Shafter Nursing Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Shafter, California.
- Location
- 140 East Tulare Avenue, Shafter, California 93263
- CMS Provider Number
- 056035
- Inspections on file
- 53
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Shafter Nursing Care during CMS and state inspections, most recent first.
The facility failed to ensure an RN was on duty for 8 consecutive hours a day, 7 days a week. Review of staffing sign-in sheets showed no RN available for a consecutive 8-hour shift on multiple dates, and the DSD confirmed there was no RN present in the building for 8 hours on those days. The facility policy stated that F727 requires an RN onsite at least 8 consecutive hours daily.
A resident’s quarterly MDS incorrectly listed Depression and Schizophrenia as active diagnoses even though the DI did not document either diagnosis. During record review, the MDSC confirmed the resident had no active diagnosis of Depression or Schizophrenia and was not taking medication for either condition, and stated the assessment was not completed accurately before submission.
A resident's lunch tray was prepared with spinach even though the resident's meal ticket listed spinach as a disliked food. During tray line, an aide confirmed the tray was ready for delivery and stated she had not noticed the spinach and should have removed it. The facility policy stated resident food preferences would be adhered to within reason and disliked foods would be substituted from the appropriate food group.
Hand hygiene was not offered to two residents before lunch trays were delivered, including one resident who was cognitively intact and stated he had not received hand hygiene. In the kitchen, a cook was observed handling food with an uncovered beard while checking food temperatures, despite the facility’s dress code requiring a beard restraint.
A resident’s responsible party was informed by phone by an SSD that the resident would be discharged to a room and board setting but did not receive or sign the written Notice of Medicare Non-Coverage (NOMNC), did not fully understand the notice, and was not informed of appeal rights. Review of the NOMNC showed no representative signature, and although an alternate delivery form indicated phone notification, there was no documentation that the responsible party verbalized understanding of the NOMNC or was advised of the option to appeal.
The facility failed to ensure food was stored and dated properly, and maintained at safe temperatures, potentially leading to foodborne illnesses. Observations revealed unsealed and undated food items, and lasagna trays left at unsafe temperatures. The Dietary Supervisor and Certified Dietary Manager confirmed these lapses, which were against the facility's policies.
The facility failed to obtain informed consent for psychotherapeutic drugs for eight residents, as required by their policy. The VRIC forms lacked signatures from residents or their representatives, and interviews with the DON and MDSN confirmed this oversight. The facility's policy mandated informed consent before administering such medications, which was not adhered to.
The facility failed to have an RN on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews with the DSD, revealing numerous days from July to December 2024 where no RN was present for the required duration. The DSD confirmed the facility's non-compliance with their RN Staffing Coverage Policy, potentially impacting resident care.
The facility failed to complete Performance Evaluations for two CNAs, potentially impacting patient care. CNA 3 and CNA 4, hired in 2023 and 2021 respectively, did not have completed evaluations in their files. The facility's policy requires evaluations to provide feedback on job performance, which were not conducted, leaving CNAs unaware of areas needing improvement.
The facility failed to complete a quarterly MDS assessment for a resident, as confirmed by the MDS Nurse. The resident's admission MDS was completed, but the quarterly assessment due in October was overdue. Facility policy requires timely assessments, including quarterly ones, to be conducted every three months.
The facility failed to update the PASRR Level 1 screenings for two residents with serious mental illness diagnoses. A resident's PASRR from GACH was negative despite a history of Schizoaffective Disorder, Anxiety, and Depression, and the MDSN did not verify its accuracy. Another resident's PASRR was also negative, missing diagnoses of Schizophrenia and Schizoaffective Disorder, Bipolar Type. The DON acknowledged the error and the facility's responsibility to ensure accurate PASRR completion.
A resident at high risk for falls due to medical conditions was not provided with necessary footwear and was in a dimly lit environment, leading to a fall and a nondisplaced fracture of the right femur. The care plan required footwear to prevent slipping and a well-lit environment, but these interventions were not followed. Staff interviews confirmed the resident was barefoot at the time of the fall, and the necessary footwear could not be found.
The facility failed to develop discharge care plans for two residents, potentially leading to unmet care needs upon discharge. Despite the residents expressing their post-discharge preferences, the Director of Nursing confirmed that discharge care plans were not completed, contrary to the facility's policy.
A resident with severe cognitive impairment was financially abused by the Social Services Director (SSD) who used the resident's credit and debit cards without consent, resulting in over $6,500 in unauthorized charges. The facility lacked a policy to protect vulnerable residents from financial exploitation, and the SSD impersonated the resident to access her accounts. Despite the resident's inability to manage her finances, the facility failed to prevent this abuse.
A facility failed to report a financial abuse allegation involving a resident to the CDPH within 24 hours and did not conduct a thorough investigation within five business days. The SSD impersonated the resident to reset her bank pin, and the police were involved due to credit card fraud concerns. Despite these events, the SSD, DON, and Administrator did not report the abuse allegation to the CDPH, violating the facility's policy on abuse investigation and reporting.
The facility failed to conduct required reference checks for an LVN and a CNA before their hire dates, as per their abuse prevention policy. This oversight was identified during interviews and record reviews, where it was found that the employee files lacked documented reference checks. The Director of Staff Development acknowledged the incomplete files, which could potentially place residents at risk for abuse.
The facility failed to administer a resident's Percocet within the ordered time frame, resulting in a delay of 59 minutes beyond the allowed parameter. The DON confirmed the medication should have been administered and documented by 1:00 p.m., but it was given at 1:59 p.m.
RN Not On Duty for Required 8 Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week. During interview and record review with the Director of Staff Development, the facility's Nursing Staffing Assignment and Sign-In Sheets showed that no RN was available to work a consecutive 8-hour shift on 1/17/26 and 1/24/26 in January 2026, and no RN was available to work a consecutive 8-hour shift on 12/24/25 in December 2025. The Director of Staff Development stated there was no RN present in the building for 8 hours a day on those dates. The facility policy titled RN Staffing Coverage Policy, dated 8/9/2016, stated that F727 requires nursing homes to have an RN onsite at least 8 consecutive hours a day, 7 days a week.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to accurately complete the quarterly MDS assessment for one resident. In the MDS dated 3/9/26, Section I listed active diagnoses in the last 7 days as Depression and Schizophrenia. However, the resident’s Diagnosis Information dated 3/9/26 did not contain documentation of either Depression or Schizophrenia. During a concurrent interview and record review on 4/9/26 at 9:35 a.m. with the MDS Coordinator, the resident’s MDS active diagnosis section was reviewed and the MDS Coordinator stated the resident did not have an active diagnosis of Depression or Schizophrenia and was not taking medication for either condition. The MDS Coordinator stated she did not complete the assessment accurately and should have reviewed it before submitting. The facility policy stated the resident assessment coordinator is responsible for ensuring timely and appropriate resident assessments, and that persons completing any portion of the MDS must sign attesting to the accuracy of the information.
Meal Preference Not Honored for Resident Who Disliked Spinach
Penalty
Summary
The facility failed to ensure meal preferences were honored for Resident 82. Resident 82's Meal Ticket dated 4/7/26 indicated a dislike for spinach. During a concurrent observation and interview in the kitchen, a dietary aide checked Resident 82's lunch tray during tray line and the tray was observed to contain Meatballs and Gravy, Penne pasta with Garlic & Herbs, Zesty Spinach, Fresh [NAME] Salad, and Chocolate Cake. The dietary aide stated the tray was ready to be delivered to Resident 82 and, after reviewing the Meal Ticket, stated she had not noticed the spinach on the tray and should have removed it because Resident 82 did not like spinach. The facility policy titled Food Preferences stated resident food preferences would be adhered to within reason and substitutes for disliked foods would be given from the appropriate food group.
Hand hygiene and beard restraint not followed
Penalty
Summary
Hand hygiene was not provided for two sampled residents before their lunch trays were given. Resident 19 had a BIMS score of 15 and was cognitively intact. During a concurrent observation and interview in Resident 19’s room, the resident was sitting up in bed eating lunch and stated that the CNA had not offered hand hygiene and that he would like his hands cleaned. When asked, CNA 1 stated she had not provided hand hygiene and said she should have offered it. In a concurrent observation and interview in Resident 86’s room, CNA 1 delivered the resident’s lunch tray and stated she had not provided hand hygiene before giving the tray and that she should have offered it. The facility policy titled Hand Hygiene During Mealtime stated that hand hygiene is offered to all residents prior to meal tray service and that staff must ensure residents clean their hands before trays are passed or meals are served. In the kitchen, one of two sampled cooks, Cook 1, was observed uncovering food to check the temperature while wearing a beard that was not covered with a beard restraint. During the interview, Cook 1 stated he should have been wearing a beard restraint while in the kitchen. The CDM stated the cook should have been wearing a beard restraint and that it was her expectation for all staff in the kitchen to use a hair or beard restraint. The facility’s DRESS CODE policy stated that if applicable, beards and mustaches must wear a beard restraint.
Failure to Provide and Document NOMNC and Appeal Rights for a Resident’s Responsible Party
Penalty
Summary
The facility failed to provide a resident’s responsible party with a written Notice of Medicare Non-Coverage (NOMNC), ensure understanding of the notice, and inform her of appeal rights prior to discharge. The responsible party reported that she received a phone call from the Social Service Designee (SSD) stating the resident was being discharged to a room and board setting. She stated she did not fully understand the NOMNC notice and was not given the option to appeal the decision, explaining that she simply complied with what she was told and did not know she had options. Record review with the SSD showed the NOMNC letter for the resident contained a line for the patient representative’s signature to indicate receipt and understanding, but there was no signature from the responsible party. The SSD stated that the responsible party was notified by phone of the NOMNC and that the option to appeal was not discussed because the responsible party was not opposed to discharge. A facility form titled “Optional Form to Document Alternate Delivery Notice of Medicare Non-Coverage” indicated the responsible party was notified by phone, with instructions to document that the representative verbalized understanding of the information. However, upon review of the clinical record, the SSD was unable to provide documentation that the responsible party verbalized understanding of the NOMNC notice.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure food was dated and stored under sanitary conditions, as well as maintained at safe temperatures, which could potentially result in foodborne illnesses for residents. During an observation, a container labeled peas was found with a cracked and unsealed lid, and an egg tray was open, uncovered, and undated. Additionally, a carton of Liquid Pasteurized eggs was opened without an open date, and corn salad bowls were undated. In the dry storage room, a plastic bag containing elbow macaroni was not labeled or dated, and a container of nonfat dry milk was not sealed. These observations were confirmed by the Dietary Supervisor, who acknowledged that the items should have been sealed and dated according to the facility's policies. The facility also failed to maintain food at safe temperatures. Lasagna trays were observed sitting on a shelf above the steam table with temperatures below the safe range. The Certified Dietary Manager confirmed that the lasagna trays should not have been left to cool off on a shelf. Additionally, peas were added to a resident's lunch plate without taking the temperature prior to plating. The facility's policy requires cooked potentially hazardous food to be cooled and reheated in a method to ensure food safety, which was not adhered to in these instances.
Failure to Obtain Informed Consent for Psychotherapeutic Drugs
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding informed consent for psychotherapeutic drugs for eight sampled residents. The policy required that an informed consent form, specifically the VERIFICATION OF RESIDENT INFORMED CONSENT FOR PSYCHOTHERAPEUTIC DRUGS (VRIC), be signed by the resident or their representative before administering such medications. However, the review revealed that none of the VRIC forms for the sampled residents contained the necessary signatures. This oversight was noted across various medications prescribed for conditions such as anxiety, schizophrenia, major depressive disorder, bipolar disorder, and insomnia. Interviews with the Director of Nursing (DON) and the Minimum Data Set Nurse (MDSN) confirmed the absence of signatures on the VRIC forms. The DON acknowledged that the facility did not have residents sign the VRIC forms, while the MDSN pointed out that the forms lacked a designated area for resident or representative signatures and for a nurse to witness the signature. The facility's policy, dated November 30, 2020, explicitly stated the requirement for obtaining informed consent prior to the administration of psychotherapeutic drugs, which was not followed, as confirmed by the Administrator.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews conducted with the Director of Staff Development (DSD) on multiple occasions. The review of the Nursing Staffing Assignment and Sign-in Sheets from July to December 2024 revealed numerous days where no RN was present for the required duration. The DSD confirmed the absence of an RN for the specified hours on these days, acknowledging the facility's non-compliance with their RN Staffing Coverage Policy. The facility's policy, dated August 9, 2016, mandates that an RN must be onsite for at least eight consecutive hours per day, seven days a week. Despite this policy, the facility consistently failed to meet this requirement over several months, as evidenced by the staffing records. The DSD admitted that the facility did not meet the requirement for RN presence, which could potentially impact resident care. The report does not mention any specific residents or their conditions being directly affected by this deficiency.
Incomplete Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete Performance Evaluations (PE) for two Certified Nursing Assistants (CNAs), which could impact patient care. During an interview and record review with the Director of Staff Development (DSD), it was found that CNA 3, hired on March 28, 2023, did not have a completed PE in their employee file. Similarly, CNA 4, hired on November 1, 2021, also lacked a completed PE. The facility's policy and procedure on Employee Performance Evaluation mandates that employees receive performance evaluations, which are to be kept in their personnel files. The absence of these evaluations means that the CNAs may not be aware of areas needing improvement, potentially affecting the quality of care provided to patients.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) quarterly assessment was completed for one of the sampled residents, identified as Resident 77. During an interview, the MDS Nurse confirmed that MDS assessments are required on admission, quarterly, annually, and at discharge, and must be completed within 14 days of the Assessment Reference Date (ARD). A review of Resident 77's clinical record revealed that the admission MDS was completed on July 30, 2024, but the quarterly MDS assessment, due in October 2024, was not completed and was overdue. The facility's policy, dated November 2019, mandates that the resident assessment coordinator ensures timely and appropriate assessments, including quarterly assessments conducted not less frequently than three months following the most recent assessment of any type.
Failure to Update PASRR for Residents with Mental Illness
Penalty
Summary
The facility failed to adhere to its policy and procedure for Pre-Admission Screening and Resident Review (PASRR) for two residents with serious mental illness diagnoses. For Resident 66, the PASRR Level 1 screening conducted by the General Acute Care Hospital (GACH) was negative, incorrectly indicating no serious mental disorder despite the resident's history of Schizoaffective Disorder, Anxiety, and Depression. The Minimum Data Set Nurse (MDSN) admitted that there was no process in place to verify the accuracy of the PASRR against the resident's diagnoses, which should have prompted a new PASRR Level 1 screening upon admission. Similarly, for Resident 38, the PASRR Level 1 screening from GACH was also negative, failing to acknowledge the resident's diagnoses of Schizophrenia, Major Depressive Disorder, Anxiety, and Schizoaffective Disorder, Bipolar Type. The Director of Nursing (DON) acknowledged that the PASRR was incorrectly completed by the GACH and emphasized that it is the facility's responsibility to ensure the PASRR reflects all current diagnoses. The facility's policy mandates that a new PASRR Level 1 should be completed if there is a significant change in the resident's mental or physical condition or if the MDS does not match the PASRR from GACH.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a care plan for a resident, resulting in a fall and subsequent injury. The resident, who was at high risk for falls due to conditions such as spondylosis, muscle weakness, anemia, and unsteadiness on feet, was not provided with the necessary footwear and was in a dimly lit environment at the time of the incident. The care plan specifically required the resident to wear footwear to prevent slipping and to keep the environment well-lit, but these interventions were not followed. On the night of the incident, the resident attempted to sit on the edge of the bed after using the restroom and slipped, resulting in a nondisplaced fracture of the neck of the right femur. The resident was barefoot, and the room was dimly lit, which contributed to the fall. The resident's Minimum Data Set indicated that walking was not attempted due to safety concerns, and the resident required substantial assistance with footwear, which was not provided at the time of the fall. Interviews with staff revealed that the resident was supposed to wear nonskid footwear when walking, but the footwear could not be found at the time of the incident. The resident expressed fear of falling again and stated that assistance was needed for walking. The facility's policy on care planning emphasized the need for a comprehensive, person-centered care plan based on individual needs, which was not adequately implemented in this case.
Failure to Develop Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop discharge care plans for two residents, which could lead to unmet care needs upon their discharge. Resident 2 was admitted and later discharged without a discharge care plan, despite expressing a wish to return to room and board when appropriate. Similarly, Resident 3 was admitted and discharged without a discharge care plan, even though they expressed a desire to move to an assisted living facility upon discharge. The Director of Nursing (DON) confirmed that neither resident had a discharge care plan, which is expected to be completed after the Multidisciplinary Care Conference (MCC). The facility's policy and procedure on care planning, revised in 2017, mandates that a comprehensive person-centered care plan be developed for each resident, including discharge plans as appropriate. The DON acknowledged that discharge planning should begin at admission and involve a team effort. However, the review of the residents' care plans revealed that the facility did not adhere to its policy, as the discharge care plans were not developed for the two residents in question.
Financial Abuse of Resident by Social Services Director
Penalty
Summary
The facility failed to protect a resident from financial abuse, as evidenced by the unauthorized use of the resident's credit and debit cards by the Social Services Director (SSD). The resident, who had severe cognitive impairment and was diagnosed with dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, and bipolar disorder, was unable to manage her own financial matters. Despite this, the facility did not have a policy in place to protect vulnerable residents from financial exploitation. The SSD impersonated the resident to gain access to her financial accounts, resulting in over $6,500 in unauthorized charges. These charges included purchases at gas stations, grocery stores, clothing stores, and other retail outlets. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 6, signifying severe cognitive impairment, and she required supervision with activities of daily living. Interviews with facility staff and the resident revealed that the resident did not leave the facility to make these purchases, and there was no documentation of her going out for shopping trips as claimed by the SSD. The facility's failure to have a policy for financial protection and the SSD's actions led to the resident being a victim of financial abuse. The Business Office Manager confirmed the lack of a policy, and the Administrator later suspended and terminated the SSD after an investigation. The facility's policy on abuse prevention stated a zero-tolerance for abuse and misappropriation of property, yet the SSD's actions directly contradicted this policy, resulting in significant financial loss for the resident.
Failure to Report Financial Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of financial abuse involving a resident to the California Department of Public Health (CDPH) within the required 24-hour timeframe and did not complete a thorough investigation within five business days. The Social Services Director (SSD) admitted to impersonating the resident to reset her bank pin number, and the police department was involved due to concerns of credit card fraud. Despite these events, neither the SSD, Director of Nursing (DON), nor the Administrator reported the financial abuse allegation to the CDPH. The facility's policy and procedure on abuse investigation and reporting, dated July 2017, mandates that all reports of abuse, neglect, exploitation, or misappropriation of resident property be promptly reported to local, state, and federal agencies and thoroughly investigated. The Administrator acknowledged awareness of the financial abuse allegation when the police arrived but did not take steps to report it to the CDPH. This oversight in following the established protocol for reporting and investigating abuse allegations led to the deficiency noted in the report.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding abuse prevention by not completing reference checks for two employees before their hire dates. Specifically, the facility did not conduct reference checks for a Licensed Vocational Nurse (LVN 2) and a Certified Nursing Assistant (CNA 5) prior to their employment. During an interview and record review, it was revealed that LVN 2's reference checks were not documented, and the Director of Staff Development (DSD) acknowledged that the employee file was incomplete. Similarly, CNA 5's employee file lacked evidence of reference checks, and the DSD admitted that the reference check was not followed up. The facility's policy, titled "Abuse Prevention," mandates that all applicants undergo reference checks with current and/or past employers to prevent abuse, neglect, and other violations. This policy applies to all employees working in California. The failure to complete these checks for LVN 2 and CNA 5 had the potential to place residents at risk for abuse, as the facility did not ensure that these staff members were safe to work with residents. The absence of documented reference checks indicates a breach in the facility's screening process, which is a critical step in preventing abuse and ensuring resident safety.
Failure to Administer Medication on Time
Penalty
Summary
The facility failed to ensure that ordered medication for one of three sampled residents was administered within the ordered time frame. Specifically, Resident 1's Percocet, which was scheduled to be administered at 12:00 p.m., was not given until 1:59 p.m., which is 59 minutes outside the allowed parameter for administration. During an interview, Resident 1 confirmed that the medication was delayed, and the Director of Nursing (DON) acknowledged that the medication should have been administered and documented by 1:00 p.m. A review of the facility's policy and procedure on medication administration indicated that medications should be administered in a safe, accurate, and effective manner and documented immediately following administration.
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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