Totally Kids Rehabilitation Hospital - D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Loma Linda, California.
- Location
- 1720 Mountain View, Loma Linda, California 92354
- CMS Provider Number
- 555587
- Inspections on file
- 23
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Totally Kids Rehabilitation Hospital - D/p Snf during CMS and state inspections, most recent first.
Arbitration Agreements Lacked Venue Selection Language: The facility failed to ensure arbitration agreements for three residents included a venue selection convenient to both parties. Record review showed the residents had significant medical conditions, and the DCM confirmed the agreements did not contain the required venue information. The ADMIN stated the form did not provide for venue selection and the facility had no P&P for arbitration agreements.
Late Comprehensive MDS Assessment: The facility failed to complete and submit a comprehensive MDS within the required 14-day timeframe for a resident admitted with arthrogryposis and multiple congenital anomalies. The MDSC and CNO both acknowledged the assessment was completed 21 days late, despite the facility policy requiring comprehensive assessments within 14 calendar days of admission.
Late Quarterly MDS Assessment: The facility failed to complete a resident’s quarterly RAI/MDS within the required 92-day timeframe. The MDSC and CNO stated the last quarterly assessment was completed 100 days after the prior one, and the next quarterly assessment due was still not completed when reviewed. The resident had diagnoses including arthrogryposis and multiple congenital anomalies, and the facility policy required quarterly reviews at least every 92 days.
MDS Section I active diagnoses were inaccurately coded for four residents. One resident’s quarterly MDS incorrectly checked viral hepatitis and left seizure disorder blank despite a seizure dx, while another resident’s annual MDS left neurogenic bladder blank despite a bladder problem. Two other residents’ annual or quarterly MDSs left seizure disorder blank even though their records showed seizures. The MDSC, CM, and CNO verified the coding errors and stated the assessments were incorrectly completed.
A resident with cerebral palsy and chronic respiratory failure was hospitalized for new-onset seizures and later had recurrent tonic seizures documented by Neurology. The resident was prescribed Keppra and clonazepam for seizure management, but the LTCP did not reflect the seizure diagnosis until much later. The CM stated the seizure care plan should have been started when the resident returned from the hospital, and the CNO stated a new diagnosis like seizures requires an immediate individualized care plan.
A facility failed to follow its P&P for weekly replacement of suction canisters and suction tubing for two trach/vent-dependent residents. One resident’s suction setup was 13 days old with light green fluid, and another’s was 9 days old with cloudy green fluid, brown foam, and sediment. RT confirmed the equipment should be changed at least weekly, and the CNO stated staff were expected to follow the weekly replacement policy.
Hand Hygiene Not Performed During Wound Care: An LVN did not follow infection control practices during wound care for a resident with a right neck wound, quadriplegia, and cerebral palsy. After removing the old dressing and cleansing the wound, the LVN applied skin prep, collagen, calcium alginate, and a new dressing without performing hand hygiene or changing gloves, despite facility training and policy requiring hand hygiene after contact with wound dressings.
A resident with complex medical needs was subjected to verbal abuse by a CNA, who used foul and intimidating language in the presence of a nursing student. Prior concerns about the CNA's conduct had been raised by staff and a family member, and facility records showed previous disciplinary action for unprofessional behavior. The incident violated the facility's abuse prevention policy, as confirmed by the CNO.
The facility failed to complete and submit MDS assessments for nine residents within the required timeframes, resulting in inadequate monitoring and lack of information for CMS. The DCM cited staffing issues as the reason for delays, with some assessments being overdue by up to 157 days.
The facility failed to review the Monthly Medication Review (MRR) recommendations from the pharmacist in a timely manner for two residents. The pharmacist sent the MRR to the CNO, but the facility lacked a policy with specific timelines for review, resulting in a two-month delay in physician response. The CNO acknowledged the delay, which contradicted the facility's goal of a one-week review period.
A facility failed to implement Enhanced Barrier Precautions during wound care for a resident, as staff did not wear gowns, contrary to CMS guidance. Additionally, a nurse did not follow sterile technique during urinary catheterization for a resident with neurogenic bladder, using non-sterile gloves and compromising the sterile field. The nurse also failed to perform hand hygiene after resident contact, breaching infection control policies and CDC guidelines.
A facility failed to maintain a comprehensive care plan for a resident with a tracheostomy and ventilator-dependent status. Despite physician's orders for respiratory care, the care plan was mistakenly closed, leaving the resident without an active plan for his respiratory needs. Interviews with facility staff confirmed the oversight, which was contrary to the facility's policy requiring individualized care plans.
The facility failed to ensure the proper verification process for controlled medications was completed accurately for two medication carts. Observations and interviews revealed missing signatures on Controlled Substance Inventory Count forms for Valtoco Nasal Spray, indicating that the required verification process was not followed. The facility's policy mandates that both the nurse leaving the shift and the nurse coming on duty must verify and document the count of controlled substances, which was not adhered to, potentially leading to the diversion of medications.
A resident with complex medical needs was prescribed lorazepam for agitation with a PRN order exceeding the 14-day limit without documented rationale. The medication was administered multiple times over 20 days. Interviews revealed a lack of policy and reliance on the pharmacist for compliance, leading to a deficiency in medication management.
An expired bottle of Humulin R was found in an E-Kit during an observation in the medication storage room. The Charge Nurse confirmed the expiration, and the facility's policy for medication management was not followed. The in-house Director of Pharmacy stated that nurses should ensure medications are not expired and notify the pharmacy for replacements.
The facility failed to follow safe food storage practices, with expired onions and unlabeled ice cream found in storage areas. A staff member acknowledged the oversight, and the Registered Dietician confirmed the need for proper labeling. These lapses could risk foodborne illness to residents.
Arbitration Agreements Lacked Venue Selection Language
Penalty
Summary
The facility failed to ensure that arbitration agreements provided a selection of a venue convenient to both the facility and the resident for three sampled residents. During interview and record review, Resident 27’s admission record and H&P showed admission with diagnoses including chronic respiratory failure, deletion of chromosome 1p36, and Tetralogy of Fallot; Resident 47’s H&P showed admission with diagnoses including chronic lung disease, recurrent pneumonias, and gross developmental delay; and Resident 51’s admission record and H&P showed admission with diagnoses including chronic respiratory failure, cerebral palsy, and spastic quadriplegia. During a concurrent interview and record review with the Director of Case Management, the arbitration agreements for Residents 27, 47, and 51 were reviewed and each was found not to include information regarding the selection of a venue convenient to both parties. The Director of Case Management confirmed that the binding arbitration agreements for all three residents did not have this information and stated there should have been. During a later interview, the Administrator stated the arbitration agreement form did not provide for the selection of a venue convenient to both parties and that the facility did not have a policy and procedure for arbitration agreements.
Late Comprehensive MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive MDS assessment was completed and submitted to CMS within the required federal timeframe for one sampled resident. Resident 23 was admitted with diagnoses including arthrogryposis and multiple congenital anomalies. The MDS Coordinator Nurse stated that comprehensive assessments are expected to be completed within 14 calendar days of admission, and the Chief Nursing Officer gave the same expectation during interview. Record review showed Resident 23’s comprehensive/admission MDS assessment for May 2025 was due on April 28, 2025, but was not completed until May 19, 2025, which was 21 days late. During interview and record review, the MDS Coordinator Nurse and the Chief Nursing Officer both acknowledged the assessment was late. The facility policy titled Minimum Data Set (MDS) Assessments, dated March 2024, stated comprehensive assessments must be completed within 14 calendar days after admission, on significant change in status, and annually.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that Resident 23’s quarterly RAI/MDS assessment was completed within the required 92-day timeframe following the prior assessment. Resident 23’s history and physical dated April 14, 2024, documented admission to the facility with diagnoses including arthrogryposis and multiple congenital anomalies. During interview and record review, the MDS Coordinator Nurse stated that quarterly assessments are her responsibility and that they are expected to be completed within 92 days of the prior quarterly assessment. During the review, the MDS Coordinator Nurse and the Chief Nursing Officer both stated that Resident 23’s last quarterly assessment was completed on January 5, 2026, which was 100 days from the previous assessment, and that the quarterly assessment due on April 7, 2026 had not been completed and was 8 days late. Review of the facility’s policy titled Minimum Data Set (MDS) Assessments, dated March 2024, showed that quarterly review assessments must be completed at least 92 days following the previous assessment of any type. The CNO stated that the policy was not followed.
MDS Section I Active Diagnoses Were Inaccurately Coded
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ active diagnoses in Section I for four residents. During review of Resident 1’s admission record and H&P, the resident was noted to have traumatic brain injury, left foot fracture, and right big toe fracture. On review of the resident’s quarterly MDS, Section I incorrectly had viral hepatitis checked, and the seizure disorder item was left blank even though the resident had a seizure disorder. The Case Manager Nurse stated the viral hepatitis entry was checked by mistake and verified that the seizure disorder was not documented correctly. Resident 19’s admission record and H&P showed diagnoses including anoxic brain injury, spastic quadriplegia, and ventilator dependence. On review of the resident’s annual MDS, Section I for active diagnoses, the neurogenic bladder item was left blank, indicating no bladder issue was coded. The MDS coordinator verified that the MDS was coded incorrectly and stated the resident had a bladder problem. Resident 20’s admission record and H&P identified diagnoses including premature infant, chronic lung disease, and seizure. On review of the resident’s annual MDS, Section I for active diagnoses, seizure disorder or epilepsy was left blank. The Director of Case Management verified that the seizure was not documented correctly because the resident had seizures. Resident 23’s H&P listed arthrogryposis, chronic lung disease with tracheostomy, and focal seizures. On review of the resident’s quarterly MDS, Section I for seizure disorder or epilepsy was left blank. The Case Manager stated the MDS coordinator did not accurately complete the assessment and that active diagnoses should not have been left blank. The facility’s policy required accurate and complete MDS data to be transmitted within 14 days, and the Chief Nursing Officer stated the policy was not followed and the quarterly MDS was incorrectly coded.
Failure to Develop Seizure Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 46 after the resident was diagnosed with new-onset seizures and prescribed seizure medications. Resident 46 had been admitted with diagnoses including cerebral palsy and chronic respiratory failure. A discharge summary dated January 15, 2026, documented hospitalization for new-onset seizure, and a neurology consult dated January 22, 2026, documented recurrent tonic seizures. An LTC physician order review dated April 15, 2026, showed orders for Keppra 750 mg twice daily and clonazepam 0.25 mg once daily for seizure management. During interview and record review on April 16, 2026, the resident’s LTCP was reviewed and showed the seizure care plan was initiated that day. The case manager stated the seizure LTCP should have been put into place when the resident returned from the hospital on January 15, 2026, but there was no documented evidence of a seizure care plan in the electronic chart. The case manager also stated the LTCP should be individualized and communicate specific resident needs to ensure consistent observation and care between staff. The CNO stated that when a patient has a new diagnosis such as new-onset seizures, staff are expected to initiate a care plan related to the diagnosis and new medication immediately.
Expired suction equipment left in use for tracheostomy patients
Penalty
Summary
The facility failed to provide respiratory and tracheostomy care consistent with its policy and procedure for two sampled patients, Patient 14 and Patient 46, when suction canisters and suction tubing were not changed weekly and remained available for continued use. Patient 14 was admitted with acardi syndrome and respiratory failure with tracheostomy and ventilator dependence. During observation, Patient 14’s suction canister and tubing were dated 13 days from the last change and contained 500 ml of light greenish liquid. The respiratory therapist confirmed the dates and stated the canister should be changed at least every seven days, and more often if dirty or gunky. Patient 46 was admitted with cerebral palsy and chronic respiratory failure with tracheostomy and ventilator dependence. During observation, Patient 46’s suction canister and tubing were dated 9 days from the last change and contained 750 ml of cloudy green liquid with brownish foam and sediment in the canister. The respiratory therapist confirmed the dates and stated the canister and tubing should be changed at least every 7 days, and more often if soiled or full. The chief nursing officer reviewed the facility’s disposable equipment policy, which required suction tubing and suction canisters to be replaced weekly, and stated staff were expected to follow that policy.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when an LVN did not follow safe infection control practices during wound care for one resident with a right neck wound. The resident had diagnoses including quadriplegia, cerebral palsy, and an erosive right neck wound. MD orders dated March 2, 2026 directed daily wound care to cleanse the right neck wound with normal saline, pat dry, apply skin prep, collagen sheet, calcium alginate, and cover with a Mepilex dressing. During observation in the resident’s room, the LVN performed hand hygiene, put on sterile gloves, removed the old dressing, cleansed the wound with sterile normal saline and gauze, and patted the wound dry. The LVN then applied skin prep and placed the collagen, calcium alginate sheet, and new dry dressing without performing hand hygiene and without changing gloves. In interview, the LVN acknowledged she did not change her gloves after removing the old dressing and before cleansing the wound and applying the new dressing. The facility’s dressing change training stated to remove the soiled dressing, perform hand hygiene again, don sterile gloves, clean the wound as ordered, and apply the dressing as ordered. The facility’s hand hygiene policy stated to decontaminate hands after contact with wound dressings if hands are not visibly soiled, and the CNO stated the policy was not followed.
Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) verbally abused a resident, as witnessed by a nursing student. The CNA used foul and intimidating language, telling the resident to "get back in that damn bed" and later repeating the command with profanity. The incident was corroborated by a nursing student's written statement and was reported to facility management. The resident involved had a history of extreme prematurity, short gut syndrome, and was dependent on a gastrostomy tube for nutrition and medication. Interviews with other staff and a resident's family member indicated prior concerns about the CNA's behavior, including rough handling and negative interactions with staff and residents. Review of facility records showed that the CNA had previously received a disciplinary action for unprofessional interactions and had signed an acknowledgment of the facility's abuse prevention policy, which defined verbal abuse and required staff to maintain respectful conduct. Despite these measures, the CNA's actions violated the facility's policy and the resident's right to be free from abuse. The Chief Nursing Officer confirmed that the policy was not followed in this instance.
Failure to Timely Complete and Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for nine residents were conducted and submitted to the Centers for Medicare and Medicaid Services (CMS) within the required federal submission timeframes. The Director of Case Management (DCM) acknowledged that the MDS assessments were supposed to be completed quarterly, approximately every 90 days. However, due to staffing issues, multiple residents had their assessments completed late, with some assessments being delayed by up to 157 days. This resulted in inadequate monitoring of the residents' progress or decline and a lack of resident-specific information being sent to CMS for payment and quality measure monitoring. The facility's policy and procedure for MDS assessments, revised in March 2024, required comprehensive assessments to be completed within 14 days after patient admission, on significant change in status, and annually. Additionally, quarterly review assessments were to be completed at least every 92 days following the previous assessment. Despite these guidelines, the facility did not adhere to the required timeframes, as evidenced by the late completion of MDS assessments for the nine residents reviewed. The DCM attributed the delays to being the sole individual responsible for entering the assessments, which typically involved more personnel.
Delayed Review of Monthly Medication Recommendations
Penalty
Summary
The facility failed to ensure that the Monthly Medication Review (MRR) conducted by the pharmacist was reviewed in a timely manner for two residents. The pharmacist completed the MRR and sent the recommendations to the Chief Nursing Officer (CNO) at the beginning of each month. However, the facility did not have a policy and procedure in place that included timelines and steps to be followed once the MRR was received. This resulted in a delay of two months in the physician's review of the MRR recommendations, which included medications for antipsychotics and hypnotics. The CNO acknowledged the delay and stated that the goal for review is one week. The facility's policy did not outline the expectations related to the MRR and physician review or specify time frames for the process. The CNO had delegated a nurse to review the MRR with the physicians, but the delay persisted. The policy indicated that urgent concerns should be brought to the CNO's attention immediately, but this was not effectively implemented, leading to potential risks for the residents involved.
Infection Control Deficiencies in Wound Care and Catheterization
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident with erosive wounds caused by tracheostomy dressing changes. During an observation, a registered nurse and a respiratory therapist did not wear gowns while providing high-contact care, which is contrary to the Centers for Medicare & Medicaid Services (CMS) guidance on EBP. The facility's policy on isolation precautions did not include EBP procedures, and the Infection Preventionist acknowledged the lack of policy updates and implementation of EBP, which could lead to the spread of multidrug-resistant organisms (MDRO). In another incident, a licensed vocational nurse did not follow sterile technique during urinary catheterization for a resident with anoxic encephalopathy and neurogenic bladder. The nurse used non-sterile gloves to handle sterile supplies, compromising the sterile field. The facility's policy required the use of sterile technique for catheter insertion, but this was not adhered to, increasing the risk of infection. Additionally, the same nurse failed to perform hand hygiene after attempting catheterization, which is a breach of the facility's infection control policy and the Centers for Disease Control and Prevention (CDC) guidelines. The nurse did not wash hands after resident contact, which is essential to prevent the spread of infections. The facility's policy emphasized the importance of hand hygiene in all patient care activities, but this was not followed, posing a risk of urinary tract infections.
Failure to Maintain Comprehensive Respiratory Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place for a resident with a tracheostomy and ventilator-dependent status. The resident, who was admitted with diagnoses including dependence on a ventilator, tracheostomy status, and bronchopulmonary dysplasia, did not have an active care plan addressing his respiratory needs. This oversight was identified during a review of the resident's clinical records, which revealed the absence of a care plan for his respiratory status, despite the presence of physician's orders for tracheostomy care and other related interventions. Interviews with the Director of Respiratory Therapy and the Director of Case Management confirmed the lack of an active respiratory care plan. The Director of Case Management acknowledged that the care plan had been mistakenly closed out after someone indicated the goal was met, leading to its inactivation. The facility's policy requires comprehensive and individualized care plans, but this was not adhered to in the case of the resident, resulting in a deficiency in care planning for his respiratory needs.
Controlled Medication Verification Process Not Completed
Penalty
Summary
The facility failed to ensure the proper verification process for controlled medications was completed accurately for two of seven medication carts. This deficiency was identified during observations and interviews with a Licensed Vocational Nurse (LVN) and the Chief Nursing Officer (CNO). The Controlled Substance Inventory Count (CSIC) forms for Valtoco Nasal Spray, a medication used to treat episodes of uncontrolled bodily movements, were found to have missing signatures from both oncoming and off-going nurses during shift changes. Specifically, on multiple occasions in December 2024 and January 2025, signatures were missing from the CSIC forms, indicating that the required verification process was not followed. The facility's policy and procedure for controlled substance management, which mandates that both the nurse leaving the shift and the nurse coming on duty must verify and document the count of controlled substances, was not adhered to. The CNO confirmed that the policy was not followed, which had the potential to lead to the diversion of controlled medications in a population of 50 patients. The failure to complete the verification process accurately was confirmed by LVN 2, who acknowledged the missing signatures and the oversight in the procedure.
Non-compliance with PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of PRN psychotropic medications, specifically lorazepam, for a resident. The resident, who had a complex medical history including tracheostomy status and hypoxic ischemic encephalopathy, was prescribed lorazepam for agitation with an order that exceeded the 14-day limit without documented rationale from the prescriber. The medication order was active for 20 days, from December 20, 2024, to January 8, 2024, and the resident received the medication multiple times during this period for agitation. Interviews with the facility's pharmacist and Chief Nursing Officer (CNO) revealed that there was no documented rationale for extending the PRN order beyond 14 days, which is required by regulation. The pharmacist acknowledged the irregularity of the order duration, and the CNO confirmed the absence of a policy and procedure regarding PRN psychotropic medication orders. The facility relied on the pharmacist to ensure compliance with regulations, but this oversight led to a deficiency in medication management for the resident.
Expired Medication Found in Emergency Kit
Penalty
Summary
The facility failed to ensure proper medication management when a bottle of Humulin R, a short-acting insulin, was found expired by 33 days in one of the four medication emergency kits (E-Kits). This was discovered during an observation and interview with the Charge Nurse in the medication storage room. The Charge Nurse confirmed the expiration and acknowledged the potential risk of administering expired medication during an emergency, which could be detrimental to a resident's health and safety. Further investigation revealed that the facility's policy and procedure for medication management, which mandates the removal and appropriate disposal of expired medications, was not followed. The Chief Nursing Officer confirmed the policy breach. Additionally, the in-house Director of Pharmacy stated that nurses are responsible for ensuring medications are not expired and should notify the pharmacy for replacements. Despite checks documented in the Subacute Charge Nurse Report, the expired medication was not identified or replaced, indicating a lapse in the medication management process.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to adhere to safe and sanitary food storage practices, as observed during a survey. In the dry storage area, seven onions were found labeled with an expired use-by date, indicating they were three days past their intended use. The kitchen staff member, CK 1, acknowledged the oversight and removed the onions from the storage area. Additionally, in the walk-in freezer, a large bucket of ice cream was discovered without any labeling to indicate the date it was received or its intended use-by date. CK 1 admitted uncertainty about when the ice cream was purchased, noting it was intended for an employee Christmas party but was not labeled as such. The Registered Dietician (RD 1) confirmed that all food items should be labeled with the date of receipt and a use-by date, and that food for employee events should be clearly marked to distinguish it from resident food. RD 1 also stated that onions could be stored for up to 30 days in the dry storage area, provided they were properly labeled. A review of the facility's policy on food labeling and dating revealed that a labeling and dating machine was supposed to be used to ensure food items were rotated and used by their expiration dates. These lapses in food storage practices had the potential to compromise food integrity and pose a risk of foodborne illness to 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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