructions for staff to check its placement every shift. However, the resident had a known history of removing the wander guard, and staff interviews confirmed that the elopement risk assessment was not completed upon admission as required by facility policy. On the day of the incident, staff discovered the resident missing during routine checks and initiated a search, but the resident could not be found within the facility. The care plan documented the resident's tendency to wander and desire to leave, as well as previous episodes of removing the wander guard. Facility policies required elopement risk assessments for residents with cognitive impairment or a history of wandering upon admission, but this was not completed. The lack of timely assessment and monitoring contributed to the resident's unsupervised exit from the facility.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment when a resident with idiopathic peripheral autonomic neuropathy and significant burn injuries eloped from the facility. According to the resident's routine, they would typically come to the nurse's station early in the morning to request medication, but on the day of the incident, the resident did not appear as expected. The RN searched the resident's room and surrounding areas, and after being unable to locate the resident, initiated a code green to alert staff of a missing resident. Subsequent attempts to contact the resident by phone revealed that the resident had left the facility and did not intend to return. Further review indicated that the resident later returned to collect personal belongings and signed an AMA (Against Medical Advice) form before leaving again. The Administrator acknowledged that the facility was responsible for resident safety and stated that the resident was able to leave unnoticed when a pharmacy technician failed to close the door upon exiting. The facility's policy emphasized the importance of a safe environment and adequate supervision, including addressing risks such as unsafe wandering, but these measures were not effectively implemented in this instance.
Failure to Maintain Infection Control in Shower Rooms
Penalty
Summary
The facility failed to maintain acceptable infection control practices in four shower rooms, as evidenced by multiple observations and staff interviews. In one shower room, a red drinking cup was found on the sink, which a licensed nurse confirmed was unsanitary and should not have been present. Another shower room was observed to have dark brown and black mold and mildew on the walls and flooring, which a certified nurse assistant stated had been an ongoing issue for several months. Additional observations revealed mold and mildew between tiles, dark mildew under a resident shower bed, and cracked tiles in another shower room, with staff confirming these conditions and acknowledging that they should have been addressed through more thorough cleaning. Environmental personnel and the housekeeping supervisor both confirmed the presence of mold and mildew in the shower rooms, noting that housekeeping was responsible for cleaning but that the problem was ongoing and known to facility management. The infection preventionist and administrator also acknowledged awareness of the unsanitary conditions, including the presence of a resident cup and mildew, and stated these could potentially expose residents to infectious diseases. A review of facility policies indicated that infection prevention measures and cleaning protocols were in place, but these were not followed as required, resulting in unsanitary conditions in the shower rooms.
Failure to Follow Physician Orders and Medication Administration Protocols
Penalty
Summary
The facility failed to follow physician orders and professional standards of practice for two residents. For one resident with diabetes and a history of slow wound healing, staff did not implement the physician's order to cleanse and treat both legs and ensure the resident's feet were placed in protective boots while in bed. Observations showed the resident's legs were not off-loaded as required, and the boots were not in use, despite the resident expressing a preference and expectation to wear them for wound protection. A licensed nurse confirmed the order was not followed and acknowledged the potential for the resident's condition to worsen if the treatment was not implemented. For another resident with multiple diagnoses including GERD, a nurse was observed pre-pouring medications into multiple cups and preparing to administer Donepezil before the scheduled time, contrary to physician orders and facility policy. The nurse also left unlabeled medication cups in the medication cart. The RN supervisor confirmed that medications should be prepared and administered for one resident at a time, at the correct time, and that pre-pouring and leaving unlabeled medications was not acceptable. Facility policies reviewed supported these expectations for medication administration.
Delay in Fracture Management Following Resident Fall
Penalty
Summary
A resident with a history of metabolic encephalopathy, bipolar disorder, and dementia, and with moderate cognitive impairment, experienced a fall while attempting to change position in bed. Initially, no injury was noted, but the following day, swelling and discoloration were observed in the resident's right hand and wrist. A STAT X-ray was ordered and performed, revealing an acute fracture at the base of the fourth finger. Despite this finding, no immediate interventions to support or stabilize the fractured finger were implemented. The physician assistant (PA) reviewed the X-ray results but did not communicate the fracture to the nursing staff or discuss treatment options with the resident. The director of nursing (DON) and other staff were unaware of the fracture until several days later, as the PA had cleared the result in the electronic dashboard without notification. There was no documentation of any refusal by the resident to be sent to the hospital, and the PA later confirmed that the resident had not refused transfer and that standard practice would have been to send the resident for treatment. During this period, the only interventions provided were neuro checks and continued pain management, with no specific care for the fracture. The resident was eventually sent to the emergency department at her request, where a splint was applied. The facility's fall management policy required appropriate care for injuries resulting from falls, but timely interventions to manage the fracture were not implemented, resulting in a delay in treatment.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
Facility staff failed to protect a resident's right to be free from physical abuse when a staff member witnessed another resident approach and strike the resident on the head twice—once with a closed fist and once with an open hand. The incident was unprovoked, and the victim did not initiate or provoke the aggression in any manner. The event occurred in a hallway near the nursing station, and was directly observed by a licensed nurse. Documentation in both residents' progress notes and the care plan confirmed the details of the altercation. The resident who was the victim had severe cognitive impairment, including diagnoses of anxiety disorder, dementia, and adult failure to thrive. The aggressor had a history of dementia and traumatic brain injury but was assessed as having intact cognition. Staff interviews confirmed the expectation that all residents should be free from abuse, and facility policies reviewed also emphasized the prohibition of abuse and the right of residents to be treated with respect and dignity.
Failure to Provide Timely Written Notification of Room Change to Responsible Party
Penalty
Summary
A deficiency occurred when a resident was moved from one room to another without the responsible party (RP) receiving prior written notification, as required by federal regulations and the facility's own policy. The resident, who had a moderately impaired mental status as indicated by a Brief Interview for Mental Status (BIMs) score of 8, was determined by the Director of Nursing (DON) to lack the capacity to make decisions, making it necessary for the RP to be notified of significant changes such as a room transfer. Documentation in the resident's medical record showed that the room change took place at 5 p.m. on July 16, 2024. However, the RP was not notified of the move until July 24, 2024, and this notification was made via phone with a voicemail left. The facility's policy required that the resident, the RP, and all affected roommates receive timely advance notice, either orally or in writing, including the reason for the change, prior to any room or roommate assignment change. During interviews and record reviews, the DON confirmed that the RP was not notified before the room change occurred, and that the facility's policy was not followed in this instance. The lack of timely notification to the RP before the room change constituted a violation of the resident's rights under federal regulations and the facility's own procedures.
Failure to Implement Elopement Prevention Care Plan and Supervision
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder and psychoactive substance abuse was not adequately supervised, resulting in the resident eloping from the facility. The resident's care plan required Q 15-minute checks for safety and to prevent elopement, but documentation and staff interviews revealed that these checks were not implemented correctly or consistently. On one occasion, the resident was found missing from the facility and was located by staff approximately 30 minutes later down the street with a bag. On another occasion, the resident was found at a bus stop about 20 minutes after being discovered missing. Record reviews showed inconsistencies between the Q 15-minute check documentation and the nurse's progress notes, with the resident documented as "in bed asleep" during times when the resident was actually missing from the facility. The facility's elopement policy required adequate supervision and care in accordance with the resident's person-centered care plan, but this was not followed, resulting in the facility not knowing the resident's whereabouts and failing to prevent the resident from leaving the premises.
Failure to Implement Physician's Order for Pressure-Relieving Devices
Penalty
Summary
A deficiency occurred when a facility failed to implement a physician's order for a resident requiring soft heel lift boots to relieve pressure on the heels. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease and had a deep tissue injury on the right heel and lateral foot, had a physician's order dated 04/14/24 to elevate heels off the bed or apply soft heel lift boots every shift. The care plan also specified the need for these interventions to protect the resident's heels. Despite these orders, observations on 04/16/25 revealed that the resident was not wearing heel boots. Interviews with nursing staff confirmed that the resident should have had at least one boot on, and that the use of wound prevention devices was crucial to prevent wound progression. The resident reported that the heel boots had disappeared and were not available. Further, staff acknowledged the importance of heel boots, especially given the resident's contractures, which made turning difficult and increased the risk of pressure on the heels. The facility's own policies required staff to review care plans for special needs and to implement physician orders promptly. However, these procedures were not followed, as evidenced by the lack of heel boots on the resident during multiple observations and staff interviews. The Director of Nursing confirmed that staff are expected to follow physician orders and that heel boots should have been applied as ordered.
Plan Of Correction
Note: This plan of correction is submitted as required by law. By submitting the plan of correction, Windsor El Camino does not admit that the citations listed on the CMS 2567 exist nor does it admit to any statements, findings, facts or conclusions that form the basis of the alleged deficiencies. This plan of correction represents our written and credible statement of compliance. We reserve the right to challenge in legal and/or regulatory or administrative proceedings the deficiencies, statements, facts, and conclusions that form the basis for the deficiencies. POC F658 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The physician's order was immediately reviewed, and soft heel boots were applied to Resident 2 as ordered. Resident 2 was assessed by nursing staff and the interdisciplinary team to ensure there were no adverse effects due to the delay in reapplying the soft heel boots. No injuries or complications were noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A review of all current physician orders was conducted to ensure compliance with pressure-relief interventions. No other residents were affected by the same deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur; On 4/16/25 a 4/17/25 the DON or designee provided an in-service to Licensed Staff on the importance of timely implementation of physician orders, specifically for pressure-relieving devices. A new protocol was established requiring a second nurse to verify and document that pressure-relief devices are applied within 2 hours of the physician order. The DON or designee will audit new physician orders daily to ensure implementation within the required timeframe. How does the facility plan to monitor its performance to make sure that solutions are sustained? The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The POC is integrated into the quality assurance system; and. The DON or designee will conduct weekly audits of 3-5 random residents with physician orders for assistive or pressure-relieving devices for 4 weeks, then monthly for 2 months. Findings will be reported to the QAPI committee monthly. The committee will evaluate the effectiveness of corrective actions and adjust as necessary. Include dates when corrective actions will be completed. The corrective action completion dates must be acceptable to the State Agency. COMPLETION DATE: 4/25/25
Improper Sharps Disposal and Infection Control Breach
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when staff did not dispose of used disposable razors appropriately and allowed a sharps container to become overfilled in the resident shower room at nursing station seven. During observations, multiple uncovered disposable razors were found placed on top of an overfilled sharps container, and the shower room door was left open, allowing resident access. Both a licensed nurse and a CNA confirmed the sharps container was full, the razors were not properly discarded, and the room was accessible to residents, which was acknowledged as a safety concern for both staff and residents. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the sharps container should have been replaced when full and that staff should not place used, uncovered razors on top. The facility's policy required sharps containers to be sealed and replaced when 75% to 80% full, but this was not followed. The improper disposal of contaminated razors and failure to secure the shower room created a risk of exposure to sharps and contamination, as confirmed by staff interviews and policy review.
Failure to Follow Physician's Order for Fluid Restriction
Penalty
Summary
The facility failed to provide care in accordance with professional standards for one of three sampled residents. Specifically, the facility did not follow a physician's order for fluid restriction for a resident, as identified through observation, interview, and record review. This lapse resulted in the resident not receiving the prescribed limitation on daily fluid intake as ordered by the physician. The deficiency was identified based on direct evidence that the resident's care did not align with the physician's instructions regarding fluid restriction, which is a diet limiting the amount of daily fluid consumption.
Failure to Provide Adequate Supervision to Prevent Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one of two sampled residents. This deficiency was identified through observation, interview, and record review. The report specifically notes that the facility did not ensure sufficient supervision for Resident 2, which resulted in a failure to prevent the resident from eloping.
Failure to Obtain Physician Orders for IV Flushes
Penalty
Summary
The facility failed to provide intravenous (IV) care in accordance with professional standards of quality for two residents. Specifically, both residents did not have physician orders for IV flushes, which are necessary to clear out IV lines after medication administration and to prevent blockages. This omission was identified through observation, interview, and record review, and it directly affected the administration of IV care for these residents.
Failure to Maintain Safe IV Care and Labeling Practices
Penalty
Summary
The facility failed to provide safe and sanitary intravenous (IV) care for two residents who required IV antibiotics for infections. For one resident with a bone and hip joint infection, the PICC line dressing was observed to be dated from 11 days prior, and the IV tubing was not labeled with the date or time. The care plan for this resident specified that IV sites and dressings should be changed per policy, but these actions were not followed. A licensed nurse confirmed that the dressing and tubing were overdue for change and not properly labeled, acknowledging the need for timely changes to prevent infection. A second resident with a lower leg wound infection also had a PICC dressing that was not changed within the required timeframe, and the IV tubing was similarly not labeled. Facility policies required that IV tubing be labeled with the date, time, and nurse's initials, and that transparent PICC dressings be changed at least weekly. Interviews with nursing leadership confirmed these requirements and the importance of adhering to them for infection control. The facility's infection prevention and control policy also mandated compliance with IV therapy protocols, but these were not followed for the two residents.
Resident Dignity Compromised by CNA's Behavior
Penalty
Summary
The facility failed to ensure that a resident was cared for in a manner that promoted dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who spoke to a resident with a rude and upset tone during toileting assistance. The resident, who was admitted with chronic kidney disease, muscle weakness, and required substantial assistance for personal care, experienced a delay in response to her call light, leading to an accident. The CNA, who was reportedly the only one on the floor, expressed frustration and threw a disposable brief at the resident, further exacerbating the resident's embarrassment and discomfort. Interviews with the resident and a witness confirmed the CNA's inappropriate behavior, which included speaking in a rude tone and throwing items at the resident. The Director of Nursing and the Administrator both acknowledged that the CNA's actions were not in line with the facility's policy of treating residents with dignity and respect. The facility's policy on Resident Rights emphasizes the importance of treating all residents with kindness, respect, and dignity, which was not upheld in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices for three residents, increasing the risk of infection transmission. Resident 99, who was readmitted with acute pyelonephritis and resistance to multiple antimicrobial drugs, did not have Enhanced Barrier Precautions (EBP) in place despite having a midline in his arm. The Assistant Director of Nursing confirmed the absence of EBP signs or personal protective equipment (PPE) outside Resident 99's room, and the Director of Nursing acknowledged the lack of physician orders for EBP. Similarly, Resident 115, admitted with ESBL resistance and a history of MRSA infection, did not have EBP signage or equipment outside her room, despite having an indwelling catheter and open areas on her body. The Director of Nursing confirmed the oversight. Additionally, Resident 31, who had a diagnosis of leukoencephalopathy, was observed receiving direct care from a CNA without the use of gown and gloves, despite signage indicating the need for EBP. Furthermore, the facility staff failed to sanitize a blood pressure cuff between resident uses. A Licensed Nurse admitted to not sanitizing the cuff between residents, and the Director of Nursing confirmed that vital sign equipment should be sanitized after each use. The facility's policy on cleaning and disinfection of resident-care items and equipment supports this requirement.
Failure to Develop Comprehensive Care Plans for Anticoagulation Therapy
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, Resident 87 and Resident 161, which included measurable objectives and timetables to meet their medical and nursing needs. Resident 87 had a physician's order for Clopidogrel Bisulfate, an anticoagulant, for DVT prophylaxis, but there was no care plan regarding the anticoagulant medication in the resident's clinical record until it was created on 11/20/24. The Director of Nursing and the Regional Clinical Resource Nurse acknowledged the absence of care plans for residents on anticoagulation medication, which was identified during a review of Resident 87's records. Resident 161, admitted with chronic systolic heart failure, was taking Ticagrelor, an antiplatelet medication, for DVT prophylaxis. However, there were no monitoring orders or care plan for the medication in the resident's medical record. Licensed Nurses confirmed the absence of a care plan and monitoring orders for bleeding, despite the medication having a black box warning for significant bleeding risk. The facility's policies required comprehensive care plans with measurable objectives and timetables, as well as specific protocols for anticoagulation therapy, which were not followed in these cases.
Failure to Provide Prescribed Dialysis
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident diagnosed with End Stage Renal Disease (ESRD) who was dependent on renal dialysis. The resident had a physician's order for dialysis on Tuesdays, Thursdays, and Saturdays, with transportation arranged for these days. However, the resident did not receive dialysis as prescribed, leading to a transfer to the emergency room. The resident had not received dialysis since the previous Thursday, and there was no documentation to confirm that dialysis was provided during a hospital visit on a regular dialysis day. The Director of Nursing (DON) and Social Service Director (SSD) were unable to provide reasons or documentation for the missed dialysis appointments. The DON stated that Social Services was responsible for arranging transportation, and if there were issues, a backup transportation company should have been called. The SSD confirmed that Social Services was responsible for transportation arrangements but was not employed at the time of the incident and could not explain the transportation issues. The facility's policy indicated that it was responsible for arranging dialysis care and transportation as ordered by the attending physician.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two certified nursing assistants (CNAs), increasing the risk of residents receiving poor-quality care. During a record review with the Director of Staff Development, it was found that CNA 1, hired in 2007, had their last performance evaluation in 2019, and CNA 2, hired in 2015, had their last evaluation in 2022. An interview with the Regional Human Resource Manager revealed that due to staff turnover, annual performance evaluations had not been conducted, despite their importance for providing feedback to CNAs. The facility's policy indicated that performance evaluations should be conducted annually around the anniversary date to help staff become aware of their progress and areas for improvement.
Infection Control Breach: Cook Without Beard Restraint
Penalty
Summary
The facility failed to adhere to infection control practices when a cook did not wear a beard restraint while preparing food for a census of 165 residents. This was observed during an initial kitchen tour, where the cook was seen preparing food without a beard guard. During a concurrent observation and interview with the Dietary Manager (DM), it was confirmed that the cook was not wearing a beard restraint, which is required to prevent foodborne illness and potential hair contamination in the food served to residents. The facility's policy and procedure titled 'Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices,' revised in November 2022, mandates that hair nets, caps, and/or beard restraints must be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food, clean equipment, utensils, and linens. Additionally, the policy titled 'Food Preparation and Service,' also revised in November 2022, specifies that food and nutritional services staff must wear hair restraints to ensure hair does not contact food.
Ice Buildup in Walk-In Freezer
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, as evidenced by ice buildup on the ceiling and back wall of the freezer. This issue was confirmed during an observation and interview with the Dietary Manager, who acknowledged the ice buildup and stated that maintenance is responsible for de-icing the freezer. The ice buildup had the potential to affect the safety and quality of food served to 165 residents who consume meals prepared by the facility. Further confirmation of the ice buildup was provided by the Maintenance Director, who acknowledged that the condition could impact food quality. The Maintenance Director mentioned adjusting the door closure mechanism to prevent warm air from entering, which could exacerbate the ice buildup. A review of the facility's policy and procedure indicated that the Maintenance Department is responsible for ensuring equipment is maintained in a safe and operable manner. Additionally, the FDA Food Code 2022 emphasizes the importance of maintaining equipment according to manufacturer specifications to prevent health risks, such as improper cooling or holding of food.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that resident bedrooms met the minimum requirement of 80 square feet per resident. Specifically, there were 13 rooms with three occupants each, which did not meet the required space per resident, as they provided only 68-79 square feet per resident. This deficiency was confirmed by the Administrator, who acknowledged that these rooms were below the required space standards. Despite this, the facility had a room waiver in place and requested its continuation, citing that the rooms provided a reasonable amount of privacy, sufficient room for movement, and adequate space for nursing care and equipment. During the survey, observations and interviews were conducted with residents and staff. Residents expressed that while the rooms were small, they were organized and managed to respect each other's space. Staff, including a Certified Nursing Assistant, reported having sufficient space to provide care. The survey team did not express concerns about safety or obstruction in the rooms, and the Department recommended continuing the room size variance waiver for the specified rooms.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident yanked, tugged, and shook the resident's hair. This incident involved Resident 1, who had a history of bipolar disorder, dementia, and major depressive disorder, and Resident 4, who had cerebral infarction, anxiety disorder, failure to thrive, and muscle weakness. Resident 1 had a moderately impaired cognition with a BIMS score of 12 out of 15, while Resident 4 had intact cognition with a BIMS score of 13 out of 15. The altercation occurred when Resident 4 was passing Resident 1 in a wheelchair, and Resident 1 became aggressive, resulting in Resident 4 experiencing physical harm and emotional distress. Interviews with staff revealed that Resident 1 had a history of violent behavior when upset, and there was a lack of adequate supervision to prevent such incidents. The facility's policy on abuse prohibition emphasized the need for prevention and adequate supervision, especially when the risk of resident-to-resident altercation was suspected. Despite this, the facility did not provide sufficient supervision for Resident 1, leading to the altercation and subsequent harm to Resident 4.
Rodent Droppings Found in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain a sanitary environment for food preparation and service, as evidenced by the presence of rodent droppings in the kitchen and dry food storage area. This deficiency was identified during an observation and interview with the Dietary Supervisor, who acknowledged the presence of droppings on a stainless steel counter and in the dry food storage room. The Dietary Supervisor noted that the droppings were discovered after lunch service, despite pest control services having been conducted the previous day. The facility's pest control reports indicated that three kitchen rodent traps were missing during inspections on two separate occasions. The Maintenance Director was unaware of the missing traps and needed to consult with the pest control company for clarification. The pest control technician confirmed that the traps were not present during the last service visit, preventing them from checking for rodent activity. The Dietary Aide also reported having seen rodent droppings in the storage room in the past. Interviews with the Director of Nursing and pest control personnel highlighted the potential hazard posed by the presence of rodents in the kitchen. The facility's policies and procedures, as well as the US Food and Drug Administration's Food Code, emphasize the importance of maintaining a pest-free environment to prevent food contamination. However, the facility's failure to ensure the presence and inspection of rodent traps contributed to the unsanitary conditions observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of trash and garbage, as observed during a survey. During an observation and interview with the Maintenance Director (MD), it was noted that outside garbage dumpsters were not fully covered, with two out of three blue dumpsters only half-covered and a large compactor bin left open without a cover. Additionally, the compactor machine was observed without a bin underneath, and trash was found in the uncovered dumpsters and compactor bin, attracting multiple flying pests. The MD acknowledged the issue, stating that the garbage service did not cover the bins after emptying them and did not move the compactor bin back under the compactor machine. The MD also mentioned that staff had been improperly disposing of garbage into the open compactor bin, despite the compactor machine not being operational. Interviews with the Director of Nursing (DON) and the Vice President of Operations (VPO) confirmed that the dumpsters should be covered, although the VPO was unaware of the compactor bin's existence. A review of the facility's policies and procedures indicated that all trash should be properly disposed of in external receptacles and that outside dumpsters should be kept closed and free of surrounding litter. This failure to adhere to the facility's policies had the potential to create an unsanitary and uncomfortable environment for the residents.
Failure to Provide Adequate Communication for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide necessary means of communication for a resident who primarily speaks Spanish and has limited English proficiency. The resident, who was admitted with multiple diagnoses including hemiplegia, diabetes, and dysphagia, was moderately cognitively impaired and had the capacity to make decisions. Despite the resident's ability to communicate mostly in Spanish, the facility did not consistently use translation services or provide a communication board, which was noted as missing during a room inspection. Interviews with staff revealed a lack of awareness and training regarding the use of the Language Line, a phone translation service. A Licensed Nurse and a Certified Nursing Assistant admitted to not using the Language Line and instead relied on finding Spanish-speaking staff to assist with communication. The facility's policy required the use of trained interpreters or contracted services to ensure meaningful access to information for residents with limited English proficiency, but this was not adhered to in practice. The facility's failure to provide adequate communication tools and services was confirmed by multiple staff members, including the MDS Coordinator and the Regional Nurse Consultant. The facility's policies emphasized the importance of providing culturally relevant and appropriate translation services, yet the staff's lack of training and awareness led to the resident's communication needs being unmet, posing a risk to the resident's care and well-being.
Unsanitary Conditions in Resident's Room
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for a resident, resulting in an unsanitary and uncomfortable living condition. The resident's privacy curtain was observed to have a brown crusted stain, and the top drawer of the bedside dresser contained insect fragments, stains, and solid particle matter. The resident, who was moderately cognitively impaired, did not use the top drawer as it was locked and inaccessible. The resident's family had previously reported the presence of bugs and mold in the drawer, and the maintenance staff was notified but did not have the key to unlock the drawer. During observations and interviews, facility staff, including the Accounts Manager, Licensed Nurse, and Regional Nurse Consultant, confirmed the unsanitary conditions of the resident's room. The facility's housekeeping procedures, which require regular cleaning and immediate removal of stained curtains, were not adequately followed. The facility's policies emphasize providing a clean, sanitary, and homelike environment, but these standards were not met in this instance, compromising the resident's right to a safe and comfortable living space.
Failure to Revise Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to revise the care plan for a resident, which did not accurately reflect the feeding assistance provided. The resident, who was admitted with multiple diagnoses including hemiplegia, diabetes, and dysphagia, was noted to be independent with eating according to the Minimum Data Set (MDS) assessment. Despite this, the care plan created indicated that the resident required total assistance for feeding, which was inconsistent with the resident's actual ability and preference to feed herself independently. Observations and interviews with the resident, a Certified Nursing Assistant (CNA), and an Occupational Therapist (OT) confirmed that the resident was able to feed herself using her left hand and refused assistance. The Regional Nurse Consultant (RNC) and the OT acknowledged the discrepancy in the care plan interventions, noting that the care plan was misleading and should be revised. The facility's policy and procedure for care planning indicated that the interdisciplinary team, including nursing staff and therapists, is responsible for developing and revising care plans based on comprehensive assessments. However, the care plan for this resident was not updated to reflect her current feeding assistance status, leading to a potential risk of the resident receiving incorrect feeding assistance not in accordance with her wishes.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a physical altercation between them. Resident 2, who had intact memory and was admitted with conditions including spinal cord disease and brain injury, was seen hitting Resident 1 on the arm in an attempt to retrieve her hat. Resident 1, who had moderately impaired memory and was admitted with conditions such as sepsis, pneumonia, and schizophrenia, retaliated by throwing coffee on Resident 2. This incident occurred in the hallway and was witnessed by a Certified Nursing Assistant (CNA 3), who intervened to separate the residents. The Director of Nursing (DON) acknowledged that there was a care plan in place for Resident 2 due to increased behaviors, which included monitoring her every 15 minutes. Despite these measures, the altercation still occurred. The facility's policy on abuse prohibition, dated February 2021, clearly states that all forms of abuse, including physical abuse such as hitting and slapping, are prohibited. The failure to prevent this incident increased the potential for physical and psychosocial injury to the residents involved.
Failure to Maintain Resident's Hearing Aids in Working Condition
Penalty
Summary
The facility failed to maintain a resident's assistive devices in working condition, specifically the resident's hearing aids, which were inoperable. This deficiency was identified through observation, interviews, and record reviews. The resident, who had diagnoses including lung problems and depression, was observed having difficulty communicating due to her hearing impairment. Staff members, including a CNA and a licensed nurse, were unaware of the resident's hearing aids, which contributed to the communication challenges. The resident expressed frustration over her inability to hear and communicate effectively. The Social Service Director recalled a previous issue with the resident's hearing aids in April 2024, which was resolved at that time. However, the hearing aids were later found in the resident's room, and the resident reported they were not working. The Director of Nursing acknowledged that the inoperable hearing aids could have impeded the resident's communication. The facility's policy required the maintenance and supervision of assistive devices, but this was not adhered to, as evidenced by the lack of awareness and action from the staff regarding the resident's hearing aids.
Food Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in several instances. A dietary aide was seen using non-sterile, gloved fingers to prepare a food thermometer for insertion into food, instead of using alcohol wipes as expected. This practice was confirmed by the Registered Dietitian, who stated that the thermometer should have been cleaned with alcohol wipes to prevent infection. Additionally, during an inspection of the kitchen, a trash can without a lid was found near food preparation areas, a glove was on the floor, and a small sink next to prepared food was dirty. These observations were confirmed by the Payroll Director, who acknowledged the need for covered trash cans and clean sinks to prevent infection spread. Furthermore, a resident with a history of osteomyelitis, methicillin-resistant staphylococcus aureus infection, hypertension, and glaucoma was served a breakfast tray that had been taken from a cabinet designated for discarded trays. The resident expressed dissatisfaction with the meal, noting it was cold and incomplete. The Certified Nursing Assistant involved admitted to retrieving the tray from the leftover cart after the resident changed their mind about refusing it. The facility was unable to provide the requested policies and procedures for measuring food temperatures, handling food trays, and infection control related to cleaning and trash disposal.
Facility Fails to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide meals at a safe and appetizing temperature for three residents, as observed during a survey. The Registered Dietician (RD) measured the food temperatures from a food cart delivered to Hall 6 and found that the hot entree, country fried steak, was at 108.1 degrees Fahrenheit, and the mashed potatoes were at 99.1 degrees Fahrenheit. These temperatures did not meet the facility's policy requirement of 120 degrees Fahrenheit or greater for hot entrees and starches. Interviews with the Administrator, Licensed Nurse, and Nursing Assistant revealed that residents frequently complained about cold food, indicating that this issue had been ongoing. Residents expressed dissatisfaction with the temperature of their meals, with one resident stating that breakfast was almost always cold, and another mentioning that the food was never hot enough. The facility's policy, dated 2020, emphasized the importance of serving meals at appropriate temperatures to meet residents' nutritional needs. Despite this, the facility's failure to maintain the required food temperatures had the potential to impact residents' food intake and nutritional status.
Improper Storage and Labeling of Toileting Devices
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for a resident when staff stored five unlabeled bedpans and one unlabeled, uncleaned bedside commode bucket under the sink in the resident's bathroom. The bedside commode bucket had brown dried residue on its inner bottom surface. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the improper storage and cleanliness of the toileting devices, noting that they should be labeled, cleaned, and stored properly to prevent cross-contamination. The resident involved was admitted with diagnoses including epilepsy, hemiplegia, and muscle weakness, and required staff assistance for toileting. The Infection Preventionist Nurse confirmed that bedpans and bedside commode buckets should be labeled with the resident's room and bed number, cleaned, and stored in a plastic bag for individual use only. The facility's policy and procedure on bedpan and urinal handling emphasized cleaning and proper storage, which was not followed in this instance, leading to a potential increase in the spread of infection.
Failure to Serve Hot Food at Appetizing Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature, as evidenced by multiple resident complaints about consistently receiving cold hot foods. Three residents specifically voiced their dissatisfaction, with one resident feeling disrespected and others settling for cold meals. The issue was brought up during a resident council meeting, and staff, including a CNA and the Activity Director, acknowledged the problem, attributing it to old meal delivery carts. Despite being aware of the complaints, the facility did not resolve the issue, leading to ongoing dissatisfaction among residents. Interviews with residents and staff revealed that the problem had persisted for a while, with residents frequently receiving cold meals such as eggs, pancakes, oatmeal, pasta, steamed vegetables, and mashed potatoes. The facility's policy stipulated that meals should be served at appropriate temperatures and resident preferences should be honored, but this was not adhered to. The Director of Nursing also acknowledged the issue, stating that hot food should be served hot for residents to enjoy, yet the problem remained unresolved.
Non-Functional Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for two residents, compromising their ability to communicate with staff for assistance. During an observation and interview, it was noted that the call lights for both residents did not activate the light above their room or the call light panel at the nursing station. This issue was confirmed by a Licensed Nurse, who acknowledged that there were no audible or visual signals to notify staff when the residents pressed their call buttons. The Maintenance Assistant also verified the malfunctioning call lights and mentioned that the facility had old wiring, emphasizing the importance of a working call light system for resident safety. The facility's policy from September 2022 stipulated that the call system should remain functional at all times, with audible and visual signals maintained. However, this policy was not adhered to, as evidenced by the non-functional call lights for the two residents. The Director of Nursing confirmed that residents relied on the call light system to communicate with staff and that it should always be operational. The failure to maintain a functional call light system compromised the major communication link for staff to meet the residents' needs and placed them at risk for safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 444 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmichael
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Pointe Post-acute | 0 mi | — | 31 | 0 |
| Mountain Manor Senior Residence | 0.1 mi | — | 1 | 0 |
| Whitney Oaks Care Center | 1.7 mi | — | 5 | 0 |
| American River Center | 1.8 mi | — | 12 | 0 |
| Casa Coloma Health Care Center | 1.8 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River City Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.