San Rafael Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 1601 5th Avenue, San Rafael, California 94901
- CMS Provider Number
- 055331
- Inspections on file
- 37
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at San Rafael Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with severe memory impairment and a history of wandering was able to leave the facility unsupervised, despite being identified as an elopement risk and wearing a wander management monitor. Staff did not hear any alarm from the monitor, and the resident was later found by a friend and taken to the responsible party's home. Required sign-out procedures were not followed, resulting in a lapse in supervision.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents experienced delays in call light response, with staff failing to answer requests for assistance in a timely manner, and one resident had a Foley catheter drainage bag left uncovered, contrary to facility policy. Staff interviews confirmed that all staff were responsible for prompt call light response and for maintaining resident privacy and dignity, but these expectations were not met.
A nurse left a medication intended for a resident with dysphagia, who receives tube feedings, unattended on the overbed table. The resident confirmed that staff sometimes leave medications at the bedside, and the Director of Staff Development acknowledged this was a safety issue, as facility policy prohibits leaving medications unattended due to the risk of access by confused residents.
Surveyors found that two toothbrushes in a shared bathroom were not labeled with resident names, contrary to facility policy, creating the potential for accidental use by the wrong individual. Additionally, a resident's Foley catheter tubing was observed touching a contaminated fall mattress, which staff confirmed was against infection control procedures. These failures were verified through staff interviews and review of facility policies.
The facility did not report an alleged sexual abuse incident between two residents to the required authorities within the mandated two-hour timeframe. Staff interviews revealed inconsistent knowledge of abuse reporting guidelines, and the facility's abuse policy had not been updated to reflect current regulations, contributing to the delay and confusion.
Multiple residents were found without access to their call light systems, with devices placed out of reach in locations such as dressers, drawers, and clipped to curtains. Staff, including LNs, the SSD, and the RD, confirmed the inaccessibility of the call lights and acknowledged that they should have been within easy reach, as required by facility policy.
A resident with chronic pain and a stage IV pressure ulcer, who was on hospice care, did not receive a pain reassessment within one hour after receiving morphine as required by facility policy. Instead, the LPN assessed the resident's pain nearly three hours later, at which time the resident continued to report significant pain. The DON confirmed that the pain reassessment policy was not followed.
Several residents and their families were not informed prior to admission that physical therapy would be provided via telehealth and limited to one or two sessions per week. The facility relied on remote therapists due to staffing shortages, and staff changed therapy recommendations to match what could be provided. Residents expressed disappointment and some declined therapy after learning of the telehealth format, while documentation and interviews confirmed that neither residents nor hospital case managers were made aware of these limitations before admission.
A resident with dementia and anxiety disorder suffered two falls, the second resulting in serious fractures, after the facility failed to implement and document care plan interventions such as PT, frequent room checks, and objective monitoring of behaviors and medication side effects. Nursing and therapy interventions were not consistently ordered or recorded, and staff could not provide evidence of required monitoring in the medical record.
A facility failed to notify the LTC Ombudsman of a resident's transfer to an emergency department, as required by regulations. The Social Services Director and Director of Nursing acknowledged the oversight, citing the newness of the regulation. The Medical Record Director confirmed the lack of documentation. The All Facilities Letter mandates such notifications to protect resident rights.
A resident was prescribed an anti-anxiety medication without first attempting non-pharmacologic interventions or monitoring for side effects and adverse drug reactions. Facility staff confirmed the importance of these steps, but the resident's records showed no evidence of such actions.
A resident did not receive scheduled medications on time, with significant delays noted in administration. Additionally, a CNA was observed lying in a resident's bed and using a personal cellphone, actions that were against the facility's policies. Both incidents were confirmed by facility administrators.
A resident with diabetes received insulin on multiple occasions despite having blood sugar levels below the prescribed threshold of 120. An LVN administered insulin when the resident's blood sugar was 74, leading to symptoms of low blood sugar. The DON confirmed a pattern of inappropriate insulin administration, and the facility's policy required adherence to physician orders and proper assessment of blood sugar levels.
The facility failed to properly label and store medications, supplements, and supplies, leading to several deficiencies. A resident had a prescription medication at their bedside without an order, and an LVN left medication bubble packs unattended. Used topical medications lacked caps, and wound dressings were found open and unlabeled. Expired syringes were in the emergency cart, and the medication refrigerator was not at the correct temperature. Expired medications were found in a cart, and unsecured medication was at a resident's bedside, posing potential risks.
The facility failed to store food in safe and sanitary conditions, with unlabeled and uncovered cucumbers in the kitchen refrigerator and expired items in the emergency food storage area. The Dietary Manager confirmed the lack of labeling and dating, which is required by facility policy and the FDA Food Code to prevent food-borne illnesses.
A resident with COPD was unable to reach her call light, which was tied to the bed rail and hanging off the bed. The DON confirmed the call light should be within reach, and an OT noted it should be placed on her lap due to limited arm motion. The facility's policy requires residents to have a means of contacting staff, which was not followed.
A resident was moved to a different room without prior written notification, as required by the facility's policy. The resident was instructed to move by staff without any advance notice, and the facility's Administrator confirmed the oversight. The resident's Electronic Health Record lacked documentation of the room change notification.
A resident reported that the shower water never stayed warm. An observation with the Maintenance Director showed the water temperature was 90°F, below the required 110°F as per facility policy. This failure resulted in the resident not receiving a comfortable shower.
The facility failed to notify the ombudsman of the transfer of a resident to the hospital and the discharge of another resident to home, as required by their policy. The Director of Medical Record and Assistant Administrator confirmed the lack of notification, and the facility's ombudsman was not informed of these events.
A resident admitted with PTSD, anxiety disorder, and major depressive disorder did not have their Level I PASRR reassessed by the facility, leading to potential gaps in mental health services. Additionally, the resident's MDS inaccurately indicated an active diagnosis of viral hepatitis, despite no treatment orders, resulting in incorrect data transmission to CMS.
The facility failed to develop a fall care plan for a resident with a history of multiple falls and a physical therapy care plan for another resident requiring rehabilitation services. Despite the facility's policies, these care plans were not initiated, leaving the residents without necessary interventions.
A resident with spinal stenosis and failure to thrive was not provided timely feeding assistance, as observed on two occasions with untouched lunch trays. The resident was nonverbal and unable to feed himself, requiring assistance that was delayed due to staff workload. The facility's policy on accommodating residents' needs was not followed, risking potential weight loss.
A resident admitted for rehabilitation services did not receive ordered physical therapy from mid-January to mid-March due to staff unavailability. This oversight, confirmed by the Director of Rehabilitation and facility administrators, left the resident frustrated with her recovery progress.
A facility failed to label an enteral feeding bottle, pump bag, and syringe for a resident, risking cross-contamination. The resident, admitted with a gastrostomy malfunction, had specific physician orders for enteral feeding. The facility's policy required labeling with the date and time, which was not followed, leading to a deficiency.
An LVN failed to properly prime a Lantus insulin pen before administering it to a resident with diabetes mellitus type 2. The LVN incorrectly primed the pen before attaching the needle, contrary to the guidelines, which require priming with the needle attached to ensure an accurate dose. This oversight was confirmed by the DON and had the potential to compromise the medication dose.
A LTC facility was found to have a medication error rate of 8.33%, exceeding the acceptable threshold. Errors included administering Losartan without checking blood pressure, giving Insulin Glargine without a current blood sugar reading, and failing to administer Metoprolol due to pharmacy unavailability without notifying the physician. These actions were against the facility's policies and had potential health implications for the residents.
A resident admitted for rehabilitation services did not receive prescribed physical therapy from January to March due to staff unavailability. The resident, who had a shattered kneecap and broken femur, expressed frustration over the delay in recovery. Facility staff, including the DON and physician, were unaware of the missed treatments.
The facility failed to implement Enhanced Barrier Precautions (EBP) for three residents. A PTA assisted a resident with a chronic ulcer without wearing a gown, contrary to EBP requirements. An RNA repositioned another resident with a chronic wound and Foley catheter without a gown, unaware of the EBP status. Additionally, a resident with an open wound was not placed on EBP, and no sign was posted to inform caregivers of necessary precautions.
A resident with cognitive and physical impairments was found with black insects in her bed, despite previous reports to environmental services. The CNA and DON confirmed the presence of ants, and a housekeeper also observed the insects. The facility's housekeeping policy mandates a clean and sanitary environment to ensure resident safety.
A resident with multiple mental health diagnoses was moved to a different room without prior written notice to their responsible party (RP). The facility's policy requires advance notice and participation in such decisions, but the RP was informed only after the move. The Social Services Director cited safety concerns as the reason for the move.
A resident with Alzheimer's Disease and severe cognitive impairment eloped from the facility unsupervised due to the lack of a person-centered care plan addressing their wandering and elopement risk. Despite using a Wander Management Monitor, no care plan was documented, and staff interviews confirmed previous elopement attempts. The CNA at the front desk did not notice the resident leaving or hear the door alarm.
A resident with Alzheimer's Disease and severe cognitive impairment eloped from the facility without staff knowledge. Despite having a Wander Management Monitor, the resident left through the front door and was returned by a neighbor after 15 minutes. The facility lacked a documented care plan for the resident's elopement risk, and staff failed to notice the departure or hear the door alarm, indicating inadequate supervision.
A resident with end-stage renal disease experienced deficiencies in dialysis care management, including the lack of a physician's order for dialysis, failure to include the dialysis schedule in the care plan, and issues with transportation leading to missed or shortened sessions. Facility staff did not document missed appointments or notify the physician, and there was confusion about the resident's schedule and transportation arrangements.
The facility failed to validate the competencies of registry nurses, risking resident care by potentially unqualified staff. The DON could not provide a registry nurse's competency evaluation, as records were with the staffing agency. The Administrator was unaware of the agency's evaluation process, and the facility's policy did not cover registry staff.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A resident with a diagnosis of toxic encephalopathy and severe memory impairment was admitted to the facility and identified as being at risk for elopement due to mental confusion and memory loss. The resident's care plan included the use of a wander management monitor, which was documented as being in place and functioning. Physician orders specified that the resident could only leave the facility with supervision. Despite these measures, the resident was able to leave the facility unaccompanied, walk several busy streets, and was eventually found by a friend who transported him to his responsible party's home. Staff interviews revealed that the resident was last seen in the facility's lobby and was discovered missing when a nurse checked on him for dinner. Neither the nurse nor the CNA assigned to the resident heard the wander management monitor alarm. The resident was still wearing the monitor when he arrived at his responsible party's home, and it was later removed with scissors. Facility policy required residents or their responsible persons to notify a licensed nurse and sign out when leaving on a pass, but this procedure was not followed. The failure to provide adequate supervision and ensure the effectiveness of the wander management system resulted in the resident's unsupervised departure from the facility.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Timely Call Light Response and Privacy for Residents
Penalty
Summary
Two residents experienced failures related to respect, dignity, and the right to personal property. One resident, who was dependent on staff for toileting and personal hygiene due to chronic pain syndrome and functional quadriplegia, had a call light activated for assistance. Multiple staff members were observed passing by the call light without responding, and the resident reported previous instances of waiting for hours for assistance, sometimes resorting to yelling without receiving help. Staff interviews confirmed that answering call lights was the responsibility of all staff and should occur within a few minutes, but this expectation was not met. Another resident, admitted with dysphagia and requiring assistance with personal care, also reported waiting between 30 minutes to an hour for staff to answer her call light. She described the experience as frustrating and disrespectful. Staff and facility leadership confirmed that the facility's policy required call lights to be answered promptly, typically within 2 to 3 minutes, and that delays beyond 10 minutes were unacceptable. Additionally, the first resident was observed with a Foley catheter drainage bag that did not have a privacy cover, contrary to facility policy. The resident stated that staff never placed a cover on the drainage bag and was unaware if the facility had any. Staff interviews confirmed that covering the drainage bag was required to protect privacy and dignity, and failure to do so could cause residents to feel humiliated or undignified. Facility policies reviewed also emphasized the importance of prompt call light response and maintaining resident privacy and dignity.
Medication Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a nurse left a whitish watery medication, intended for a resident with dysphagia who receives nutrition and medication via feeding tube, unattended on the resident's overbed table. The resident confirmed that the medication was left by the nurse and stated that staff sometimes leave medications at her bedside or overbed table. Observations confirmed the medication and a syringe were left unattended, and the nurse acknowledged that this was against facility policy due to safety concerns, especially given the presence of confused residents who wander and could access the medication. The Director of Staff Development verified that the medication was left unattended and confirmed it was a safety issue. Facility policy requires that medications, once removed from their packaging, should be administered safely or disposed of according to the medication destruction policy, and that bedside medication storage is only permitted when it does not present a risk to confused residents. The failure to follow these procedures resulted in the medication being left in a location accessible to unintended persons.
Infection Control Deficiencies: Unlabeled Toothbrushes and Improper Catheter Care
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices affecting three out of five sampled residents. During observations, two toothbrushes were found in a shared bathroom without labels identifying which resident each belonged to. Unlicensed staff confirmed that the facility's policy requires toothbrushes to be labeled with resident names, especially when stored in shared spaces, to prevent confusion and accidental use by the wrong resident. The Director of Staff Development also verified that labeling is necessary for infection control and to ensure each resident uses their own toothbrush. Additionally, a resident with a Foley catheter was observed with the catheter tubing touching a fall mattress, which is considered a contaminated surface. Licensed nursing staff and unlicensed staff both acknowledged that facility policy prohibits catheter tubing from touching the floor or fall mattress due to the risk of contamination. The Director of Staff Development confirmed that such contact is unsanitary and could result in infection. A review of the facility's policies and procedures corroborated the requirements for labeling personal hygiene items and ensuring catheter tubing does not come into contact with contaminated surfaces. These lapses in following established infection control protocols were directly observed and verified by staff interviews, indicating a failure to maintain a safe and sanitary environment as required by federal regulations.
Plan Of Correction
F 880 F 880 F 880 F 880 SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes SAN RAFAEL HEALTHCARE & WELLNESS CENTER, LP's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to ensure residents are treated with respect and dignity, including the right to retain and use personal possessions, and to ensure call lights are answered promptly and catheter drainage bags are properly covered to maintain resident privacy and dignity. Corrective Action for Affected Residents: On 6/3/25, Resident 1's foley catheter drainage bag was immediately provided with a privacy cover. On 6/3/25, the Director of Nursing (DON) and DSD conducted one-on-one counseling with staff members who failed to respond to Resident 1's call light. The DON met with both Resident 1 and Resident 2 to address their concerns regarding call light response times and implemented immediate monitoring of call light response times for their rooms. Identifying other Residents having the Potential to be Affected: On 6/4/25, the DON and DSD conducted a facility-wide audit of all residents with foley catheters to ensure proper privacy covers were in place. A facility-wide assessment of call light response times was conducted for all residents from 6/4/25 to 6/6/25 to identify any additional concerns with call light response times. Measures put into place or Systemic Changes: The DON or designee will conduct in-service education for staff by 7/1/2025 on: • Call light response protocols and expectations for maximum response (promptly) • Proper use and importance of foley catheter privacy covers • Resident dignity and respect requirements • Staff accountability for responding to call lights regardless of assignment New processes implemented include: • Call light monitoring audit to track response times Plan to Monitor Performance: The DSD will conduct audits of call light response times and catheter privacy cover compliance weekly for 8 weeks, and monthly thereafter. Audits will include: • Random observations of call light response times • Review of call light monitoring audit data • Inspection of all catheter drainage bags for proper privacy covers & positioning • Interviews with residents regarding satisfaction with call light response times via audit tool The DON will analyze audit results and report findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly. The QAPI committee will review the effectiveness of interventions and make additional recommendations as needed until substantial compliance is achieved and maintained.
Failure to Timely Report Alleged Sexual Abuse and Update Abuse Reporting Policy
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving two residents within the required two-hour timeframe to the local ombudsman, the California Department of Public Health, and local law enforcement. The incident occurred when one resident inappropriately touched another resident, and the event was reported to the facility's dietary supervisor. However, the official report to the state was not sent until over three hours after the incident, exceeding the mandated reporting window. Both the Social Services Director and the Director of Staff Development confirmed that the report did not meet the two-hour guideline and acknowledged the importance of timely reporting for resident safety. Interviews with facility staff revealed a lack of consistent knowledge regarding abuse reporting guidelines. Licensed nurses and unlicensed staff provided varying answers about the appropriate authorities to notify and the required timeframe for reporting abuse allegations. Some staff believed that all abuse allegations should be reported within 24 hours, while others were unclear about when to involve law enforcement, indicating confusion about the current regulatory requirements. A review of the facility's abuse policy and procedure showed that it had not been updated to reflect the most recent reporting guidelines as outlined in the All Facilities Letter 21-26. The policy, last revised in 2014, did not fully align with current federal and state requirements for reporting suspected abuse, neglect, or exploitation, particularly regarding the two-hour reporting mandate for incidents involving abuse or serious bodily injury. This outdated policy contributed to the staff's inconsistent understanding and the facility's failure to report the incident in a timely manner.
Call Light System Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to four out of five sampled residents, as required by facility policy. During observations and interviews, it was found that one resident's call light was stored in a box on a dresser, and the resident was unaware of its location. Another resident was unable to reach her call light, which was clipped to a curtain out of her reach. A third resident did not know where her call light was, and it was confirmed to be attached to a curtain, making it inaccessible. The fourth resident's call light was found behind her, in a drawer on a dresser, and not within her reach while she was seated in a reclined chair. Staff members, including licensed nurses, the Social Services Director, and the Registered Dietician, confirmed during interviews that the call lights were not within reach of the residents and acknowledged that they should have been. The Director of Nursing also stated that it was her expectation for call lights to be easily accessible to residents and recognized that having them out of reach could pose a safety issue. A review of the facility's policy confirmed that call cords are to be placed within the resident's reach in their rooms.
Failure to Timely Reassess Pain After Medication Administration
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, a stage IV pressure ulcer, and on hospice care did not receive timely reassessment of pain following administration of pain medication. The resident's care plan required pain to be managed with both scheduled and PRN medications, and the facility's policy specified that pain intensity should be reassessed one hour after administration of pain medication. However, after the resident was given morphine for pain, the licensed nurse did not perform the required follow-up pain assessment within the one-hour timeframe. Instead, the nurse assessed the resident's pain nearly three hours after medication administration, at which time the resident continued to report pain, describing a sensation of having a ball inside her abdomen and rating her pain as a five while visibly grimacing and holding her abdomen. The nurse documented the follow-up assessment as "effective" despite the resident's ongoing pain. The DON confirmed that the facility's policy was not followed, as the reassessment should have occurred one hour after medication administration.
Failure to Inform Residents of Telehealth Physical Therapy and Limited Session Frequency
Penalty
Summary
The facility failed to fully inform residents about the nature and frequency of their physical therapy services prior to admission, specifically that therapy would be provided via telehealth and limited to one or two sessions per week. Multiple residents and their family members reported that they were not told about the telehealth format or the reduced frequency of therapy sessions before admission. Some residents expected in-person therapy and a higher frequency of sessions, as was communicated to them by hospital staff or based on their previous experiences in other facilities. The marketing director and staff involved in admissions did not consistently disclose these details, and there was no written consent for telehealth therapy; only verbal consent was obtained at the start of sessions. Observations and interviews revealed that the facility had been unable to hire a full-time physical therapist, resulting in reliance on telehealth services provided by therapists located remotely. The rehabilitation director confirmed that therapy was limited to one or two sessions per week due to staffing constraints, and that recommendations for more frequent therapy were changed to match what the facility could provide. Residents expressed disappointment and frustration with the telehealth format and the limited frequency, with some stating that their progress was slower than expected or that they were not making improvements. Two residents chose not to participate in physical therapy after learning it would be conducted via telehealth. Documentation reviews showed that initial therapy recommendations for higher frequency were altered by facility staff to reflect the reduced availability. Staff interviews confirmed that prospective residents and their families were not informed about the telehealth delivery or session limitations prior to admission, and that hospital case managers were also unaware. The facility's own policy emphasized residents' rights to be informed and participate in care planning, but this was not upheld in practice for the sampled residents.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
A resident with dementia and anxiety disorder, who was independently mobile prior to admission, experienced a fall resulting in a head laceration and hand skin tear. Following this incident, the care plan was updated to include interventions such as a PT consult, frequent room checks, and staff education on safety. However, the facility failed to implement and monitor these interventions effectively. Specifically, there was no physician's order for PT, and the resident did not receive PT services after the evaluation and plan of treatment were completed. Additionally, there was no documentation in the medical record to confirm that frequent room checks or monitoring interventions were conducted as required by the care plan. Nursing staff reported that rounding and monitoring of fall risk residents were performed, but these actions were not consistently documented in the resident's medical record or the electronic medical record system. The DON and DSD acknowledged that documentation of fall interventions should have been present but could not locate any records to support that monitoring was performed. Communication about monitoring was maintained on paper forms or communication sheets, which were not part of the official medical record, further contributing to the lack of evidence that interventions were carried out. The facility also failed to follow the consultant pharmacist's recommendation to objectively monitor and quantify behaviors and side effects related to the resident's psychoactive medication, lorazepam. The MAR only indicated whether a behavior was observed, without specifying which behaviors or side effects were being monitored, and there was no objective data collected. This lack of monitoring and documentation contributed to the resident experiencing a second fall, resulting in a left intertrochanteric hip fracture and a T3 vertebral fracture, which significantly reduced the resident's mobility.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care Ombudsman for one of the sampled residents. This deficiency was identified during interviews and record reviews, where it was found that there was no evidence of the notice being sent when the resident was transferred to an emergency department. The Social Services Director acknowledged that a notice of transfer form should have been completed and sent to the Ombudsman to protect the resident's rights. The Director of Nursing confirmed the oversight, attributing it to the regulation being relatively new. The Medical Record Director also verified the absence of documentation indicating that the Ombudsman was notified. The All Facilities Letter AFL-17-27, effective from January 1, 2018, mandates that LTC facilities notify the local LTC Ombudsman at the same time notice is provided to the resident or their representatives when a transfer or discharge occurs, including emergency transfers to a general acute care hospital.
Failure to Implement Non-Pharmacologic Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident was prescribed an anti-anxiety medication without implementing non-pharmacologic interventions to address the resident's behavior. Additionally, there was no monitoring of the resident's behavior, response to the medication, or monitoring for side effects and adverse drug reactions. This lack of monitoring and absence of non-pharmacologic interventions put the resident at risk of side effects and adverse drug reactions related to the psychotropic medication use. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, confirmed that non-pharmacologic interventions should be attempted first before administering psychotropic medications. They also emphasized the importance of monitoring the resident's behavior and any side effects or adverse drug reactions when on such medication. However, the resident's electronic medical record did not indicate any such monitoring or interventions were in place, which was verified by the Director of Nursing.
Medication Administration and Staff Conduct Deficiencies
Penalty
Summary
The facility failed to ensure that Resident 54 received scheduled medications in a timely manner. During an observation and interview, it was noted that Resident 54 received her medications, including ibuprofen, docusate, multivitamin, and ascorbic acid, significantly later than scheduled. The medications were supposed to be administered at 8 a.m. and 9 a.m., but were not given until 11:42 a.m. This delay was confirmed during a review of the Medication Admin Audit Report and acknowledged by the Administrator, who stated that medications should be administered within an hour of the scheduled time. The facility's policy on medication administration supports this standard. Additionally, the facility failed to maintain professional standards of conduct when CNA 1 was observed lying in Resident 37's bed and using a personal cellphone. This incident occurred while Resident 37 was in the dining room for lunch. The Director of Nursing and the Administrator both confirmed that staff should not use personal cellphones in patient care areas and should not be in residents' beds. The facility's policy on employee conduct prohibits malingering on the job and the use of personal communication devices in resident care areas.
Insulin Administered Despite Low Blood Sugar
Penalty
Summary
The facility failed to ensure that insulin was not administered to a resident when their blood sugar was below the target range of 120. This deficiency was observed in one of the sampled residents, who received insulin on 10 out of 19 days in March 2025 despite having blood sugar levels below 120. On March 19, 2025, a Licensed Vocational Nurse (LVN) administered 15 units of Insulin Glargine to the resident when their blood sugar was 74, contrary to the physician's order to hold insulin if blood sugar was less than 120. The resident was later observed to be sweating and lethargic, symptoms indicative of low blood sugar. The Director of Nursing (DON) confirmed that there was a pattern of insulin administration when the resident's blood sugar was below 120 on multiple days in March. The facility's policy and procedure for medication administration required that medications be administered as prescribed, with necessary tests performed and results recorded. The pharmacist stated that the standard practice was for nurses to assess blood sugar levels before administering insulin and to follow the physician's orders. The failure to adhere to these protocols resulted in the administration of insulin when it was not required, potentially leading to low blood sugar symptoms in the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, supplements, and supplies, leading to several deficiencies. A prescription nystatin powder was found on a resident's bedside table without an order to keep it there, and the resident had obtained it from an outside pharmacy due to insurance issues. Additionally, two medication bubble packs were left unattended on top of a medication cart by an LVN, which was confirmed by the Director of Nursing (DON) as a breach of protocol. Further observations revealed that two used topical medications in the treatment cart lacked caps, and a collagen matrix dressing and Xeroform gauze dressing were found open and unlabeled. The Infection Preventionist confirmed these items should have been discarded or properly labeled. Moreover, five expired syringes with needles were discovered in the emergency cart, and the medication refrigerator was not maintained at the correct temperature, with no interventions documented for the out-of-range temperatures. Expired medications were also found in one of the medication carts, and unsecured medication was observed at the bedside of a resident. The DON confirmed that medications should not be left at the bedside, as it poses a risk of another resident taking them. These deficiencies indicate a failure to adhere to the facility's policies and procedures regarding medication storage and safety, potentially leading to adverse clinical outcomes.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored in safe and sanitary conditions, as observed in the kitchen refrigerator and the Dry Food Storage Area. During an inspection, it was found that seven cucumbers were left uncovered and undated in the kitchen refrigerator. Additionally, individual-packed Italian dressings and yellow mustards in the Dry Food Storage Area were not labeled with received or expiration dates. The Dietary Manager (DM) confirmed that the expectation was for all food to be labeled and dated to prevent cross-contamination and food-borne illnesses. The facility's policy and procedure, as well as the 2022 FDA Food Code, require that all food items be labeled and dated to ensure safety. In the emergency food storage area, six gelatin boxes and six cans of three-bean salad were found to be expired and not labeled with received or expiration dates. The DM acknowledged that these items were expired and not safe for consumption, which could lead to food-borne illnesses. The DM also stated that she was solely responsible for restocking and checking the emergency food storage area. The facility's policy and procedure mandates that all canned and dry storage products be labeled and dated, which was not adhered to in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light for one of the residents was within her reach, which had the potential for her needs not being met. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was observed lying in bed with her call light tied to the left bed rail and hanging off the bed, making it unreachable for her. During an interview, the resident confirmed that she could not reach the call light and used it to call for assistance. The Director of Nursing (DON) also confirmed the call light's location and acknowledged that it should be within the resident's reach. An Occupational Therapist (OT) further stated that due to the resident's limited range of motion with her arms, the call light should be placed on her lap in front of her. The facility's policy and procedure on the communication call system indicated that residents should have a means of contacting staff for assistance, which was not adhered to in this case.
Failure to Notify Resident of Room Change
Penalty
Summary
The facility failed to provide a written notification to a resident regarding a room or roommate change, as required by their policy. The resident reported waking up to multiple male staff members instructing her to move to a different room without prior notification. The facility's Administrator confirmed that the resident's room was changed in June 2023, and acknowledged that the resident should have been notified in advance. A review of the resident's Electronic Health Record did not show any bed change notification, and the facility's policy mandates that residents receive timely advance written notice of room changes, including the reasons for such changes.
Inadequate Shower Water Temperature for Resident
Penalty
Summary
The facility failed to ensure a comfortable shower experience for a resident due to inadequate water temperature. During an interview, the resident reported that the shower water never stayed warm. An observation and interview with the Maintenance Director in the Spa Shower Room revealed that the shower's hot water temperature was only 90 degrees Fahrenheit after three minutes, whereas it should have been 110 degrees Fahrenheit according to the facility's policy. The facility's policy, dated January 2, 2012, indicated that water temperatures should be maintained at levels suitable to meet residents' needs.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the ombudsman of the transfer and discharge of two residents, which is a requirement according to their policy. Resident 58 was transferred to the hospital due to a fever and possible sepsis, but there was no documented evidence that the ombudsman was notified of this transfer. The Director of Medical Record confirmed the lack of notification, and the Director of Nursing and Director of Social Services were unaware of the requirement to notify the ombudsman for hospital transfers. The facility's ombudsman also confirmed that she was not notified of Resident 58's transfer. Similarly, Resident 59 was discharged home, but again, there was no documented evidence that the ombudsman was notified. The Assistant Administrator confirmed this oversight, and the facility's ombudsman stated she was not informed of Resident 59's discharge. The facility's policy and procedure require notification of the ombudsman for transfers or discharges initiated by the facility, but this was not followed in these cases.
Inaccurate Assessment and Data Submission for Resident
Penalty
Summary
The facility failed to reassess and submit accurate data for a resident upon admission, which led to deficiencies in the resident's care plan. The resident, who was admitted with diagnoses of PTSD, anxiety disorder, and major depressive disorder, did not have their Level I PASRR reassessed by the facility. The initial PASRR assessment, completed by the discharging hospital, indicated a negative result, which did not reflect the resident's active mental health diagnoses. The facility's policy required a PASRR reassessment to ensure accurate screening for mental illness and intellectual disability, which was not conducted, potentially affecting the resident's access to necessary mental health services. Additionally, the facility transmitted inaccurate data to CMS due to errors in the resident's MDS. The MDS indicated an active diagnosis of viral hepatitis, despite the resident having no treatment orders for this condition. The resident was discharged from the hospital with a diagnosis of Chronic Hepatitis B, but the MDS should not have been coded for an active infection. The facility's failure to accurately code the MDS resulted in the transmission of incorrect data, as the CMS LTCF RAI 3.0 User's Manual specifies that only diseases with a direct relationship to the resident's current status should be coded as active.
Failure to Develop Care Plans for Fall Risk and Physical Therapy
Penalty
Summary
The facility failed to develop a fall care plan for a resident who was admitted with diagnoses of dementia, abnormalities of gait and mobility, and difficulty in walking. Despite having a history of multiple falls within the facility, there was no fall care plan in place to address the resident's high risk for falls. The Director of Nursing confirmed the absence of a fall care plan, which was contrary to the facility's Fall Management Program policy that requires the interdisciplinary team to initiate, review, and update the resident's fall risk status and care plan at specified intervals. Additionally, the facility did not develop a physical therapy care plan for another resident who was admitted with obesity and difficulty in walking, and who required rehabilitation services following a shattered kneecap and broken left femur. Despite physician's orders for physical therapy three times a week, there was no documented evidence of a physical therapy care plan. The facility's policy on Comprehensive Person-Centered Care Planning mandates the development of a comprehensive care plan within seven days from the completion of the comprehensive MDS assessment, which was not adhered to in this case.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely assistance with feeding for a resident who was unable to feed himself, leading to a potential risk of weight loss. The resident, who was admitted with diagnoses including spinal stenosis and failure to thrive, was observed on two separate occasions with an untouched lunch tray on his bedside table. The resident was nonverbal and unable to move his arms or hands to feed himself, indicating a clear need for assistance. During an interview, the Director of Nursing confirmed that the resident required feeding assistance and should not have been left waiting. A Certified Nursing Assistant also acknowledged that the resident had to wait for feeding assistance due to having multiple residents to care for. The facility's policy on accommodating residents' needs was not adhered to, as the resident's individual needs for feeding assistance were not met in a timely manner, despite a registered dietitian's note specifying the need for one-on-one assistance with meals and snacks as part of a weight loss intervention plan.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide necessary physical therapy services to a resident, identified as Resident 9, who was admitted with diagnoses of obesity and difficulty in walking, following a shattered kneecap and a broken left femur. Despite physician's orders for physical therapy three times a week for four weeks, the resident did not receive these services from January 14, 2025, to March 16, 2025, due to the unavailability of physical therapy staff. This lack of service led to Resident 9 feeling frustrated about her recovery progress, as she was in the facility primarily for rehabilitation services. Interviews with the Director of Rehabilitation, Director of Nursing, and the attending physician revealed that none were aware of the lapse in physical therapy services for Resident 9. The facility administrators also confirmed the oversight and acknowledged that the physician should have been notified about the missed treatments. The deficiency was identified through a review of the resident's records and interviews, which confirmed the absence of documented attempts to provide the ordered physical therapy during the specified period.
Failure to Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to properly label an enteral feeding bottle, pump bag, and syringe for a resident, which could lead to cross-contamination. During an observation, it was noted that a bottle of Glucerna 1.5, an enteral feeding pump bag containing a clear liquid, and a syringe were hanging on a pole in the resident's room without labels or dates. The Director of Staff Development confirmed that these items should have been labeled with the resident's name, room number, and the expiration date of the enteral feeding. The resident involved had been admitted with a diagnosis of gastrostomy malfunction. The physician's orders indicated specific instructions for changing the enteral tubing and syringe daily and administering Glucerna 1.5 at a specified rate and duration. The facility's policy required labeling of the bag and tubing with the date and time hung, with a hang time of no more than 24 hours. The failure to adhere to these labeling protocols was identified as a deficiency during the survey.
Improper Priming of Insulin Pen by LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly primed a Lantus insulin pen before administering it to a resident diagnosed with diabetes mellitus type 2. During a medication administration observation, the LVN removed the cap of the Lantus insulin pen, turned the dial, and pressed the injection button before attaching and screwing the needle onto the pen. The LVN incorrectly stated that the pen needed to be primed before attaching the needle, which contradicts the proper procedure outlined in the Lantus SoloStar pen guidelines. The Director of Nursing confirmed that the correct procedure involves priming the insulin pen with the needle already attached. The guidelines specify that after attaching the needle, a safety test should be performed by dialing a test dose, holding the pen with the needle pointing up, and lightly tapping the insulin reservoir to allow air bubbles to rise to the top. This ensures an accurate dose is administered. The failure to follow these steps had the potential to compromise the medication dose given to the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of 8.33%. Three specific medication errors were identified during the survey. The first error involved the administration of Losartan Potassium to a resident without checking their blood pressure beforehand, despite the medication label indicating it should be held if the systolic blood pressure (SBP) was less than 110. The Licensed Vocational Nurse (LVN) confirmed that the blood pressure was not checked prior to administration, which was against the facility's policy and procedure. The second error involved the administration of Insulin Glargine to the same resident without obtaining a current blood sugar reading. The LVN administered the insulin based on a previous shift's blood sugar result of 74, which was below the threshold of 120 indicated in the medication order. The LVN acknowledged the mistake and confirmed that insulin should not have been administered under these conditions. This was also contrary to the facility's policy, which required blood sugar monitoring before insulin administration. The third error occurred when Metoprolol Succinate ER was not administered to the resident as per the physician's order because it was unavailable from the pharmacy. The LVN did not notify the physician about the unavailability of the medication. This oversight was a violation of the facility's policy, which mandates that medications be administered as prescribed. These errors had the potential to result in adverse health outcomes for the residents involved.
Failure to Provide Prescribed Physical Therapy
Penalty
Summary
The facility failed to provide physical therapy treatment as ordered by a physician for a resident who was admitted with a shattered kneecap and a broken left femur. The resident was in the facility primarily for rehabilitation services but had not received physical therapy from January 14 to March 16, despite having physician's orders for therapy three times a week. The Director of Rehabilitation confirmed the lack of documented evidence of attempts to provide the therapy during this period, citing the unavailability of physical therapy staff as the reason. Interviews with the resident, the Director of Nursing, the physician, and the facility administrators revealed that none were aware of the missed physical therapy treatments. The resident expressed frustration over the lack of therapy, which she believed was delaying her recovery and her ability to walk enough to return home. The physician and administrators acknowledged that the resident was in the facility for rehabilitation and should have been receiving the prescribed therapy.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control practices for three residents who were on Enhanced Barrier Precautions (EBP). For Resident 7, a Physical Therapist Assistant (PTA) was observed assisting the resident without wearing a gown, despite the resident being on EBP due to a chronic ulcer and a history of MSSA. The PTA's clothes came into contact with the resident's bedsheets, and the PTA stated that she was informed by a nurse that only gloves were necessary. The facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines require the use of gowns and gloves during such interactions. Similarly, for Resident 55, a Restorative Nursing Assistant (RNA) was observed repositioning and changing the resident's blanket without wearing a gown, even though the resident was on EBP due to a chronic wound and a Foley catheter. The RNA was unaware of the EBP status and acknowledged the need for a gown during high-contact care. The Infection Preventionist confirmed that the RNA should have worn a gown, as per the facility's infection control policy. Additionally, Resident 1, who had an open wound and required daily dressing changes, was not placed on EBP. There was no EBP sign posted outside the resident's room, which was verified by both a Registered Nurse and the Infection Preventionist. The facility's policy mandates posting EBP signs for residents with open wounds to inform caregivers of the necessary precautions. This oversight was contrary to the guidelines outlined in the facility's infection prevention and control manual and the All Facilities Letter from the California Department of Public Health.
Insect Infestation in Resident's Bed
Penalty
Summary
The facility failed to maintain a sanitary environment for one of the sampled residents, identified as Resident 3, who was observed with black insects crawling in her bed. Resident 3, who was admitted with diagnoses including cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness, was found lying in bed with tiny black insects scattered around the bed linens and on her legs. A Certified Nursing Assistant (CNA) confirmed that Resident 3 was dependent on all care and had difficulty communicating her needs. The CNA mentioned that this issue had been reported to environmental services a couple of months ago. The Director of Nursing (DON) also observed the insects and identified them as ants. A housekeeper confirmed seeing the insects in Resident 3's room on the same day. The facility's housekeeping policy, dated 1/1/12, requires the facility to be clean and sanitary at all times to promote the health and safety of residents.
Failure to Notify Resident's Responsible Party of Room Change
Penalty
Summary
The facility failed to provide a written notice to the responsible party (RP) of a resident before moving the resident to a different room. The resident, who was admitted to the facility with diagnoses including autistic disorder, anxiety disorder, and schizoaffective disorder bipolar type, was moved without prior notification to the RP. The room change notification indicated that the RP was notified after the move had already occurred, and the care plan was not updated at the time of the move. The facility's policy requires that residents and their representatives receive timely advance written notice of room changes, including the reasons for the change. Interviews revealed that the resident's RP was not informed of the room change until after it had been completed. The Social Services Director stated that the move was necessary for the safety of the resident and his roommate, as the resident was interfering with the roommate's belongings and personal space. However, the RP confirmed that she was not consulted or given the opportunity to participate in the decision-making process prior to the move, which is a violation of the resident's rights as outlined in the facility's policy.
Failure to Implement Care Plan for Resident's Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with Alzheimer's Disease, who was at high risk of elopement. Despite the resident's severe cognitive impairment and use of a manual wheelchair, the facility did not initiate a care plan addressing the resident's wandering and elopement risk. This oversight was evident when the resident eloped from the facility unsupervised, as documented in the facility's records and confirmed by staff interviews. The resident's records indicated the use of a Wander Management Monitor, but there was no documented care plan for elopement risk prior to the incident. Interviews with the Director of Nursing and the Administrator revealed that the resident had attempted to leave the facility before, yet no care plan was in place. The Certified Nursing Assistant assigned to the front desk did not notice the resident leaving and did not hear the door alarm, further highlighting the lack of adequate supervision and care planning for the resident's safety needs.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident with Alzheimer's Disease, resulting in the resident eloping from the facility without staff knowledge. The resident, who had a severe cognitive impairment and used a manual wheelchair for mobility, was admitted to the facility in January 2024. Despite having a Wander Management Monitor (WMM) ordered to be placed on the resident's wrist in October 2024, the resident managed to leave the facility unsupervised on February 10, 2025. The resident was returned to the facility by a neighbor after being outside for approximately 15 minutes. Interviews and record reviews revealed that the facility did not have a documented care plan addressing the resident's risk of elopement, even though the resident had attempted to leave the facility in the past. The Director of Nursing confirmed the elopement incident, and the Administrator acknowledged that the front door was the only accessible exit for the resident. The Certified Nursing Assistant assigned to the front desk did not notice the resident leaving and did not hear the door alarm, indicating a lapse in supervision and monitoring. The facility's policy on wandering and elopement was not effectively implemented, as staff failed to prevent the resident's departure or follow the resident to ensure safety until assistance arrived.
Deficiencies in Dialysis Care Management
Penalty
Summary
The facility failed to manage the dialysis care for a resident with end-stage renal disease, as evidenced by several deficiencies in their care processes. The staff did not obtain a physician's order for the resident's dialysis, which is crucial for ensuring that the resident's dialysis schedule is accurately reflected in their care plan and medication administration record. This oversight meant that the resident's dialysis schedule was not included in their care plan, leading to confusion about the resident's treatment schedule. Additionally, the facility failed to ensure timely transportation for the resident to their dialysis appointments. The resident was either transported late or not at all, resulting in missed or shortened dialysis sessions. The facility did not document these missed appointments or notify the resident's physician, which is essential for maintaining continuity of care and ensuring that the resident's health needs are met. The lack of documentation and communication could potentially leave the resident's healthcare providers unaware of the frequency and reasons for missed dialysis sessions. Interviews with facility staff revealed a lack of clarity and responsibility regarding the resident's dialysis schedule and transportation arrangements. The Social Services Director and MDS Nurse were unsure of the resident's dialysis schedule and did not ensure it was accurately documented in the electronic medical record. Furthermore, the facility's policy on dialysis management was not followed, as documentation concerning dialysis services was not maintained in the resident's medical record, and there was no system for scanning assessments into the electronic record.
Failure to Validate Competencies of Registry Nurses
Penalty
Summary
The facility failed to establish a system for validating the competencies of registry nurses, which could lead to residents being cared for by nurses lacking necessary skills for safe care. During an interview, the Director of Nursing (DON) was unable to provide the personnel file of a registry nurse involved in a reported incident, as the records were held by the staffing agency. Despite requests, the competency evaluation of the nurse was not obtained, and the DON was unaware of how the agency evaluated the nurses' skills. The Administrator confirmed that their contract with the staffing agency assumed the nurses had the required skills, but he was not familiar with the agency's evaluation process. The facility's policy on staff competency assessment did not include registry staff, and a specific policy for registry nurses was not provided. The lack of documentation and understanding of the evaluation process led to uncertainty about the competency of registry nurses working in the facility.
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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