The Springs Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Murrieta, California.
- Location
- 25924 Jackson Ave, Murrieta, California 92563
- CMS Provider Number
- 555915
- Inspections on file
- 51
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Springs Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not provide required notice of transfer or discharge to the State LTC Ombudsman prior to the planned discharge of three residents with complex medical needs, despite facility policy and federal requirements. Staff interviews confirmed the omission, and there was no documentation in the records that the Ombudsman was notified before the discharges.
A resident admitted for hospice care with dementia and Parkinson's disease was prescribed lorazepam and quetiapine for anxiety and psychosis, but staff did not initiate monitoring for targeted behaviors or medication side effects until two days after starting the medications. Nursing staff and leadership confirmed that monitoring should have begun with the initiation of psychotropic medications, as required by facility policy.
A resident with a history of heart failure and kidney disease was transferred to a hospital due to low blood pressure and oxygen levels, but the facility failed to notify the responsible person and emergency contacts. The resident was admitted to the ICU and passed away shortly after. The facility's DON acknowledged the communication lapse, as the charge nurse assumed others had notified the family, contrary to the facility's policy.
A resident with acute congestive heart failure and other conditions was transferred to a GACH due to low blood pressure and oxygen levels. The facility failed to notify the resident's family of the transfer, resulting in the family discovering the resident's absence the following day. The resident was admitted to the ICU and passed away shortly after. The DON acknowledged the communication lapse, as the LVN responsible assumed others had notified the family.
A resident with atherosclerotic heart disease and polyneuropathy did not receive pain medications as ordered, leading to unmanaged pain. The MAR showed morphine sulfate was given for moderate pain and tramadol for mild and severe pain, contrary to physician orders. The DON confirmed the discrepancy, and the facility's policy emphasized proper medication administration and pain assessment.
A resident with a known allergy to aspirin was administered the medication for 19 days due to a failure to update the allergy list, resulting in a severe allergic reaction and hospitalization. Despite the resident's history, the facility did not prescribe medication to treat the allergic reaction symptoms, leading to a life-threatening condition.
The facility failed to ensure accurate MDS assessments for two residents, one with unplanned weight loss inaccurately coded as a physician-prescribed regimen, and another with severe cognitive impairment whose use of bed and wander alarms was not reflected in the MDS. Interviews confirmed the discrepancies between documented care and MDS coding.
A facility failed to ensure staff donned PPE before entering the room of a resident on contact precautions for MRSA. Despite a policy requiring gloves and gowns, a CNA entered the room without PPE. The resident was admitted with right foot osteomyelitis and was under contact isolation. Interviews confirmed staff awareness of the precautions, yet the protocol was not followed.
A resident with severe cognitive impairment and other mental health conditions was verbally abused by a CNA, who used explicit language towards the resident in the hallway. Multiple staff members confirmed the incident, and the CNA was terminated following an investigation.
The facility failed to report an incident of verbal abuse towards a resident to the CDPH within the required two-hour timeframe. Multiple staff members overheard the abuse, but the incident was not reported to the DSD until several hours later, resulting in a delay in notifying the CDPH. The resident involved has severe cognitive impairment and was exhibiting increased confusion and agitation at the time.
A facility failed to remove a CNA from patient care after the CNA was witnessed verbally abusing a resident with severe cognitive impairment. Despite immediate knowledge of the abuse, the CNA remained in the facility for approximately two hours, violating the facility's abuse prevention policy.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the notice of transfer or discharge to the State Long-Term Care Ombudsman prior to the planned discharge for three sampled residents. For each resident, documentation showed that the resident and their representative were notified of the discharge, and the discharge was carried out as planned. However, there was no evidence in the records that the Ombudsman was notified prior to the discharge, as required by facility policy and federal regulations. Interviews with facility staff, including the Social Worker, Case Manager, and Assistant Administrator, confirmed that the process for notifying the Ombudsman was not followed, with explanations including uncertainty about the Ombudsman's coverage and issues with email communication. The residents involved had significant medical conditions, including hemiplegia and hemiparesis following cerebral infarction, metabolic encephalopathy, dementia, acute osteomyelitis, and dissection of the descending thoracic aorta. Despite the facility's policy requiring notification of the Ombudsman and documentation of such notification in the medical record, this step was omitted for all three residents prior to their discharge. The facility's own policies also require that residents and their representatives be informed of their right to appeal the discharge, including contact information for the Ombudsman, but the lack of Ombudsman notification was a clear deficiency in the discharge process.
Failure to Monitor Behaviors and Side Effects for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure appropriate monitoring of a resident who was admitted under general in-patient hospice care with diagnoses including dementia, Parkinson's disease, and uncontrolled behaviors posing a danger to self and others. Upon admission, the resident was prescribed psychotropic medications, specifically lorazepam for anxiety, restlessness, agitation, and shortness of breath, and quetiapine fumarate for psychosis and unprovoked physical behavior. However, there was no documented evidence that monitoring for targeted behaviors such as anxiety and psychosis, or for side effects related to the use of these psychotropic medications, was initiated until two days after admission. Interviews with nursing staff and facility leadership confirmed that monitoring for behaviors and side effects should have been conducted from the time the medications were started. The facility's own policy required staff to monitor for adverse side effects associated with psychotropic medication use. The lack of timely monitoring was acknowledged by the RN, ADON, LVN, and DON, all of whom stated that such monitoring was expected and should have been implemented as soon as the medications were ordered.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible person (RP) and emergency contacts of a resident's change of condition and subsequent transfer to a general acute care hospital (GACH). On January 17, 2025, the resident experienced low blood pressure and low oxygen levels, prompting the facility to initiate intravenous fluid hydration and consider an X-ray. The RP was informed of the low blood pressure and potential X-ray but was not updated about the resident's transfer to the hospital. The following day, a family member discovered the resident was not in their room and was informed by staff that the resident had been transferred to the GACH due to low blood pressure and low oxygen levels. The resident, who had a medical history including acute congestive heart failure, atrial fibrillation, and chronic kidney disease, was admitted to the intensive care unit at the GACH and passed away on January 19, 2025. The facility's Director of Nursing (DON) acknowledged the communication lapse, stating that the charge nurse, LVN 1, assumed other nurses had notified the RP, which did not occur. The facility's policy requires notifying the resident's representative of significant changes in health status, which was not adhered to in this case.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to accurately document the notification of the Responsible Person (RP) regarding the transfer of a resident to a general acute care hospital (GACH). On January 17, 2025, the resident was transferred due to low blood pressure and low oxygen levels. However, the RP and family members were not informed of this transfer, leading to a lack of awareness about the resident's critical condition and subsequent admission to the Intensive Care Unit. The RP only discovered the transfer when a family member visited the facility the following day and found the resident missing from their room. The resident, who had been admitted to the facility with acute congestive heart failure, atrial fibrillation, and chronic kidney disease, passed away on January 19, 2025. The facility's documentation indicated that the RP was notified at 6:30 p.m. on the day of the transfer, but interviews and record reviews revealed that this notification did not occur. The Director of Nursing acknowledged the communication lapse, and it was found that the Licensed Vocational Nurse (LVN) responsible for the resident's care assumed that other nurses had informed the RP, which was not the case.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered by the physician for a resident, leading to potential unmanaged pain. The resident, who was admitted with diagnoses including atherosclerotic heart disease and polyneuropathy, had specific orders for pain management. The care plan indicated that medications should be administered as ordered, with tramadol prescribed for moderate pain and morphine sulfate for severe pain. However, the Medication Administration Record (MAR) showed that morphine sulfate was given for moderate pain and tramadol was administered for mild and severe pain, contrary to the physician's orders. The Director of Nursing (DON) confirmed during an interview that the medications were not administered according to the physician's orders. The facility's policy on pain assessment and management emphasized the importance of administering medications as ordered and conducting comprehensive pain assessments. Despite this, the resident's pain was not managed appropriately, as evidenced by the hospice nurse's progress note indicating the resident's pain was not controlled with the current medication regimen. The resident also exhibited signs of distress, such as confusion, sadness, and refusal of wound care.
Failure to Prevent and Treat Allergic Reactions
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and treatment to prevent and treat allergic reactions. The resident, who had a known allergy to aspirin, was administered the medication for a total of 19 days. This oversight occurred because the resident's allergy to aspirin was not listed in the facility's allergy list, despite being documented in previous medical records. The administration of aspirin led to the resident developing a severe allergic reaction, resulting in toxic epidermal necrolysis, a life-threatening condition. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) were aware of the resident's allergies, but the allergy list was not updated to include aspirin. The Medical Doctor (MD) acknowledged that the resident's allergy to aspirin was known, but the medication was continued due to its perceived benefits for the resident's stroke condition. The facility's failure to accurately document and communicate the resident's allergies led to the administration of a contraindicated medication, resulting in severe adverse effects. The resident's family expressed concerns about the administration of medications to which the resident was allergic. Despite the resident's history of allergic reactions, the facility did not prescribe or administer medication to treat the allergic reaction symptoms. The resident's condition worsened, leading to hospitalization for further evaluation and treatment. The facility's policies on monitoring and documenting adverse drug reactions were not adequately followed, contributing to the deficiency in care.
Inaccurate MDS Assessments for Nutrition and Dementia Care
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to deficiencies in the areas of nutrition and dementia care. For one resident, the MDS inaccurately indicated that their weight loss was due to a physician-prescribed weight-loss regimen, despite the absence of any such order. Interviews with the MDS Coordinator, MDS Assistant, and the Director of Nursing confirmed that the resident's weight loss was unplanned and due to poor intake, and the MDS should have been coded accordingly. For another resident, the MDS did not accurately reflect the use of a bed alarm or a wander/elopement alarm, despite documentation in the resident's care plan and progress notes indicating their use. The resident had severe cognitive impairment and was at risk for falls and wandering, necessitating these interventions. The Director of Nursing acknowledged the need for accurate MDS assessments, highlighting the discrepancy between the documented interventions and the MDS coding.
Failure to Adhere to PPE Protocols for Contact Precautions
Penalty
Summary
The facility failed to ensure that staff properly donned personal protective equipment (PPE) before entering the room of a resident on contact precautions. The facility's policy, revised on September 1, 2023, required staff to wear gloves and gowns when entering the room of residents with infections transmitted by direct or indirect contact, such as MRSA. Despite this policy, a Certified Nursing Assistant (CNA) entered the room of a resident diagnosed with MRSA without wearing any PPE. The resident had been admitted from a hospital with a diagnosis of right foot osteomyelitis and was under contact isolation for a right foot wound. An observation on July 2, 2024, noted a sign on the resident's door indicating the need for contact precautions, including the use of gloves and gowns. During an interview, the CNA acknowledged awareness of the contact precautions but failed to comply. The Director of Nursing and the Administrator both stated that staff were expected to wear the appropriate PPE before entering rooms of residents on contact precautions. This incident highlights a lapse in adherence to established infection control protocols within the facility.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a CNA was witnessed using explicit language towards the resident in the hallway. The incident occurred on March 28, 2024, at around 4:30 a.m., when multiple staff members overheard CNA 2 telling the resident, 'Shut the fuck up, you are a grown woman, why are you acting like that?' The facility's Assistant Administrator confirmed that the verbal abuse was substantiated through their investigation, and CNA 2 was terminated as a result. The resident involved had severe cognitive impairment, dementia, anxiety disorder, psychotic disorder, and mood disorder, and was observed to be calm but easily awakened with no physical injuries noted. Interviews with various staff members, including CNA 1, CNA 3, and CNA 4, corroborated the incident. CNA 1 reported hearing the explicit language while attending to another resident, and CNA 3 and CNA 4 also confirmed hearing the verbal abuse from CNA 2. The facility's policy on abuse prevention emphasizes the importance of providing an environment that prohibits and prevents abuse, including the use of derogatory language. Despite these policies, the incident of verbal abuse occurred, highlighting a failure in supervision and staff behavior management.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an incident of verbal abuse towards Resident A to the California Department of Public Health (CDPH) within the required two-hour timeframe. On March 28, 2024, at around 4:30 a.m., CNA 2 verbally abused Resident A by saying, 'Fuck you, you are a grown woman, why are you acting like this?' This incident was overheard by multiple staff members, including CNA 1, CNA 3, and CNA 4. However, the incident was not reported to the Director of Staff Development (DSD) until around 11:30 a.m. by CNA 1, and subsequently, the CDPH was not notified within the mandated two-hour period. The delay in reporting was confirmed during an unannounced visit on April 10, 2024, and through interviews with the Assistant Administrator (AADM) and other staff members involved. Resident A, who has severe cognitive impairment with a BIMS score of 3, was admitted to the facility with diagnoses including dementia, anxiety disorder, psychotic disorder, and mood disorder. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. Despite the facility's policy requiring immediate reporting of any alleged abuse, the staff failed to comply, resulting in a delay in the investigation and reporting of the verbal abuse incident. This failure potentially placed Resident A and other residents at risk for further abuse.
Failure to Remove CNA After Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident was free from further abuse when a CNA was not removed from all patient care after being witnessed verbally abusing a resident in the hallway. The incident occurred on March 28, 2024, when CNA 2 was overheard by multiple staff members telling Resident A, 'Fuck you, you are a grown woman, why are you acting like this?' Despite the immediate knowledge of the abuse, CNA 2 was not removed from the facility until approximately two hours later. This delay in action was confirmed by the Assistant Administrator and multiple staff members, including CNA 1, CNA 3, and CNA 4, who all provided consistent accounts of the incident and the failure to follow protocol by LVN 1, who did not remove CNA 2 immediately after the abuse was known. Resident A, who has severe cognitive impairment with a BIMS score of 3, along with diagnoses of dementia, anxiety disorder, psychotic disorder, and mood disorder, was the victim of the verbal abuse. The resident's progress notes indicated increased confusion, agitation, and aggressive behavior on the day of the incident. The facility's policy on Abuse Prohibition and Prevention, which mandates the immediate suspension of personnel involved in abuse allegations, was not followed, leading to a potential risk for further abuse to Resident A and 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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