Riverside Village Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 17040 Arnold Dr., Riverside, California 92518
- CMS Provider Number
- 555404
- Inspections on file
- 48
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Riverside Village Healthcare Center during CMS and state inspections, most recent first.
A resident with schizoaffective disorder and depression, assessed as cognitively intact, began refusing multiple medications (including psychotropics), meals, blood sugar checks, and ADL care, while exhibiting delusional thoughts and escalating behavioral changes such as calling law enforcement, yelling at staff, and repeatedly refusing showers and incontinence care. Nursing notes and IDT documentation reflected ongoing refusals and impaired cognition, and CNAs reported the resident frequently declined hygiene care despite noticeable odor. Although a psychiatric consult was eventually ordered, it was delayed and not completed before the resident was transferred to the hospital for continued refusal of food, medications, and basic care, resulting in a failure to provide necessary behavioral health care and services as outlined in facility policy.
A resident with multiple chronic conditions reported feeling neglected and dismissed by hospital nursing staff prior to admission. After the resident disclosed this experience, facility staff did not implement or document the required 72-hour monitoring of the resident's psychosocial condition, as outlined in facility policy.
A resident with a history of gastroenteritis and protein-calorie malnutrition experienced multiple instances of consuming less than 50% of meals without being offered substitute options, despite facility policy requiring alternatives for low intake. Staff interviews confirmed that meal substitutes should have been provided but were not.
A resident admitted with multiple cardiac and neurological conditions was using continuous oxygen therapy, as noted in the admission assessment, but no physician order for oxygen was present in the medical record. The DON confirmed the omission and stated that the nurse should have verified and obtained the correct order, in accordance with facility policy.
A resident with multiple medical conditions did not receive timely evaluation for suture removal, blood sugar monitoring after insulin discontinuation, prompt baseline weight assessment, physician notification for low blood pressure, or oral care after meals. These lapses were confirmed through record review and staff interviews, showing failures to follow established care protocols.
A resident with end-stage renal disease missed scheduled hemodialysis treatments because transportation to the dialysis center was not arranged as required. Facility staff confirmed that transportation should have been pre-arranged and followed up according to policy, but this did not occur, resulting in the resident not receiving necessary dialysis care.
Staff did not consistently maintain resident dignity or respond promptly to call lights. A CNA failed to ensure bodily privacy for a resident with severe cognitive impairment during care. Call lights were not answered in a timely manner, with one resident and his roommate reporting significant delays in receiving assistance, and another resident feeling disrespected due to slow responses. Facility leadership and policies confirmed that these actions did not meet expectations for resident dignity and timely care.
The facility did not ensure that advance directives were readily available in the records for a resident who had executed one, and failed to provide or document written information about formulating advance directives to several other residents or their representatives. Residents affected had a range of medical conditions and varying cognitive abilities, but in each case, the required documentation and information regarding advance directives was missing, as confirmed by the Social Service Director.
Surveyors found that two residents, as well as others in additional rooms, were living in areas with peeled and damaged paint on the walls behind their headboards. Both the Maintenance Supervisor and Administrator acknowledged the issue and stated that such damage should have been repaired to maintain a clean and homelike environment, as required by facility policy.
Nursing staff failed to follow professional standards during medication administration, including leaving a resident's medication unattended and accessible to another resident, not verifying a resident's identity before giving medication, and not providing privacy during medication administration. These actions involved residents with various medical conditions and were confirmed by both the nursing staff and the DON as not meeting facility policy requirements.
Multiple residents reported long delays in receiving assistance with ADLs and call lights, with some waiting over 30 minutes or more for help, including for pain medication and toileting. Facility records showed that required CNA direct care hours were not met on numerous days, and staffing levels frequently fell below the facility's own projections, resulting in high resident-to-CNA ratios. Both the DSD and DON acknowledged that these staffing shortages led to inadequate care and delays in meeting resident needs.
A CRNA was observed placing a soup ladle directly on a tablecloth between servings instead of in a clean container, contrary to training and facility protocol. Both the CRNA and the DND acknowledged this practice could lead to cross-contamination and potential illness.
Surveyors identified several infection control deficiencies, including improper disposal of soiled diapers, a direct care staff member wearing long artificial nails, failure to use PPE and perform hand hygiene when caring for a resident with an active MRSA wound, lack of disinfection of shared equipment, and a CNA providing care while symptomatic without a mask to a resident with significant respiratory and metabolic conditions.
The facility did not ensure the lint trap of dryer 3 was maintained in safe and operable condition, as it was found damaged and filled with lint that had not been cleaned since the previous day. Laundry staff continued to use the dryer despite the damage, and records showed the issue had been previously identified as a safety concern. Maintenance and administrative staff confirmed the equipment should have been repaired or replaced according to facility policy.
A resident with a history of stroke and severe ankle contractures did not have a comprehensive care plan in place to address her contractures. Staff confirmed that only heel pads were used to prevent skin breakdown, and no specific interventions or care plan were documented or implemented, despite facility policy requiring such plans for mobility and range of motion issues.
A resident with severe ankle contractures and a history of cerebral infarction did not receive appropriate contracture management or range of motion (ROM) care. Staff interviews and record reviews confirmed that the resident was not included in the restorative nursing program, did not receive ROM exercises, and was not provided with devices to maintain joint alignment, despite facility policy and therapy recommendations.
A resident with severe cognitive impairment, dysphagia, and no natural teeth did not receive a required dental consultation despite physician orders and facility policy. Staff interviews and record review confirmed the absence of dental services for the resident, who had not been seen by a dentist since the previous year.
A nurse left a computer open and unattended during medication administration, exposing a resident's electronic health record to unauthorized view. The resident had multiple medical conditions and was cognitively intact. Facility policy and the DON both require staff to lock screens when leaving computers, but this was not followed, resulting in a breach of privacy.
A baseboard heater cover was found detached and laying on the floor in a resident's room, leaving the heating element exposed. The resident, who uses a wheelchair, reported feeling direct heat and expressed fear of being burned. The Maintenance Supervisor and Administrator acknowledged the equipment was damaged and should have been repaired to maintain safety.
Two residents with cognitive impairments were filmed by a staff member and their videos were posted on social media without obtaining consent from the residents or their representatives. The staff member acknowledged not seeking proper permission, and facility leadership confirmed that this violated resident privacy and confidentiality policies.
A resident with severe cognitive impairment and total dependence for oral hygiene did not receive required oral care after meals, resulting in food remnants being found in her mouth during a physician appointment. Staff interviews and facility policy confirmed that oral care should have been provided after every meal, but this was not done on the day in question.
A resident with left-sided weakness required two-person assistance or a mechanical lift for transfers. However, a CNA attempted to transfer the resident alone, leading to the resident experiencing pain in the right shoulder and left hip. The care plan and MDS indicated the need for two or more helpers, but the CNA did not seek assistance or use the mechanical lift, contrary to facility policy.
A resident with a history of hypertension and other medical conditions was administered Hydralazine despite having a systolic blood pressure below the physician-ordered threshold. The facility's policy requires checking vital signs and adhering to prescriber orders, which was not followed in this instance, as confirmed by interviews with LVNs and the DON.
A resident was transferred to a GACH without proper documentation justifying the transfer. The resident, admitted with fractures, expressed mental instability, prompting the transfer. However, the facility failed to document why the resident's needs couldn't be met in the facility, as required by policy.
The facility failed to maintain a comfortable environment for several residents when the air conditioning unit malfunctioned, causing room temperatures to exceed 81°F. Residents with various medical conditions expressed discomfort, and the facility lacked proper temperature monitoring. The issue was not reported to the CDPH, despite awareness from the administration.
Two residents were not properly assessed or provided with care plans for bladder and bowel incontinence. One resident experienced incontinence episodes without an assessment or care plan, while another was frequently incontinent without interventions. Facility policies on change in condition and bowel and bladder protocol were not followed.
The facility failed to accurately code MDS assessments for four residents, leading to discrepancies in their medical records. Errors included incorrect coding of hospice care, discharge status, and POLST forms. The inaccuracies were confirmed by the MDS Coordinator and the DON.
The facility failed to provide advance directive information to a resident upon admission, as required by their policy. The resident's POLST and Consents form were incomplete, and interviews with staff revealed that the process of providing this information was not followed correctly.
A facility failed to ensure privacy during resident care for a cognitively impaired, quadriplegic resident. Two CNAs transferred the resident without a privacy curtain, with the window blinds open and the roommate watching. The CNAs initiated incontinence care before realizing the need for privacy and paused to retrieve the privacy curtain. Interviews confirmed staff awareness of privacy protocols but failure to adhere due to the curtain's absence.
The facility failed to develop a care plan addressing the smoking needs of a resident and did not specify the level of assistance required for ADLs for another resident with severe cognitive impairment and quadriplegia. Staff interviews confirmed these deficiencies.
The facility failed to provide necessary assistance with ADLs for two residents, leading to deficiencies in personal hygiene and grooming. One resident was observed with disheveled hair on multiple occasions, while another had long, jagged fingernails and thick, discolored toenails. Staff acknowledged the oversights, and the care plans did not adequately address the required level of assistance.
The facility failed to supervise two residents during smoking breaks, contrary to their policy. One resident with COPD and asthma was observed smoking unsupervised and in possession of a cigarette box and lighter, while another resident with severe cognitive impairments was also smoking unsupervised. The facility's policy requires staff supervision during smoking breaks and prohibits residents from keeping smoking paraphernalia.
A resident missed his scheduled medications because an LVN left the medications in his hand and exited the room without verifying ingestion. The resident, who has moderate cognitive impairment and no orders to self-administer medications, was later found with the pills scattered around him.
Failure to Provide Timely Behavioral Health Services for Resident With Schizoaffective Disorder
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with known behavioral health needs received necessary behavioral health care and services when she began refusing medications, meals, and care. The resident was admitted with schizoaffective disorder and depression, had a documented history of schizophrenia, and was assessed as cognitively intact with decision-making capacity. Physician orders included psychotropic medications (aripiprazole and Lexapro) for schizoaffective disorder and depression. Beginning in early January, the resident progressively refused multiple medications, including psychotropic, pain, cardiovascular, gastrointestinal, and supplement medications, as well as blood sugar checks. Progress notes and interdisciplinary team documentation showed that from early January the resident exhibited behavioral changes and delusional thoughts, including repeatedly refusing medications and meals, calling law enforcement to report she had not eaten in several days, and refusing care such as changing, repositioning, and showers. Staff documented that she yelled at staff, shouted at CNAs, refused dinner and blood sugar checks, and declined to return to bed after being in her wheelchair. CNAs reported that the resident frequently refused showers and hygiene care, refused to have her incontinence brief changed, remained in her wheelchair in front of the nurse’s station, and at times had noticeable odor while continuing to refuse bathing despite repeated offers. Despite these ongoing refusals and documented behavioral changes related to her schizoaffective disorder, the resident did not receive timely psychiatric or psychological evaluation. A psychiatric consult was ordered several days after the onset of significant refusals and behavioral changes, but the evaluation was postponed and not completed before the resident was sent to the hospital for continued refusal of food, medications, and basic care. The facility’s own policies required comprehensive assessment and behavioral health services when there was a significant change in a resident’s physical, emotional, or mental condition, including refusal of treatment or medications and signs of emotional or psychosocial distress, but the necessary behavioral health services were not provided during the period of escalating refusals and behavioral symptoms.
Failure to Monitor Emotional Distress After Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident's emotional distress following an allegation of abuse and neglect that occurred at a general acute hospital prior to admission. The resident, who had diagnoses including postlaminectomy syndrome, diabetes mellitus, and fibromyalgia, reported to a treatment nurse that she felt neglected and dismissed by nursing staff in the emergency room during her hospital stay. Despite this report, there was no documented follow-up or monitoring of the resident's psychosocial condition after the allegation was made. Interviews with facility staff confirmed that residents are to be monitored for 72 hours after a change of condition, which includes significant changes in emotional or mental status. The facility's policy also requires nurses to notify the attending physician and document changes in the resident's condition. However, in this case, the required 72-hour monitoring and documentation were not implemented after the resident reported the incident, resulting in a failure to provide appropriate psychosocial support.
Failure to Offer Meal Substitutes for Low Food Intake
Penalty
Summary
The facility failed to ensure that meal substitutes were offered to a resident when food intake was below 50%. Record review showed that the resident, who had diagnoses including gastroenteritis and protein-calorie malnutrition, experienced significant weight fluctuations, including a 7-pound loss in one week. Documentation indicated that on multiple occasions across August and September, the resident consumed less than half of their meals and was not offered alternative menu options as required by facility policy. Interviews with the DON and Food and Nutritional Services Director confirmed that staff should have offered meal substitutes when intake was low, but this did not occur. The facility's policy stated that a variety of foods and snacks should be available and that care plans should be adjusted if a resident is dissatisfied with their diet. Despite these guidelines, the resident was not provided with appropriate alternatives during numerous meals when intake was insufficient.
Failure to Reconcile Oxygen Therapy Orders on Admission
Penalty
Summary
The facility failed to ensure accurate reconciliation of medications on admission for a resident who was admitted with multiple complex cardiac and neurological diagnoses, including encephalopathy, chronic systolic cardiac failure, ischemic cardiomyopathy, atherosclerotic heart disease, non-rheumatic aortic valve stenosis, and difficulty walking. Upon admission, the resident was using continuous oxygen therapy at 2 liters per minute via nasal cannula, as documented in the admission assessment summary. However, a review of the physician's orders from admission through several days after did not include any order for oxygen therapy. The DON confirmed during interview and record review that the resident's record lacked a physician order for oxygen, despite the resident's continuous use of oxygen during her stay. The DON acknowledged that the licensed nurse should have verified the orders for accuracy and contacted the physician to obtain the necessary order for oxygen therapy, as required by the facility's medication reconciliation policy.
Failure to Provide Timely Wound, Blood Sugar, Weight, Blood Pressure, and Oral Care
Penalty
Summary
A resident with multiple complex medical conditions, including encephalopathy, sepsis, diabetes mellitus II, muscle wasting, and hypertension, was admitted to the facility. The facility failed to provide necessary care and treatment in several areas. The resident's left forehead laceration, which had six sutures, was not evaluated or referred to a physician for suture removal during the fourth week of stay. Documentation and interviews confirmed that no wound or suture evaluation was conducted, and the healing surgical wound with sutures was not reported to a physician as required by facility policy. Additionally, after the discontinuation of insulin medication, the resident's blood sugar levels were not monitored, despite a diagnosis of diabetes and care plan instructions to check blood glucose. The last documented blood sugar level was recorded on the day insulin was discontinued, with no further monitoring or clarification from nursing staff to the physician regarding ongoing blood sugar checks. This lapse was acknowledged by both nursing staff and the DON, who confirmed that blood sugar monitoring should have continued per facility protocol. The facility also failed to obtain the resident's baseline weight in a timely manner after admission, with a two-day delay in obtaining the initial weight. This delay was recognized by both the restorative nursing assistant and the RN, who stated that timely weight measurement is necessary for appropriate nutritional management. Furthermore, the resident experienced a change in condition with low blood pressure readings, but this was not reported to a physician as required by policy. Lastly, oral care was not provided after a meal, despite the resident's severe cognitive impairment and dependence on staff for oral hygiene, resulting in food residue being found in the resident's mouth during a subsequent physician appointment.
Failure to Arrange Timely Transportation Resulting in Missed Dialysis
Penalty
Summary
The facility failed to ensure timely and appropriate hemodialysis care for a resident with end-stage renal disease, resulting in missed dialysis treatments. The resident, who had moderate cognitive impairment and a physician's order for scheduled dialysis three times per week, did not receive dialysis on at least one occasion due to transportation not being arranged. Documentation in the nurse's notes confirmed that the missed treatment was due to the transport company not arriving, and interviews with facility staff revealed that transportation should have been pre-arranged and followed up, especially after the resident's readmission. Interviews with the Social Service Director, an LVN, and the Director of Nursing confirmed that the facility's policy required pre-arrangement and follow-up of transportation for dialysis appointments. The facility's transfer agreement also specified responsibility for arranging suitable transportation, including necessary equipment and personnel. The failure to arrange transportation as required by policy and agreement led directly to the resident missing scheduled dialysis treatments while at the facility.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
Staff failed to maintain resident dignity and respect in several instances. In one case, a CNA provided care to a resident with severe cognitive impairment without fully closing the privacy curtain, resulting in the resident's body being exposed. The CNA admitted to being in a hurry and forgetting to close the curtain, while both the RN and DON confirmed that privacy should have been maintained during care. In another instance, staff did not answer call lights in a timely manner during a shift change, with observed response times averaging 5-10 minutes. A resident with a history of stroke and hemiplegia, who was cognitively intact, reported that call lights were not answered promptly, making him feel disrespected and unimportant. The DON acknowledged that call lights should be answered as soon as possible and that delays do not promote residents' sense of well-being. Additionally, a resident reported waiting 15-20 minutes for assistance to transfer from a wheelchair to bed, with no staff responding to the call light. The resident's roommate confirmed the delay and stated he had to leave his bed to find help. The DON stated that timely response to call lights is the responsibility of all staff and that delays could result in unmet resident needs. Facility policies reviewed emphasized the importance of dignity, respect, and prompt response to resident requests.
Failure to Provide and Document Advance Directive Information and Availability
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were properly documented and readily available in the records of several residents. For one resident who had executed an AD, there was no copy of the AD in either the electronic or paper chart, and the facility did not follow up with the resident's representative to obtain it. This omission was confirmed by the Social Service Director (SSD), who acknowledged that the AD should have been available and that follow-up with the family member had not occurred. Additionally, for six other residents, there was no documented evidence that written information regarding the formulation of an AD was provided to them or their representatives. These residents had various medical conditions, including acute kidney failure, cerebral vascular accident, fractures, urinary tract infection, hemiplegia, and diabetes mellitus. Some residents were cognitively intact and able to make decisions, while others had severe cognitive impairment and required information to be provided to their legal representatives. In each case, the records lacked documentation that the required information about ADs was given. During interviews, the SSD confirmed that written information about formulating an AD was not being provided to residents or their representatives, and there was no documentation to show that this requirement was being met. The facility's own policy required that residents or their legal representatives be given written information about ADs upon admission and that the existence of an AD be prominently displayed in the medical record. These requirements were not followed for the residents identified in the report.
Failure to Maintain Homelike Environment Due to Damaged Walls
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for its residents, as evidenced by multiple instances of peeled and damaged paint on the walls behind residents' headboards in several rooms. Specifically, the damaged walls were noted in the rooms of two residents, as well as in additional rooms, during multiple observations. The Maintenance Supervisor acknowledged awareness of the damaged painted walls and stated that they should have been fixed and repainted. The Administrator also confirmed that maintenance was expected to check and repair any damaged walls or surfaces in resident rooms, and that the facility should provide a homelike environment for all residents. A review of the facility's policy and procedure titled "Homelike Environment" indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment, including clean, sanitary, and orderly surroundings. The observed failure to repair and maintain the painted walls did not align with the facility's stated policy and had the potential to negatively impact the residents' experience of comfort and pleasantness during their stay.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication administration for three residents. In one instance, a nurse left an open packet of Lidocaine Patch 5% labeled for one resident on a shelf next to another resident, making it readily accessible and not secured in the medication cart or discarded. The nurse confirmed the medication was not handled according to policy, and the Director of Nursing (DON) stated that medications should not be left unattended in the presence of another resident. The facility's policy requires that medications ordered for a particular resident may not be administered to another resident and must be administered safely and as prescribed. In another case, a nurse administered medication to a resident without verifying the resident's identity. The resident was cognitively intact and had a history of a right wrist and hand fracture, bradycardia, and difficulty walking. The nurse acknowledged not following the facility's process of confirming the resident's name and date of birth or checking the identification wristband before administering medication. The DON and another nurse both confirmed that the expectation is to verify resident identity before medication administration, as outlined in the facility's policy. Additionally, a nurse did not provide privacy to a resident during medication administration. The resident, who was cognitively intact and had a history of a left femur fracture, diabetes, and hypertension, was not afforded privacy such as pulling a curtain or closing the door during the process. The nurse admitted to not providing privacy and stated that it is the resident's right. The DON reiterated that staff should promote, maintain, and protect resident privacy during treatment procedures, as required by the facility's dignity policy.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident complaints and documented staffing shortages. Several residents reported significant delays in receiving assistance with activities of daily living (ADLs) and in response to call lights, particularly during evening and night shifts. For example, one resident described waiting 15 to 20 minutes for help after sliding off his bed, with no staff responding even after his roommate also activated the call light. Other residents confirmed similar experiences, with some waiting over 30 minutes or even up to an hour for assistance, including for pain medication and toileting needs. These residents were cognitively intact and had medical conditions such as spinal fusion, cauda equina syndrome, kidney disorders, pulmonary issues, fractures, and mobility difficulties, all of which increased their need for timely care. A review of facility records revealed that the required minimum of 2.4 Certified Nursing Assistant (CNA) Direct Care Service Hours Per Patient Day (DHPPD) was not met on 16 days in March and 11 days in April. Staffing assignment sheets showed that the number of CNAs on duty frequently fell below the facility's own assessment projections, resulting in higher resident-to-CNA ratios than planned. On several occasions, three CNAs were responsible for up to 18 residents during night shifts, and day and evening shifts were also understaffed. The Director of Staff Development (DSD) and Director of Nursing (DON) both acknowledged that these staffing levels were insufficient to provide safe, efficient, and adequate care, and that the required DHPPD was not consistently achieved. Facility policies required timely responses to call lights and sufficient staffing to meet resident needs as outlined in care plans and the facility assessment. Despite these policies, the documented staffing shortages and resident reports of delayed care demonstrate that the facility did not adhere to its own standards or regulatory requirements. The DSD and DON confirmed that the lack of adequate staffing led to delays in care, increased risk for falls, and residents being left soiled or without timely assistance.
Improper Storage of Serving Utensil During Meal Service
Penalty
Summary
During a dining room observation, a Certified Restorative Nurse Assistant (CRNA) was seen using a four-ounce ladle to serve soup and then placing the ladle directly on the tablecloth instead of in a clean container between servings. The CRNA acknowledged in an interview that she had been trained to place the ladle on a clean tray and recognized that placing it on the tablecloth could cause cross-contamination and illness. The Director of Food and Dietary (DND) confirmed that the CRNA had received proper training and that the ladle should not have been placed on the table between servings, noting the potential for resident illness due to cross-contamination.
Multiple Lapses in Infection Control Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two used diapers were found placed on top of a resident's cabinet drawer instead of being disposed of in a trash bin, as confirmed by both the LVN and the Infection Preventionist. This action was contrary to facility policy and was acknowledged by staff as a source of potential contamination. Additionally, a direct care staff member was observed wearing long artificial fingernails while providing resident care. The staff member admitted to having acrylic nails that extended significantly beyond the fingertip, and both the Infection Preventionist and facility policy indicated that such nails are prohibited for direct care staff due to the risk of harboring pathogens and causing skin injury to residents. Further deficiencies were identified in the use of personal protective equipment (PPE) and hand hygiene. A Certified Restorative Nursing Assistant (CRNA) was observed providing care to a resident with an active MRSA wound infection without donning the required gown and gloves, despite clear signage and physician orders for contact precautions and enhanced barrier precautions. The CRNA also failed to clean and disinfect the Hoyer lift after use with the same resident and did not perform hand hygiene after providing care. These lapses were acknowledged by the CRNA and confirmed by the Infection Preventionist as violations of facility policy and CDC recommendations for infection control. Another incident involved a Certified Nursing Assistant (CNA) who was observed providing care to a resident while exhibiting symptoms of a respiratory infection, including sniffling and a runny nose, without wearing a mask. The CNA admitted to feeling ill and not reporting her symptoms to a supervisor, as required by facility policy. The resident receiving care had chronic obstructive pulmonary disease, diabetes, and was dependent on supplemental oxygen, making her particularly vulnerable. Facility leadership confirmed that staff are required to report illness and wear masks if symptomatic, but these procedures were not followed in this instance.
Failure to Maintain Safe and Functional Laundry Equipment
Penalty
Summary
The facility failed to maintain a safe, functional, and comfortable environment when the lint trap of dryer 3 in the laundry area was found to be damaged and not cleaned. During an observation and interview with laundry staff, the lint trap was seen with an opening at the corner and filled with thick, soft lint that had not been removed since the previous day. The laundry staff confirmed that the damaged lint trap was still being used and had not been cleaned as required. Review of the DRYER'S LINT TRAP CLEANING LOG showed that the lint trap was not cleaned from noon on one day until 8 a.m. the following day. Additionally, a daily meeting record indicated that dryer 3 had previously been identified as having safety concerns. Further interviews with the Maintenance Supervisor and Administrator confirmed that the lint trap was torn and should have been repaired or replaced to prevent hazards. The facility's maintenance policy requires that all equipment be maintained in a safe and operable manner, and that hazards be addressed promptly. Despite these requirements, the damaged lint trap remained in use and uncleaned, creating a potential safety risk.
Failure to Develop Care Plan for Foot Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the contractures of the feet for a resident with a history of cerebral infarction and severe joint immobility in both ankles. Observations showed the resident lying in bed with both ankles extended downward and no adaptive devices in use. Interviews with staff confirmed that the resident had longstanding foot drop and only heel pads were used to prevent skin breakdown, with no specific interventions or care plan in place for the contractures. Record reviews further indicated that the resident had significant lower extremity impairment and severe joint immobility, but there was no documented evidence of a care plan addressing these issues. Staff interviews, including with a CNA, LVN, and the DON, confirmed the absence of a care plan for the resident's contractures, despite facility policies requiring comprehensive, person-centered care plans to address such needs. The lack of a care plan meant that the resident did not receive tailored interventions to manage or prevent worsening of the contractures, as required by the facility's own policies and procedures regarding care planning and mobility management.
Failure to Provide Contracture Management and ROM Care
Penalty
Summary
The facility failed to provide appropriate care and treatment to manage contractures for a resident with severe joint immobility in both ankles. Observations showed the resident lying in bed with both feet extended downward, wearing only soft foam heel pads to protect against skin breakdown. Interviews with staff revealed that no range of motion (ROM) exercises or contracture management devices were provided, as there was no physician order for such interventions. The restorative nursing assistant confirmed that the resident, who had a history of cerebral infarction and severe joint immobility, was not included in the restorative nursing program for ROM exercises, despite previous physical therapy discharge instructions recommending continued ROM care. Record reviews indicated that the resident had documented contractures and impairment in both lower extremities, with multiple assessments and physician notes confirming the condition. The licensed nurse and physical therapist both acknowledged that the resident should have been referred for therapy and provided with appropriate devices to prevent further contracture and foot drop. Facility policies required treatment and services for residents with limited ROM, including proper positioning, body alignment, and passive ROM exercises, but these were not implemented for this resident.
Failure to Provide Required Dental Consultation
Penalty
Summary
The facility failed to provide a dental consultation for a resident who was observed to be missing upper and lower teeth and reported not having dentures or having seen a dentist. The resident, who had a diagnosis of dysphagia and was on a mechanical soft diet, had a physician's order for dental health services as needed and was documented as edentulous in the dental hygiene progress notes. Despite these documented needs and orders, there was no evidence in the resident's record that a dental consultation had been provided since the previous year. Interviews with the Social Service Director and the Director of Nursing confirmed that there was no documentation of a dental visit for the resident and acknowledged that the resident should have been seen by the dentist according to facility policy. The facility's policy indicated that routine and emergency dental services should be available in accordance with the resident's assessment and plan of care, and that social services should assist with appointments and transportation. The lack of dental services was identified through observation, record review, and staff interviews.
Resident Health Information Left Unsecured During Medication Pass
Penalty
Summary
A licensed vocational nurse (LVN) failed to safeguard resident-identifiable information by leaving a computer open and unattended during medication administration, with a resident's electronic health record visible to unauthorized individuals. This incident was directly observed by surveyors, and the LVN acknowledged that this action was a violation of the facility's policy, which requires staff to close or lock computer monitors when leaving the medication cart. The Director of Nursing (DON) confirmed that staff are expected to lock their screens before leaving the area to prevent unauthorized access to resident information. The resident involved had been admitted with multiple diagnoses, including a left femur fracture, difficulty walking, diabetes, and hypertension, and was assessed as cognitively intact. The facility's policies on HIPAA compliance and resident dignity require the protection of confidential clinical information and the maintenance of resident privacy. The failure to secure the electronic health record resulted in the potential for the resident's information to be disclosed to individuals not involved in their care.
Baseboard Heater Cover Detached and Unrepaired in Resident Room
Penalty
Summary
A baseboard heater cover in a resident's room was found open, detached, and laying on the floor during an observation. The resident, who was in a wheelchair, reported feeling a warm breeze directly from the exposed heater and expressed fear of passing by it due to the risk of being burned. The heater cover's condition created a direct exposure to the heating element for the resident. The Maintenance Supervisor confirmed that the heater cover was damaged and detached, acknowledging that it should have been repaired promptly to prevent further damage and potential harm. The Administrator stated that maintenance staff are expected to repair damaged equipment to ensure a safe environment. Facility policy requires maintenance of equipment in a safe and operable manner, but in this instance, the heater was not maintained according to these standards.
Failure to Protect Resident Privacy and Confidentiality in Social Media Posting
Penalty
Summary
Facility staff failed to safeguard the privacy and confidentiality of two residents when a staff member filmed them and posted the videos on social media without obtaining consent from the residents or their representatives. Both residents had cognitive impairments, with one having severe impairment and the other moderate, as documented in their records. There was no evidence in the residents' records that consent was obtained for filming or posting the videos. During interviews, both residents did not recall giving permission for the videos to be made or shared online. The Social Services Director acknowledged making and posting the videos, stating that verbal agreement was obtained from the residents, but also recognized their short-term memory loss and did not seek consent from their representatives. The Director of Nursing confirmed that representatives were not notified or asked for permission prior to the videos being made and posted, and stated that this was a violation of the residents' privacy and rights. Facility policy requires respect for resident privacy and confidentiality, which was not followed in this instance.
Failure to Provide Oral Care After Meals for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for oral hygiene did not receive appropriate oral care after meals. The resident, who had diagnoses including major depressive disorder, dementia, encephalopathy, sepsis, and muscle wasting, was known to have difficulty swallowing and would hold food in her cheeks after eating. According to the care plan and staff interviews, oral care was required after every meal and before bed, especially for residents with feeding issues. However, on the day of a scheduled physician appointment, the resident was fed breakfast and prepared for transport, but food remnants were later found in her mouth at the physician's office. Staff interviews confirmed that oral care should have been provided after meals, and the facility's policy required assistance with oral hygiene for residents unable to perform this activity independently. Documentation and staff statements indicated that the resident was dependent on staff for oral care, and the failure to provide this care after meals resulted in food being left in the resident's mouth, as discovered during the external appointment.
Failure to Provide Adequate Assistance During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate staff assistance during a transfer for Resident A, who required moderate to maximum assistance due to weakness and flaccidity on the left side following a stroke. The Rehabilitation Program Manager (RPM) recommended a two-person assist or a mechanical lift for all transfers. However, during an incident, CNA 1 attempted to transfer Resident A alone, which was against the care plan that required two-person assistance or the use of a mechanical lift. During the transfer, CNA 1 grabbed Resident A's right arm and left leg, dragging her to the edge of the bed, which caused Resident A to nearly fall. Resident A experienced pain in her right shoulder and left hip following the incident. The care plan and Minimal Data Set (MDS) indicated that Resident A was dependent on helpers for transfers, requiring two or more helpers to complete the activity safely. Interviews with staff, including the Director of Nursing (DON) and other CNAs, confirmed that CNA 1 did not seek assistance or use the mechanical lift as required. The facility's policy on Activities of Daily Living (ADLs) emphasized the need for appropriate support and assistance based on the resident's assessed needs. The failure to adhere to these guidelines resulted in Resident A experiencing physical pain and had the potential to cause injury.
Failure to Adhere to Physician's Order for Blood Pressure Medication
Penalty
Summary
The facility failed to administer medication according to the physician's order for one resident, identified as Resident 1. The resident was prescribed Hydralazine to manage hypertension, with specific instructions to hold the medication if the systolic blood pressure (SBP) was below 110 or the heart rate was below 60. However, on October 15, 2024, the medication was administered despite the resident having an SBP of 101, which was below the threshold set by the physician's order. Resident 1 had a medical history that included conditions such as fusion of the spine in the lumbar region, spinal stenosis, end-stage renal disease, dependence on renal dialysis, and hypertensive heart disease. Interviews with the facility's Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed the importance of adhering to physician orders to prevent potential harm to residents. The facility's policy on administering medications emphasized the need to verify vital signs and follow prescriber orders to ensure resident safety.
Inadequate Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure an appropriate and necessary transfer for a resident who was moved to a general acute care hospital (GACH) without documented justification. The resident, who had been admitted with a fracture of the lumbosacral spine and pelvis, was transferred without evidence in the progress notes from the physician explaining why the resident's needs could not be met at the facility. The Notice of Transfer/Discharge Form and the Interact Transfer Form indicated the transfer was necessary for the resident's welfare, but lacked specific documentation of the resident's needs and the facility's attempts to meet those needs. Interviews with the Director of Nursing (DON) and the Administrator revealed that the resident had expressed feelings of mental instability and a need for help, which led to the physician's order for transfer. However, the facility's policy requires detailed documentation of the basis for transfer, including the specific needs that cannot be met and the receiving facility's ability to meet those needs. This documentation was not present, indicating a failure to comply with the facility's transfer or discharge policy.
Failure to Maintain Comfortable Environment Due to AC Malfunction
Penalty
Summary
The facility failed to provide a comfortable environment for five of the 13 sampled residents when the air conditioning unit was not functioning, resulting in room temperatures exceeding 81 degrees Fahrenheit. This issue was observed during an initial tour where fans were placed in hallways and resident rooms to mitigate the heat. Interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN 1), and the Maintenance Director (MD) revealed that some rooms were more affected than others, and the facility was waiting for fuses to be fixed on some air conditioning units. The MD admitted to not tracking room temperatures during this period. Residents 6, 7, and 8 expressed discomfort due to the heat, with some choosing to stay in common areas like the TV room or dining room to avoid their hot rooms. Resident 7, who has peripheral vascular disease, cellulitis, and ovarian cancer, mentioned that the fan in her room was insufficient, especially with the presence of oxygen concentrators. Resident 6, diagnosed with COPD, lung cancer, and respiratory failure, also avoided her room due to the heat. Resident 8, with rib fractures, heart failure, and kidney failure, noted that her room received direct sunlight, making it particularly warm despite the fan. The facility's policy on maintaining a homelike environment specifies safe temperatures between 71 and 81 degrees Fahrenheit. However, observations showed room temperatures ranging from 77 to 85.5 degrees Fahrenheit. The DON was unable to confirm how temperatures were being monitored, as the facility's temperature gun was missing, and wall thermostats were not functioning. The Administrator acknowledged awareness of the issue but had not reported it to the California Department of Public Health (CDPH).
Failure to Assess and Address Incontinence in Residents
Penalty
Summary
The facility failed to properly assess and provide appropriate care for two residents, Resident A and Resident B, regarding their bladder and bowel continence. Resident A was admitted with diagnoses including intracerebral hemorrhage and epileptic syndrome and was initially documented as continent. However, from June 2 to June 7, 2024, Resident A experienced episodes of bladder incontinence and was placed on an adult brief. Despite this change, there was no documented evidence of an assessment or a care plan to address the incontinence. Interviews with CNAs confirmed Resident A's incontinence, and the MDS Coordinator acknowledged that a change of condition should have been initiated and a bladder program developed. Resident B, admitted with cystitis and sepsis, reported being incontinent of bladder and bowel and wearing a brief at all times. The medical record indicated frequent incontinence, but there was no documented care plan to address this issue. The MDS Coordinator stated that Resident B should have been placed on a bowel and bladder program after the fourth day of incontinence, but no interventions were implemented to help regain control. The facility's policies on change in condition and bowel and bladder protocol were not followed. The policies required a comprehensive assessment and care plan development upon significant changes in a resident's condition. The facility's in-service training records indicated that staff were trained on documenting changes in condition, but this was not reflected in the care provided to Residents A and B.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #34, who had severe cognitive impairment and was receiving hospice care, had an MDS that did not reflect the hospice services. Both the MDS Coordinator and the Director of Nursing (DON) acknowledged the inaccuracy during interviews. Similarly, Resident #61 was discharged to an assisted living facility, but the MDS incorrectly indicated a discharge to a hospital. This error was also confirmed by the MDS Coordinator and the DON during interviews. Resident #16's MDS inaccurately reflected that their Physician Orders for Life-Sustaining Treatment (POLST) form was signed by a physician, nurse practitioner, or physician assistant, despite the form lacking such a signature. Additionally, the MDS incorrectly indicated the status of the resident's advance directives. The MDS Coordinator and the DON both confirmed these inaccuracies. Resident #30's MDS had similar issues, with the POLST form not being signed and the MDS inaccurately reflecting the resident's advance directives. These errors were also acknowledged by the MDS Coordinator and the DON. The facility's policy on certifying the accuracy of resident assessments was not followed, as evidenced by the multiple inaccuracies in the MDS coding for these residents. The Administrator, DON, and MDS Coordinator all confirmed that the MDS should accurately reflect the residents' medical status and care plans, but this was not the case for the four residents reviewed. These discrepancies highlight a failure in the facility's processes for ensuring accurate and complete resident assessments.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide advance directive information to Resident #57 upon admission, as required by their policy. The resident was admitted on 04/20/2024, but the Physician Orders for Life-Sustaining Treatment (POLST) and the Consents form were incomplete regarding advance directives. The Director of Nursing (DON) confirmed that there was no documentation of discussions about advance directives with Resident #57. The Social Services Director (SSD) and the Social Services Assistant (SSA) also failed to document any discussion about advance directives during the care conference, which is a part of their standard procedure. Interviews with the DON, SSD, SSA, and the Administrator revealed that the process of providing advance directive information was not followed correctly. The SSD was on vacation during Resident #57's admission, and the SSA, who participated in the care conference, did not document any discussion about advance directives. The SSA admitted that recently they had not been documenting these discussions, but she did not know why. This lapse in procedure led to the failure to provide Resident #57 with the necessary information about advance directives, as required by the facility's policy and state law.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to ensure privacy during resident care for one resident. The incident involved a resident with severe cognitive impairment, quadriplegia, and muscle wasting, who was dependent on staff for toileting hygiene and was always incontinent of urine and bowel. During an observation, two CNAs transferred the resident from a geriatric chair to their bed using a mechanical lift without a privacy curtain in place, with the window blinds open, and the resident's roommate watching. The CNAs proceeded with incontinence care without ensuring privacy, as the privacy curtain was removed for cleaning. The resident's gown was pulled up, and their brief was unfastened in full view of the roommate before the CNAs realized the need for privacy and paused the care to retrieve the privacy curtain. Interviews with the CNAs and the Director of Nursing revealed that the staff were aware of the requirement to provide privacy during resident care but failed to adhere to this protocol due to the absence of the privacy curtain. The Director of Nursing and the Administrator both confirmed that the expectation was for staff to ensure privacy during any resident care tasks. The CNAs acknowledged that they should not have proceeded with the transfer and care without the privacy curtain in place.
Failure to Address Smoking and ADL Assistance in Care Plans
Penalty
Summary
The facility failed to develop a care plan to address the smoking needs of Resident #32, who was admitted on 04/22/2024 and was identified as a smoker using tobacco products two to five times per day. Despite the resident being cognitively intact and requiring specific safety measures such as a smoking apron, cigarette holder, supervision, and one-on-one assistance, the comprehensive care plan did not reflect these needs. Observations and interviews with staff, including the MDS Coordinator, LVN, DON, and Administrator, confirmed that the resident's smoking status and required safety interventions were not included in the care plan. Additionally, the facility did not ensure that the care plan for Resident #46, who was admitted on 02/29/2024 with severe cognitive impairment and quadriplegia, specified the level of assistance required for activities of daily living (ADLs). The resident's care plan indicated impaired ADL function and the need for assistance but did not detail the specific level of assistance needed. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the care plan lacked necessary details on the level of assistance required for ADLs, which is crucial for staff to provide appropriate care.
Failure to Provide Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in personal hygiene and grooming. Resident #44, who had severe cognitive impairment and was totally dependent on staff for personal hygiene, was observed on multiple occasions with disheveled hair. Despite the facility's policy requiring staff to assist residents with ADLs, including grooming, the resident's hair was not groomed as expected. The Director of Nursing (DON) and a Certified Nurse Assistant (CNA) acknowledged the oversight, with the CNA admitting to forgetting to brush the resident's hair after dressing them. Resident #46, who had severe cognitive impairment and was dependent on staff for personal hygiene, was found with long, jagged fingernails and thick, discolored toenails. The resident's comprehensive care plan did not adequately address the level of assistance required for grooming and personal hygiene, including routine nail care. Staff interviews revealed that the resident's nails had not been trimmed since admission, and the responsibility for nail care was not clearly defined among the staff. The DON and the Administrator confirmed that the resident was dependent on staff for nail care and that the issue should have been addressed prior to the surveyor's observation.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to establish and maintain safe resident smoking practices as per their Policy & Procedure (P&P) Smoking Policy-Resident. Two residents were observed smoking on the patio without staff supervision, which is against the facility's policy that requires staff to monitor residents during smoking breaks and to collect smoking paraphernalia afterward. The Director of Nursing (DON) confirmed that residents should not be smoking unsupervised and should not have cigarettes and lighters in their possession without staff oversight. The Activity Assistant (AA), who was responsible for monitoring the smoke breaks, was unaware of how one resident obtained his cigarettes and lighter before the designated smoke break time. Resident 1, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and asthma, was observed smoking unsupervised and in possession of a cigarette box and lighter. His medical records indicated that he should smoke with supervision and use a smoking apron, which he often refused to wear. Despite his refusal, there was no reassessment for his smoking safety without the apron, and no care plan was developed for his smoking needs. Resident 2, who has a traumatic brain injury and severe cognitive impairments, also requires supervision while smoking. However, he was observed smoking unsupervised as well. The Activity Director (AD) confirmed that activity staff are responsible for monitoring residents during smoke breaks and that new residents are assessed for smoking safety during the admission process. However, the AD did not have copies of the smoking safety documents for Residents 1 and 2, as they were discarded after the residents were discharged. The DON verified that a smoking care plan for Resident 1 was missing and should have been developed within 14 days of his admission. The facility's policy mandates that residents with restricted smoking privileges must be directly supervised while smoking and are not allowed to keep smoking articles in their possession.
Failure to Ensure Resident Took Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) did not follow the facility's medication administration policy. The LVN left the resident's medications in his hand and exited the room without witnessing the resident take his medications. This resulted in the resident missing his 8:00 a.m. dose of medications, including muscle relaxers Metocarbonal and Cyclobenzaprine. During an observation, the resident was found lying in bed with several pills on his mattress, bedside table, and shoulder, indicating that he had not taken his medications as required. The LVN admitted to not ensuring that the resident swallowed his medications before leaving the room and acknowledged that the resident did not have a doctor's order to self-administer his medications. The Director of Nursing (DON) confirmed that the facility's procedure requires nurses to verify that medications are taken before leaving the room and that the resident had not been assessed for the cognitive ability to self-administer medications. The resident's medical records indicated a diagnosis of lower leg muscle contracture and a moderate cognitive impairment, with no orders to self-administer medications.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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