Tampico Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Walnut Creek, California.
- Location
- 130 Tampico Street, Walnut Creek, California 94598
- CMS Provider Number
- 056213
- Inspections on file
- 24
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Tampico Healthcare Center during CMS and state inspections, most recent first.
A resident with cardiac conditions and a history of falls developed a purple bump on the buttock that was documented without precise anatomical location or wound measurements, and no investigation into the cause was recorded. A subsequent physician-signed wound note labeled the area as an abrasion on the right buttock but again omitted measurements and exact location. The same note documented a left heel pressure injury with a physician order for a protective boot to offload pressure, yet there was no evidence the boot order was entered or implemented. The TN and DON acknowledged that a full assessment, investigation, and implementation of the ordered preventive device did not occur, contrary to the facility’s wound management policy requiring wound measurements and detailed documentation.
During a respiratory illness outbreak, the facility failed to accurately track cases when a resident with COPD and an acute exacerbation developed shortness of breath, was sent to the hospital, and tested positive for Coronavirus OC43, but was not added to the outbreak line list. In interviews and record reviews, the LVN/IP confirmed the ongoing respiratory outbreak and acknowledged that this resident, who had a confirmed respiratory infection, should have been included on the infection control tracking tool, contrary to facility policy requiring complete infection data collection and analysis.
Surveyors found that oral care and skin care products, including toothbrushes, toothpaste, and triad paste, were stored unlabeled and exposed in shared kidney basins on a room sink. Staff present could not identify the owners of these items and acknowledged that such items should be labeled and stored separately to prevent contamination. The facility's infection preventionist and DON confirmed that these practices did not align with infection control policies and posed a risk for cross-contamination.
Surveyors found that power strips were improperly suspended under adjustable desks in the Social Services and Physician's Offices, powering computer components. Staff confirmed the setup was due to the use of adjustable desks. This deficiency affected multiple residents and smoke compartments, and did not comply with NFPA electrical safety standards.
Surveyors found that the kitchen's Dry Storage Area, a hazardous area, had an egress door without a required self-closing mechanism. This deficiency was confirmed by staff during the inspection and affected one of four smoke compartments.
Surveyors found that the facility did not have a written agreement with a fuel vendor to supply propane for its emergency generator, as required by federal regulations. Staff confirmed that a contract had been proposed but was not yet in place, leaving the emergency power plan incomplete for all residents and smoke compartments.
The facility failed to protect two residents from verbal and physical abuse by another resident. One resident was screamed at, hit, and verbally threatened in the hallway, while another was thrown at and caused to fall during a bingo game. Staff confirmed the incidents, and the aggressive resident had a history of behavioral issues related to schizophrenia and dementia.
Failure to Complete Comprehensive Skin Assessment and Implement Ordered Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure a comprehensive skin assessment and pressure injury prevention for one of two sampled residents. The resident was admitted with diagnoses including congestive heart failure, atrial fibrillation, and a history of falls. An eINTERACT Change in Condition Evaluation documented a purple bump on the buttock, but the skin evaluation did not include the precise anatomical location or measurements (length, width, depth) of this newly identified skin abnormality, and there was no documentation that the cause or origin of the skin injury was investigated. A subsequent Wound Assessment Note, signed by the physician, identified the wound as an abrasion on the right buttock but again did not include wound measurements or specify the exact anatomical location on the buttock. The same Wound Assessment Note indicated the resident had a pressure injury on the left heel and that the physician ordered a protective boot to offload pressure, but there was no documentation that this ordered device was implemented. During interviews, the Treatment Nurse stated that an investigation should have been conducted to determine the cause of the purple bump and that a complete assessment, including wound measurements and exact anatomical location, should have been performed. The DON stated that the purple bump should have been investigated to determine the cause and that without exact wound measurements it would be difficult to determine if the skin injury was improving or declining, and also acknowledged that the physician’s order for a preventive boot was not entered into the record or implemented. Review of the facility’s Wound Management policy showed that it required measurement of new wounds and documentation of wound location and measurements, which was not followed in this case.
Resident with Respiratory Virus Omitted from Outbreak Line List
Penalty
Summary
The facility failed to ensure accurate data collection during a respiratory illness outbreak by not including one resident in the outbreak line list. The resident was admitted with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation. A Change in Condition Evaluation documented that the resident experienced shortness of breath and was transferred to the hospital for evaluation. Laboratory results dated the same day showed the resident tested positive for Coronavirus OC43, a common human coronavirus that usually causes mild to moderate upper-respiratory tract illness. During interviews and concurrent record reviews with the LVN/Infection Preventionist, it was confirmed that a respiratory illness outbreak had started earlier that month and that the facility was using a line list as an infection control tracking tool to collect data and actively monitor residents and staff during the suspected outbreak. The LVN/Infection Preventionist reviewed the line list and acknowledged that the resident who tested positive for a respiratory illness was not included, and stated that the resident should have been listed. The facility’s Infection Prevention and Control Program policy required the facility to identify, investigate, control, and prevent infections, maintain records of incidents and corrective actions related to infections, and required the Infection Preventionist to collect, analyze, and provide infection data and trends, which was not fully carried out in this instance.
Improper Storage and Labeling of Personal Care Items Creates Infection Control Deficiency
Penalty
Summary
Surveyors observed that in a shared room, an open, unlabeled toothbrush and an open, unlabeled tube of toothpaste were stored together in an unlabeled kidney basin on top of the room's shared sink. Additionally, an unlabeled open tube of triad paste was stored together with two open, unlabeled tubes of toothpaste in another kidney basin in the same location. Staff present, including an LVN and a CNA, were unable to identify the owners of these items and acknowledged that oral care products should be labeled and stored separately. The LVN also stated that triad paste, used for treating skin conditions, should not be stored with oral care products. The Infection Preventionist confirmed that toothbrushes should be stored in clean, labeled plastic bags within residents' drawers to prevent contamination, and that co-mingling oral care and skin care products is not appropriate. The Director of Nursing also acknowledged that improper storage of these unlabeled items had the potential to spread infection among the residents sharing the room. Review of the facility's infection prevention and control policy indicated the requirement to maintain a safe and sanitary environment to prevent disease transmission.
Improper Suspension of Power Strips in Facility Offices
Penalty
Summary
Surveyors observed that the facility failed to maintain electrical equipment in accordance with NFPA 101 and NFPA 70 standards. Specifically, power strips were found suspended under adjustable desks in both the Social Services Office and the Physician's Office near the North Nurse station. In both instances, the power strips were powering computer components and were suspended above the floor, with one approximately 12 inches and the other about three inches above the floor. Staff confirmed that the suspension of the power strips was likely due to the use of adjustable desks in these areas. The deficiency affected 43 of 123 residents and two of four smoke compartments. The report notes that the improper suspension of power strips could result in an electrical fire, as tension on the cords may be transmitted to joints or terminals, which is not compliant with the cited NFPA codes. No specific resident medical history or condition at the time of the deficiency is mentioned in the report.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain electrical equipment of power strips. On 04/02/2025, Maintenance Director adjusted the power strips on both the desks of Social Services and in Physician's Office. The adjustment consisted of the power strips not to be suspended related to usage of the adjustable desks. II. Identify Other Residents at Risk On 04/03/2025, the Maintenance Director rounded each office to check suspension of all other power strip cords. No other power strip was identified with the same deficiency. No residents were affected. III. Systematic Changes On 04/02/2025, the Administrator had 1:1 in-service with Maintenance Director on proper placement of power strips (Attachment 4). On 04/03/2025, the Administrator conducted an in-service with office staff on proper placement of power strips (Attachment 5). IV. Monitoring Process Maintenance Director will perform a weekly audit of all power strips in the facility to ensure proper placement and not suspended for 3 months until compliance is met, the monthly audits thereafter. Findings will be reported to Administrator in the daily operations meeting. Administrator will report any findings and trends monthly to the QA Committee for 3 months or until compliance is met. V. Completion Date 04/14/2025
Hazardous Area Door Lacked Required Self-Closing Mechanism
Penalty
Summary
Surveyors observed that the facility failed to maintain proper hazardous area enclosures as required by NFPA 101. Specifically, during a tour of the facility, the egress door to the Dry Storage Area in the kitchen, which measured approximately 255 square feet and contained eight metal racks filled with dry food supplies, was found to be missing a self-closing mechanism. The absence of this mechanism was directly observed, and the staff member present confirmed that she was unaware the door required a self-closing device. This deficiency affected the kitchen and one of four smoke compartments in the facility. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was based solely on the physical observation of the hazardous area and staff interview at the time of the survey.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain the hazardous area enclosures. On 04/02/2025, Maintenance Director installed a self-closing mechanism on the egress door to the Dry Storage Area in the kitchen (Attachment 2). II. Identify Other Residents at Risk Maintenance Director checked the Kitchen for all doors requiring self-closing mechanism. No other door was identified with the same deficiency. No residents were affected. III. Systematic Changes On 04/03/2025, in-service conducted by Administrator with kitchen staff about importance of self-closing mechanism on the door of Dry Storage Area (Attachment 3). Kitchen staff will perform daily check to ensure the door to the Dry Storage Area automatically closes. IV. Monitoring Process Maintenance Director will perform a monthly audit of all doors with self-closing mechanisms. Findings will be reported to Administrator in the daily operations meeting. Administrator will report any findings and trends monthly to the QA Committee for 3 months or until V. Completion Date 04/14/2025
Lack of Emergency Generator Fuel Supply Agreement
Penalty
Summary
The facility failed to maintain its Emergency Preparedness Plan as required by federal regulations. During a document review and staff interview, surveyors requested the emergency fuel plan and found that the facility could not provide a written vendor agreement for the delivery of fuel for their 10-kilowatt propane generator in the event of an emergency. Staff confirmed that while a fuel contract had been proposed to the vendor, no agreement had been finalized or received at the time of the survey. This deficiency affected all 123 residents and four smoke compartments within the facility. The absence of a documented fuel supply agreement meant that the facility did not have a formalized plan to ensure the continued operation of its emergency power system during an emergency, as required by the applicable federal regulations and referenced NFPA codes.
Plan Of Correction
Preparation and execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The plan of correction is prepared and executed solely because it is required by the provisions of federal and state law. I. Corrective Action The facility will ensure to maintain the Emergency Preparedness Plan. On 04/02/25, the Administrator requested a written agreement with [R] to deliver propane fuel for the generator in the event of an emergency. On 04/18/25, [R] provided an amended service agreement that includes a 24-hour emergency service for our facility. (Attachment A - page 6) II. Identify Other Residents at Risk No residents were affected by this deficient practice. III. Systematic Changes On 04/03/25 in-service was conducted by the DSD to facility staff to be informed of agreement in place between propane fuel supplier and facility to deliver propane fuel for generator in the event of an emergency (Attachment 1). EOP Manual updated and reviewed by QA Committee. Next review of EOP Manual will be on 03/2026. IV. Monitoring Process Maintenance Director will review monthly EOP Manual including Propane Fuel Delivery Agreement. Findings will be reported to Administrator in the daily operations meeting. The Administrator will report findings to QA Committee monthly for 3 months or until compliance is met. V. Completion Date 04/18/2025 E 041 The facility is not in substantial compliance with 42 CFR §483.90 for Long Term Care Facilities.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from verbal and physical abuse. Resident 2 screamed, hit, and made verbal threats to harm Resident 1 during an altercation in the hallway. Resident 2 was angry that Resident 1 was in the room next to hers and demanded that Resident 1 leave her side of the hallway. During an interview, Resident 1 stated that Resident 2 made racist remarks and hit him in the chest area. Resident 2 claimed that Resident 1 called her names and spat in her face. Staff members, including an LVN and a CNA, confirmed that Resident 2 yelled at and hit Resident 1. Resident 2's behavioral care plans indicated a history of angry outbursts and physical aggression related to schizophrenia and dementia, but these behaviors were not adequately managed to prevent the altercation with Resident 1. In another incident, Resident 2 threw an object at Resident 3 during a bingo game in the dining room. Resident 3 reacted by pushing the table, which caused him to lose balance and fall. Resident 2's progress notes indicated that she got upset when Resident 3 put a bingo card on top of hers and threw an empty box of chocolate at him. The Social Services Assistant confirmed that Resident 2 pushed the table, leading to Resident 3's fall. Resident 3's Minimum Data Set indicated that he had a mood disorder and episodes of feeling bad about himself, but he was cognitively intact. The facility's failure to manage Resident 2's aggressive behavior resulted in repeated altercations and emotional distress for other residents. The facility's policy on abuse prevention clearly states that each resident has the right to be free from abuse, neglect, and mistreatment. Despite this policy, the facility did not take adequate measures to protect residents from verbal and physical abuse by Resident 2. The incidents involving Resident 1 and Resident 3 highlight the facility's failure to manage Resident 2's behavioral issues effectively, leading to emotional distress and potential injuries for other residents.
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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