The Avenues Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 2043 19th Avenue, San Francisco, California 94116
- CMS Provider Number
- 055963
- Inspections on file
- 21
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Avenues Transitional Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia, dementia, and high fall risk was left unsupervised in a high bed with side rails down during incontinent care. The staff member left the room to get supplies, leaving the resident on their side, and the ordered low air loss mattress was not in use. The resident fell from the bed, sustained serious injuries, and later died. Facility records showed lack of staff training on fall safety and failure to follow care plan interventions.
The facility failed to meet food safety standards when a dirty frying pan was found among clean ones, wet trays were improperly stored, and a dented can was found in dry storage. The DM acknowledged these issues, which could lead to contamination and foodborne illnesses among 133 residents.
The facility failed to follow physician orders for two residents by not obtaining monthly MUAC measurements as an alternative to weights, which were refused. Additionally, the facility did not monitor or document bruising at injection sites for a resident self-administering insulin, potentially affecting insulin absorption and well-being.
The facility failed to ensure proper accountability and administration of medications for several residents. Controlled Drug Records did not reconcile with Medication Administration Records, leading to unaccounted medications. An LVN administered the wrong medication to a resident and left another resident's medication at the bedside without ensuring it was ingested. Additionally, a shared pill cutter was not cleaned between uses, risking drug interactions. These actions violated facility policies and raised concerns about medication management.
The facility failed to properly store and label medications, with one storage room exceeding recommended temperatures, an undated multi-dose vial in the refrigerator, and expired lidocaine patches found in a medication cart. The DON and RNS acknowledged these issues, which contravened facility policies.
The facility failed to implement its infection control program, with deficiencies including improper storage of a urinal, lack of hand hygiene by a janitor handling soiled linens, and nursing staff not performing hand hygiene during medication administration. Additionally, an RN administered medication without gloves, posing infection risks.
Two residents with severe cognitive impairments were not treated with dignity during meal assistance, as CNAs stood over them while feeding, contrary to facility policy. Despite knowing the requirement to sit at eye level, the CNAs did not follow this procedure, impacting the residents' dignity and respect.
A facility failed to ensure safe self-administration of medications for a resident who was observed with multiple prescription medications left on their overbed table. The resident, with no cognitive impairment, had a care plan specifying self-administration of insulin but not other medications. An LVN admitted to leaving the medications at the bedside, contrary to facility policy, and the interdisciplinary team did not determine if the medications could be self-administered.
A resident on heparin for DVT prophylaxis was not monitored for bleeding, despite the facility's policy requiring such monitoring. The resident, readmitted with a femur fracture and rectal hemorrhage, had no documented evidence of bleeding monitoring in their medical record. The ADON confirmed the lack of monitoring, which contradicted the facility's anticoagulation protocol.
The facility failed to ensure two residents were free from unnecessary antipsychotic medications. One resident continued PRN Seroquel beyond 14 days without reevaluation, and another resident lacked behavioral monitoring for Seroquel use. The facility's policy requires non-pharmacological interventions and behavioral monitoring for residents on psychotropic medications, which were not followed.
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. One resident, requiring a mechanical soft diet, was served hard carrots, while another was served a regular menu despite a preference for chow mein or potstickers. These incidents highlight a failure to adhere to the facility's policy on respecting residents' food preferences.
The facility did not meet the required minimum room size of 80 square feet per resident for 47 out of 48 rooms. Observations showed rooms occupied by two or three residents, with only one room meeting the standard. Interviews with residents indicated no major concerns about room size. The Administrator requested a waiver for room size variance from the California Department of Public Health.
A resident's comprehensive MDS assessment was completed 23 days after admission, exceeding the required 14-day period. The resident had multiple diagnoses, including osteoarthritis and schizoaffective disorder. The MDS Coordinator acknowledged the delay, which contravened both facility policy and regulatory requirements.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple health issues, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. The baseline care plan, which is crucial for addressing immediate health and safety needs, was completed several days late, as confirmed by the MDS Coordinator.
Failure to Prevent Avoidable Fall Resulting in Resident Injury and Death
Penalty
Summary
A resident with quadriplegia, dementia, and a history of physical injury was admitted to the facility and assessed as being at high risk for falls, with severe cognitive impairment and total dependence on staff for mobility and toileting. The care plan specified that the resident's bed should be kept in a low position and that two or more staff were required for toileting hygiene and repositioning. Despite these interventions, the resident was left alone in a high bed position with both side rails down while a CNA left the room to obtain additional supplies during incontinent care. During this period of unsupervised time, the resident rolled from the bed and fell to the floor, sustaining multiple injuries including a head injury, abrasions, and skin tears. The CNA reported leaving the resident on their side and did not return the resident to a supine position before leaving. The resident's low air loss mattress, which was ordered to prevent skin breakdown, had been removed at the time of the incident. The facility's documentation and staff interviews confirmed that the CNA had not received specific training on the use of low air loss mattresses or fall safety, and competency validation for peri-care was not documented in the employee file. The facility's policies required a hazard-free environment and adequate supervision to prevent accidents, but these were not followed in this case. The resident's fall resulted in a traumatic brain injury, hospitalization, and subsequent death. The facility's investigation identified the resident's positioning and the absence of the low air loss mattress as contributing factors to the fall.
Food Safety Violations in Kitchen Practices
Penalty
Summary
The facility failed to adhere to food safety requirements as observed during a survey. A dirty frying pan with dried food debris was found stacked among clean frying pans under the food preparation counter. The dietary manager (DM) acknowledged that these were supposed to be clean pans, but one was visibly dirty with dried scrambled egg remains and scratches, indicating improper cleaning and storage practices. Additionally, large metal serving trays were found stacked wet under the food preparation counter, with some trays still moist and dripping. The DM confirmed that the trays were indeed wet, which contradicts the 2022 Federal Food Code that requires equipment and utensils to be air-dried before storage. Furthermore, a dented can of mushrooms was found among undented canned products in the dry storage room, which the DM admitted should not have been there. This is contrary to FDA guidelines that consider dented cans as potentially hazardous. These deficiencies have the potential to contaminate clean cooking utensils and promote the growth of foodborne illnesses among the 133 residents.
Failure to Monitor Nutritional Status and Injection Sites
Penalty
Summary
The facility failed to adhere to physician orders for two residents, Resident 32 and Resident 78, by not obtaining monthly measurements of mid upper arm circumference (MUAC) as an alternative to monthly weights, which both residents refused. Resident 32, who has severe cognitive impairment and a history of refusing care, had no recorded weights since May 2024 and no documentation of MUAC measurements, despite a physician's order from September 2023 to obtain these monthly. Similarly, Resident 78, who has no cognitive impairment but a history of refusing weights, also had no recorded weights or MUAC measurements for the year 2024, despite a similar physician's order. The lack of documentation and adherence to these orders had the potential to result in unplanned and undesirable weight loss for both residents. Additionally, the facility failed to monitor and document the condition of Resident 78's injection sites for bruising, as required by a physician's order. Resident 78, who self-administers insulin, showed signs of bruising on the right lower abdomen, which was not documented in the resident's medical records. The Assistant Director of Nursing acknowledged the oversight and stated that the nurses should have checked for bruising, notified the physician, and updated the care plan accordingly. The failure to monitor and document the injection sites could lead to uneven insulin absorption and negatively affect Resident 78's physical and psychosocial well-being. The facility's policy on weight assessment and intervention, as well as the policy on changes in a resident's condition or status, were not followed in these cases. The multidisciplinary team is expected to prevent, monitor, and intervene for undesirable weight loss, and the nursing staff is required to notify the physician of any significant changes in a resident's condition. However, these protocols were not adhered to, resulting in deficiencies in the care provided to Residents 32 and 78.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for five residents, as the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR). For Resident 105, a tablet of oxycodone was signed out but not documented on the MAR. Similarly, Resident 119's lorazepam was signed out but not recorded on the MAR. Resident 81 had two instances where oxycodone was signed out but not documented. Resident 30's oxycodone was documented on the MAR but not signed out on the CDR. Lastly, Resident 36 had four instances of oxycodone signed out but not documented on the MAR. These discrepancies resulted in unaccounted medications, raising concerns about potential abuse and diversion. The facility also failed to administer the correct prescribed medication to Resident 28. During a medication pass, an LVN administered Geri-Tussin DM instead of the prescribed guaifenesin. This error was acknowledged by the DON, who stated that medication errors should not occur. Additionally, the facility failed to ensure that Resident 432 ingested the full dose of prescribed medication. The LVN left a cup of ClearLax water on the resident's bedside table, and the resident did not finish the medication while the LVN was present. The DON confirmed that medications should not be left at the bedside and that residents should be observed to ensure they ingest the full dose. Furthermore, the facility did not adhere to proper cleaning protocols for shared medical equipment. An LVN used a shared pill cutter to split medications for Resident 432 without cleaning it between uses. This practice was acknowledged by the LVN and the DON, who noted that it could lead to potential drug interactions and expose residents to medication residue. The facility's policy requires that shared items be cleaned and disinfected between uses, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, leading to potential ineffectiveness and safety concerns. In one of the medication storage rooms, the temperature consistently exceeded the manufacturer's recommended range of 68 to 77 degrees Fahrenheit, reaching up to 81 degrees. This was observed over a period of several months, with the temperature exceeding the limit on numerous occasions. The Director of Nursing (DON) acknowledged that the elevated temperature could render medications ineffective, as evidenced by the storage of vancomycin, which requires specific temperature conditions. Additionally, the facility did not properly label a multi-dose vial of Tuberculin Purified Protein Derivative (TPPD) in the medication storage room refrigerator. The vial was opened and undated, contrary to the facility's policy that requires labeling with the date of opening. The DON confirmed awareness of the issue and stated that the vial should have been labeled to ensure timely disposal, as vials in use for more than 30 days should be discarded. Furthermore, expired medications were found in the facility's medication cart. Three lidocaine 5% patches with an expiration date of October 2020 were discovered in a bag labeled with a resident's name. The Registered Nurse Supervisor (RNS) acknowledged the presence of these expired patches and confirmed they were available for use, which is against the facility's policy that mandates the removal and disposal of expired medications. The DON also confirmed awareness of the expired patches and reiterated the expectation for staff to discard such medications.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program in several instances. In one case, a urinal used by a resident was improperly stored inside a trash bin at the bedside, rather than in the designated holder. The resident confirmed using the urinal in this manner, and staff interviews revealed that this practice was against infection control protocols, which require urinals to be stored in a holder to prevent contamination. Another deficiency was observed during the collection of soiled linen on the second floor. A janitor failed to perform hand hygiene before and after glove use while handling soiled linens. The janitor admitted to not performing hand hygiene due to a lack of gloves in the hallway and limited English proficiency. Interviews with the housekeeping supervisor and infection preventionist confirmed that hand hygiene is required before donning and after doffing gloves, especially when handling potentially infectious materials like soiled linens. Additionally, nursing staff did not adhere to hand hygiene protocols during medication preparation and administration. An LVN was observed not performing hand hygiene before preparing and administering medications to two residents and failed to disinfect a blood pressure cuff before and after use. Furthermore, an RN administered medication without wearing gloves, even when handling oral secretions. These actions were acknowledged by the staff involved and were identified as risks for cross-contamination and infection by the Director of Nursing.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect during meal assistance. Resident 92, who was admitted with severe cognitive impairment and required total assistance with eating, was observed being fed by CNA 1 while the CNA stood over the resident. This was contrary to the facility's policy, which requires CNAs to sit at eye level with residents during feeding to maintain dignity and respect. Interviews with the CNA, Assistant Director of Nursing, and Director of Staff Development confirmed that the proper procedure was not followed. Similarly, Resident 7, who also had severe cognitive impairment and required assistance with eating, was fed by CNA 2 while the CNA stood at the bedside. Despite acknowledging the requirement to sit while feeding, CNA 2 did not retrieve a chair and continued to stand throughout the meal. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident, identified as Resident 78, who was observed with multiple prescription medications left on their overbed table. The medications included hydralazine, amlodipine, Eliquis, valsartan, and amiodarone, which were left by an LVN who acknowledged that the resident preferred to take medications after breakfast. The LVN admitted that they should have stayed to encourage the resident to take the medications immediately and should not have left them at the bedside. Resident 78 was admitted with diagnoses including type 1 diabetes mellitus, end-stage kidney disease, and dependence on renal dialysis. The resident's Minimum Data Set assessment indicated no cognitive impairment and no impairment in the range of motion, requiring only setup or clean-up assistance with daily activities. Despite this, the interdisciplinary team did not determine if the medications left on the overbed table could be self-administered by the resident, and there was no active order for self-administration of medication. The facility's policy on self-administration of medications requires an assessment of the resident's mental and physical abilities and documentation of findings. However, the resident's care plan only specified self-administration of insulin Lispro and Glargine, with no mention of other medications. The Assistant Director of Nursing confirmed that there was no order for self-administration and that medications should not be left at the bedside, highlighting a lack of adherence to the facility's policy and procedure.
Failure to Monitor Resident on Heparin for Bleeding
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication, specifically in the case of a resident who was not monitored for bleeding while on heparin, an anticoagulant. The resident was readmitted to the facility with a fracture of the left femur and a hemorrhage of the anus and rectum. The physician's order prescribed heparin injections twice daily for 30 days as a prophylactic measure against deep vein thrombosis (DVT). However, there was no evidence in the resident's medical record of monitoring for bleeding, a known adverse effect of heparin. During an interview and record review, the Assistant Director of Nursing confirmed that the resident was on heparin and had not been monitored for signs and symptoms of bleeding. The facility's policy on anticoagulation required staff and physicians to monitor for possible complications in individuals receiving anticoagulation therapy. The prescribing information for heparin also indicated that hemorrhage is a common adverse reaction, underscoring the necessity for monitoring. This oversight had the potential to result in undetected adverse effects from the medication.
Failure to Monitor and Discontinue Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary antipsychotic medications. For one resident, there was no evidence of non-pharmacological interventions being attempted before the use of PRN Seroquel, and the medication was ordered for more than 14 days without discontinuation or reevaluation by a physician. The resident was readmitted with diagnoses including vascular dementia, psychotic disorder with delusion, and mood disorder. The Assistant Director of Nursing (ADON) confirmed that the PRN Seroquel should have been discontinued after 14 days, but it remained active for 23 days. For another resident, there was no evidence of specific behavioral monitoring for the use of Seroquel. The resident was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance. The ADON acknowledged that the resident's behaviors were not monitored for the effectiveness of the medication, which is necessary to determine if the medication is working and to note any changes in the resident's episodes. The facility's policy requires staff to monitor and document residents' behaviors when receiving psychotropic medication, but this was not done for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. Resident 36, who required a mechanical soft diet with soft vegetables, was served a regular menu that included hard carrots. This was observed during a kitchen tray line inspection, where the dietary manager confirmed the hardness of the carrots using a metal ladle. The cook subsequently replaced the hard vegetables with diced, soft carrots from the substitute menu. Resident 68 was also affected, as he was served a regular menu of fried rice, mixed vegetables, and pork slices, despite his meal ticket indicating a preference for chow mein with chicken or potstickers. Initially, the cook stated that the resident did not want chow mein, but after further inquiry, it was confirmed by the registered dietitian that the resident still wanted potstickers. These incidents demonstrate a failure to adhere to the facility's policy on respecting residents' food preferences, as outlined in their procedures.
Facility Fails to Meet Room Size Requirements for Residents
Penalty
Summary
The facility failed to ensure that 47 out of 48 resident rooms met the required minimum of 80 square feet per resident. During an observation conducted on March 18, 2025, it was noted that rooms on the first, second, and third floors were occupied by two or three residents, with curtains used to divide each bed. The Administrator confirmed that all rooms were equipped for three residents except for rooms 8, 25, and 41, which were for two residents. However, only one room met the required size standard. Interviews with residents revealed that some did not express concerns about the room size. Resident 1 in Room 10 stated that the space was "okay," and Resident 28, through an AI translator device, denied any issues with her room size. A review of facility-submitted documents, including a Client Accommodations Analysis and a Room Size Waiver Request, listed the rooms with less than 80 square feet per resident. The Administrator had requested a waiver for variance in room size from the California Department of Public Health.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the required 14-day period following admission. The resident, who was admitted with multiple diagnoses including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury, had their MDS assessment completed 23 days after admission, which is 9 days late. This delay was acknowledged by the MDS Coordinator during an interview. The facility's policy, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, mandates that the admission assessment be completed by the end of the 14th day, counting the admission day as day one. The failure to adhere to this requirement could potentially delay the identification of the resident's needs and significant issues affecting their well-being.
Failure to Timely Develop Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by their policy. The baseline care plan is essential to address the resident's immediate health and safety needs, including specific health concerns and risks such as elopement or falls. The resident in question was admitted with multiple diagnoses, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. Despite these significant health issues, the baseline care plan was not completed until several days after the admission. The review of the resident's records showed that the baseline care plan was completed and signed by both the resident and an LVN on a date that was beyond the 48-hour requirement. During an interview, the MDS Coordinator confirmed that the baseline care plan was completed late, acknowledging that it should have been done by the eighth day of admission. This delay in completing the baseline care plan could potentially lead to delayed identification of the resident's needs and significant issues affecting their well-being.
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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