Tracy Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tracy, California.
- Location
- 545 West Beverly Place, Tracy, California 95376
- CMS Provider Number
- 555080
- Inspections on file
- 30
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Tracy Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic kidney disease and type 2 DM repeatedly refused skilled services, morning medications, blood draws, and participation in a care conference, and experienced significant weight loss over several weeks. Although the admission record identified a family member as the responsible party and care conference contact, staff did not notify this representative of the refusals of care, the request not to be disturbed, the significant weight loss, or the scheduled care conference, and did not invite the representative to participate. The DON acknowledged that the responsible party had the right to be informed of such changes, and facility policies required notification of the representative and involvement of family in person-centered care planning, but these policies were not followed.
A resident with multiple chronic conditions, including CKD stage 3B, asthma, post-stroke hemiplegia, HTN, PTSD, and type 2 DM, repeatedly refused skilled services, morning medications, a blood draw, and participation in a care conference. Despite these ongoing refusals, staff confirmed that no comprehensive, person-centered care plan was developed to address the refusals or to guide interventions to encourage acceptance of care and involvement in care planning. This was inconsistent with facility policies requiring the IDT to assess residents who refuse care, offer alternative treatments when appropriate, and create measurable, time-bound care plan objectives to direct daily care and prevent decline.
Staff failed to follow hand hygiene requirements for a resident on Enhanced Barrier Precautions (EBP) who had multiple infections, including UTI, E. coli, cellulitis, a stage 4 pressure ulcer, and C. perfringens. An EBP sign was posted at the room door, yet the DSD entered and exited the room to respond to a call light without performing hand hygiene. In a separate instance, a CNA handled a meal tray from the hallway cart, entered the room, assisted with meal preparation, then exited and returned to the meal cart without performing hand hygiene. Both staff later acknowledged the lapse, while the IP and DON confirmed that facility policy and standard precautions require hand hygiene before entering and after exiting rooms and after contact with the resident’s environment.
A resident with multiple serious diagnoses and a documented Full Code status was found unresponsive and without vital signs. Despite clear documentation and the representative's wishes for full resuscitation, licensed staff did not initiate CPR or call a Code Blue, and no life-saving measures were attempted prior to hospice arrival. Staff interviews confirmed a lack of protocol adherence and understanding, and the facility's policy requiring basic life support in the absence of a DNR order was not followed.
The facility failed to honor the end-of-life preferences for three residents by not verifying or obtaining Advance Directives upon admission. For two residents, the facility did not determine if they had or wished to formulate an Advance Directive, and for another resident, the facility did not have a copy of the existing Advance Directive on file. Interviews with staff revealed a lack of adherence to policies and procedures regarding Advance Directives and POLST forms.
A resident was admitted with incorrect discharging documents from an acute hospital, leading to significant medication errors for three days. The facility staff failed to thoroughly check the interfacility transfer documents, resulting in the resident receiving medications not prescribed for them. The error was discovered during an unannounced survey after the acute hospital reported the mistake.
A resident with an amputation and Type 2 diabetes was not provided with a prosthetic leg despite being motivated and having an order for evaluation. The facility failed to document and follow up on the prosthetic evaluation, leaving the resident without the necessary adaptive device. The facility's policy on evaluating and accommodating residents' needs was not adhered to, as acknowledged by the DON and Administrator.
A resident was unable to store personal belongings due to inadequate space and previous resident's items left in drawers. Staff confirmed the issue, and the DON acknowledged it was against policy, impacting the homelike environment.
A resident with an indwelling catheter did not have a specific care plan developed upon admission, despite having diagnoses that required catheter care. The facility's procedures and policies were not followed, as confirmed by interviews with staff, including the DON, who acknowledged the oversight.
A resident did not receive scheduled showers over a nine-day period, as confirmed by the facility's Director of Staff Development and Director of Nursing. The resident, with a history of diabetes and heart disease, was supposed to receive showers twice a week, but documentation showed missed showers. This failure to provide basic hygiene care was against the facility's policy, which emphasizes the importance of bathing for cleanliness and skin assessment.
A resident was administered incorrect medications and care for three days due to an error in interfacility transfer documents, which had a different name despite correct stickers. The error was discovered when the acute hospital contacted the facility. Staff interviews revealed reliance on stickers without verifying document names, leading to the deficiency.
A resident with multiple diagnoses, including a history of falls and disorientation, was found outside the facility due to inadequate supervision and failure to implement care-planned interventions. The care plan required a wheelchair alarm and bed alarm checks, which were not fully executed. The facility's policy emphasized individualized safety measures, but these were not effectively applied, leading to the resident's unsupervised wandering.
A resident's IV saline lock was not managed according to professional standards, with the dressing undated, no care plan, and lack of documentation for site care and flushing. The IV was left in place for eight days, exceeding the recommended duration, despite the resident having a PICC line in place.
A facility failed to properly handle controlled medications for a deceased resident. After the resident's death, controlled medications were not removed from the medication cart or counted at shift change by the LNs. The facility's policies require that controlled medications be counted by two LNs at each shift change and stored securely until destruction. The DON confirmed that these procedures were not followed, which could have led to medication errors or diversion.
A resident experienced dental pain for two months without receiving recommended dental services, including a full mouth x-ray for a broken tooth. Despite reporting the issue to staff, no follow-up care was provided. The facility lacked a system to ensure follow-up on treatment recommendations, leading to a significant delay in addressing the resident's dental needs.
A resident with a left leg amputation and Type 2 diabetes was waiting for a prosthetic leg for a year due to missing evaluation notes in her medical record. Despite being highly motivated and having an order for a prosthetic evaluation, the facility failed to obtain and include the necessary documentation. Interviews with staff confirmed the absence of these notes, which were crucial for medical providers to review recommendations. The facility's policy on documentation was not followed, as acknowledged by the DON and Administrator.
The facility failed to maintain infection control measures when a CNA entered a Contact Isolation Precautions room without PPE and did not perform hand hygiene. Additionally, clean water pitchers were distributed from a cart with dirty items, risking cross-contamination. A resident's urinary catheter bag was found on the floor, contrary to policy, posing an infection risk. These actions did not adhere to the facility's infection control policies.
The facility did not meet the minimum space requirement of 80 square feet per resident in seven shared rooms, affecting rooms 1, 3, 5, 6, 8, 10, and 11. Despite this, staff and residents reported no complaints about room sizes, and the Department recommended continuing the room size waiver.
Failure to Notify Responsible Party of Significant Changes and Care Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of significant changes in the resident’s condition and refusals of care, despite the RP being identified in the admission record as the contact person for care conferences. The resident was admitted with chronic kidney disease stage 3B and type 2 diabetes mellitus, and the care plan indicated a preference for having family involved in discussions about care. The resident’s physical therapy evaluation documented refusal of any skilled services and identified a risk for falls. Progress notes showed that over a period of several weeks the resident repeatedly refused morning medications, requested not to be disturbed for care, refused a blood draw, and refused to attend a care conference. The interdisciplinary team also discussed the resident’s significant weight loss during this time. During interviews, a licensed nurse confirmed that the RP was not notified of the resident’s refusals of prescribed morning medications, refusal of a blood draw, request not to be disturbed, refusal to participate in a care conference, or the significant weight loss, and that the RP was not invited to the care conference. The DON stated that the RP had the right to be informed of changes in the resident’s condition, such as significant weight loss or refusal of care or treatment, and acknowledged that the RP was not given the opportunity to participate in care planning and decision-making. Review of facility policies showed requirements to inform the resident/representative regarding refusal or discontinuation of treatment, to notify the physician and RP of significant weight changes, and to develop a comprehensive person-centered care plan in conjunction with the resident and family or legal representative. These documented policies were not followed in this case.
Failure to Care Plan for Ongoing Refusals of Care and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address one resident's repeated refusals of care, treatment, and participation in a care conference. The resident was admitted with multiple significant diagnoses, including chronic kidney disease stage 3B, asthma, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, essential hypertension, PTSD, and type 2 diabetes mellitus. A PT evaluation dated 11/25/25 documented that the patient was refusing any skilled services and identified a risk for falls due to physical impairments and functional deficits. Progress notes from 11/25/25 through 12/20/25 showed ongoing refusals of morning medications, a request not to be disturbed, refusal of a blood draw, and refusal to participate in a care conference. During interviews and concurrent record reviews, an LN confirmed that these refusals required a care plan with effective interventions to encourage acceptance of care, treatment, and participation in care planning, but acknowledged that no such care plan existed for this resident. The DON stated that nursing staff were expected to assess residents who refused care and treatment and initiate a care plan to address refusals and implement appropriate interventions to prevent potential health decline. Facility policies on refusing care and on comprehensive, person-centered care plans required the interdisciplinary team to assess needs, offer alternative treatments when appropriate, and develop measurable objectives and timetables to meet residents' physical, psychosocial, and functional needs, with care plans used to guide daily care routines. Despite these policies, the resident's refusals were not incorporated into a written care plan, which, according to staff, placed the resident at risk for worsening underlying conditions, overall health decline, and preventable complications.
Failure to Perform Hand Hygiene for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently performed hand hygiene as part of its infection prevention and control program for a resident on Enhanced Barrier Precautions (EBP). The resident had multiple serious infections and conditions, including a urinary tract infection, unspecified Escherichia coli as the cause of disease, cellulitis of the buttock, local skin and subcutaneous tissue infection, resistance to multiple antimicrobial drugs, a stage 4 pressure ulcer of the right buttock, and Clostridium perfringens as the cause of disease. An EBP sign was posted outside the resident’s room. During observation, the Director of Staff Development (DSD) entered the resident’s room in response to a call light without performing hand hygiene, turned off the call light, and exited the room without performing hand hygiene. The DSD acknowledged not performing hand hygiene upon exiting the EBP room and stated that hand hygiene was supposed to be performed to prevent the spread of infections in the facility. In a separate observation, a Certified Nurse Assistant (CNA) picked up a meal tray from the meal cart in the hallway, entered the same resident’s room, delivered the tray, placed it on the over-bed table, and assisted with meal preparation, then exited the room and approached the meal cart without performing hand hygiene. The CNA stated she forgot to perform hand hygiene after exiting the room and before handling another resident’s meal tray, and acknowledged that this failure placed other residents at risk for infection. The Infection Prevention Nurse stated that staff were required to perform hand hygiene before entering and after exiting a resident’s room and before and after performing any task for residents, and that failure to do so placed other residents at risk for infection. The DON stated that staff were required to perform hand hygiene as part of standard precautions to break the infection cycle and prevent the spread of infection. Facility policies on Enhanced Barrier Precautions and Infection Control Guidelines for All Nursing Procedures required visual alerts for high-contact care and hand hygiene after contact with objects in the immediate vicinity of the resident.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Licensed staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented code status of Full Code, as indicated in the medical record, hospice documentation, and a POLST form signed by the resident's representative. Despite this, when the resident was discovered unresponsive, nursing staff did not initiate CPR or call a Code Blue, and no resuscitation efforts were made prior to the arrival of hospice personnel, who subsequently pronounced the resident deceased. The resident had multiple significant diagnoses, including chronic obstructive pulmonary disease, dementia, hypertensive heart disease with heart failure, and was under hospice care. The code status was discussed and confirmed with the resident's representative, who wished for all life-saving interventions to be performed. The facility's own policy required staff to provide basic life support in the absence of a valid DNR order, and the staff were aware of the resident's Full Code status. Interviews with the Director of Staff Development, a licensed nurse, and certified nursing assistants confirmed that no CPR was attempted, and the facility's emergency response protocol was not followed. Staff interviews revealed a lack of clarity and adherence to protocol, with the nurse on duty stating she did not know the facility's procedures and had concerns about reviving the resident. The Director of Nursing confirmed that the facility's policy was not followed and that the decision to perform CPR was not up to the nursing staff, as the representative's wishes were clearly documented. The failure to initiate CPR resulted in the resident's representative's wishes not being honored and potentially contributed to the resident's death.
Failure to Honor Residents' End-of-Life Preferences
Penalty
Summary
The facility failed to ensure that the preferences for end-of-life or emergency care were honored for three residents. For Resident 43, the facility did not determine upon admission whether the resident had an Advance Directive or wished to formulate one. The clinical records, including the Physician Orders for Life-Sustaining Treatment (POLST), did not indicate if an Advance Directive was discussed or if the resident had the capacity to make decisions. Interviews with the Director of Nursing (DON) and Medical Records staff revealed that the facility did not verify or obtain a copy of an Advance Directive for Resident 43. Similarly, for Resident 49, the facility did not ascertain if the resident had an Advance Directive or wished to create one during the admission process. The POLST form did not reflect any discussion about an Advance Directive. Interviews with the Social Services Director and the DON confirmed that the facility did not explain or assist the resident in formulating an Advance Directive. The Medical Records staff acknowledged the absence of an Advance Directive on file for Resident 49. For Resident 12, although the clinical record indicated the presence of an Advance Directive, the facility failed to have a copy available. The Preferred Intensity of Care form noted that a copy should be attached, but it was not. Interviews with the Licensed Nurse, Social Services Director, and Medical Records staff confirmed that the facility did not follow up to obtain a copy of the Advance Directive, despite being informed by the resident's responsible party that it had been provided. The facility's policies and procedures were not adhered to, as acknowledged by the DON and the Administrator.
Medication Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they were admitted with incorrect discharging documents from an acute hospital. This error was not identified for three days, resulting in the resident receiving medications that were not prescribed for them. The error was discovered during an unannounced annual recertification survey after the acute hospital contacted the facility to report the mistake. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications intended for another patient. These medications included antibiotics, anticoagulants, blood pressure medications, and others not prescribed for the resident. The facility's staff, including the Admissions Coordinator and the Director of Nursing, confirmed that the interfacility transfer documents had the correct sticker with the resident's name but contained a different name in smaller print on each page. Interviews with facility staff revealed that the nursing staff did not thoroughly check the interfacility transfer documents, relying instead on the stickers attached to the documents. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the medication errors.
Failure to Follow Up on Prosthetic Leg Request
Penalty
Summary
The facility failed to meet the needs of a resident, identified as Resident 12, by not adequately following up on her request for a prosthetic leg. Resident 12, who has Type 2 diabetes and an amputation above the knee, expressed her desire to regain independence and mobility through the use of a prosthetic leg. Despite having an order for a prosthetic evaluation from her physician, the facility did not ensure the completion and documentation of this evaluation. Interviews with the Medical Director and Director of Rehab revealed that although referrals for a prosthetic evaluation were made, the evaluation notes were missing from Resident 12's clinical record, leaving the physician unaware of the recommendations. The Prosthetic Representative confirmed that Resident 12 was assessed for a prosthetic leg and was highly motivated to receive one, but the evaluation notes were not provided to the facility. The facility's policy on Quality of Life, which mandates the evaluation of residents' needs for adaptive devices, was not followed. The Director of Nursing and the Administrator acknowledged this oversight, admitting that the facility did not adhere to its policy and procedure, resulting in Resident 12's needs not being met.
Inadequate Storage Space for Resident's Belongings
Penalty
Summary
The facility failed to provide a homelike environment for Resident 55, as evidenced by the lack of adequate space for storing personal belongings. Upon admission in July 2024, Resident 55 was assigned to bed A, but the space allocated for personal items was insufficient. During an observation and interview, a family member expressed frustration over the narrow closet space and the inability to use the drawers, which were labeled with a previous resident's name and contained their belongings. This situation prevented Resident 55 from utilizing the space for personal items, compromising the homelike environment. Further observations and interviews with facility staff, including a CNA and LN, confirmed the presence of a discharged resident's name and belongings in the drawers meant for Resident 55. The staff acknowledged that the drawers should have been cleared and relabeled for the new resident. The DON stated that the facility's policy does not include labeling drawers with resident names and emphasized that all belongings should be removed upon discharge. The failure to adhere to these policies resulted in Resident 55 being unable to use the designated space for personal belongings, thus not ensuring a homelike environment.
Failure to Develop Care Plan for Catheter Care
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan for Resident 317, who was admitted with diagnoses including a urinary tract infection and artificial openings of the urinary tract. The Minimum Data Set (MDS) assessment indicated that Resident 317 had an indwelling catheter, which required specific care. However, upon review, it was found that there was no care plan created for the use of the indwelling catheter, despite the Order Summary Report specifying catheter care every shift and monitoring for signs and symptoms of urinary tract infection. During interviews, both Licensed Nurse 8 and the Director of Nursing acknowledged the absence of a care plan for catheter care. The Director of Nursing stated that a care plan should have been created upon admission to ensure all necessary care was provided. The facility's procedures and policies emphasized the importance of a comprehensive, person-centered care plan to meet the resident's needs, which was not adhered to in this case.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate care and services for activities of daily living (ADLs) for one resident, identified as Resident 22, by not ensuring that the resident received scheduled showers. Resident 22, who was admitted to the facility with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, did not have documented evidence of receiving a shower from August 6 through August 15, 2024. This lapse was confirmed through interviews and record reviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), who acknowledged the absence of shower documentation and confirmed that the showers were missed. The facility's policy on ADLs, revised in March 2018, mandates appropriate support and assistance with hygiene, including bathing, for residents unable to perform these tasks independently. The DSD and DON both emphasized the importance of showers for maintaining hygiene, preventing infections, and conducting thorough skin assessments. The lack of showers not only compromised Resident 22's hygiene but also potentially affected their psychosocial well-being, as noted by the DSD. The facility's failure to adhere to its own procedures for bathing and showering, as outlined in their policy, resulted in this deficiency.
Medication and Care Plan Error Due to Incorrect Transfer Documents
Penalty
Summary
The facility failed to ensure that correct medications were administered and the correct plan of care was followed for a resident due to an error in the interfacility transfer (IFT) documents. Upon admission, the resident was given incorrect medications and care for three days because the IFT documents from the acute hospital contained a different name, although a sticker with the resident's name was attached to each page. This discrepancy was not identified until the acute hospital contacted the facility three days after the resident's admission. The resident, who was admitted with diagnoses including the presence of a left artificial hip joint, diabetes mellitus, and heart disease, received medications that were not prescribed for her. These included antibiotics, anticoagulants, and medications for conditions such as high blood pressure and Alzheimer's disease. The error was discovered when the acute hospital called to inform the facility that the IFT documents did not belong to the resident. Interviews with facility staff, including the Admissions Coordinator, Director of Nursing, and Licensed Nurses, revealed that the error occurred because the staff relied on the stickers attached to the IFT documents without verifying the names on the documents themselves. The facility's procedure required reconciliation of medication lists and communication with the attending physician, but these steps were not adequately followed, leading to the administration of incorrect medications and care for the resident.
Failure to Implement Care-Planned Interventions and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions for a resident, identified as Resident 62, which led to a deficiency. Resident 62, who was admitted in the spring of 2024, had multiple diagnoses including benign prostatic hyperplasia, a history of falling, anxiety disorder, major depressive disorder, and disorientation. The resident was found on his knees in the facility's front parking lot, indicating a lapse in supervision and monitoring. The care plan for Resident 62 included the use of a wheelchair alarm and a bed alarm to alert staff if the resident attempted to get up unassisted, but these interventions were not fully implemented. Interviews and record reviews revealed that the facility did not have a physician's order for a wheelchair alarm for Resident 62, despite the care plan indicating its necessity. Additionally, the bed alarm checks were not documented during the night shift on a specific date, which was a part of the facility's protocol. The Director of Nursing (DON) confirmed the absence of a wheelchair alarm order and expressed concern over the missing documentation of bed alarm checks. The DON also acknowledged that Resident 62 was at risk for falls due to psychiatric diagnoses and unsteady gait, and that closer supervision was warranted. The facility's policy on safety and supervision emphasized individualized, resident-centered approaches to address safety and accident hazards. However, the failure to implement the care-planned interventions and adequately supervise Resident 62 resulted in the resident being found outside the facility, which could have been prevented with proper monitoring. The DON and Administrator admitted that Resident 62's behaviors, such as wandering and removing the mattress from the bed, required more vigilant supervision and possibly the use of a Wander Guard, which was not in place at the time of the incident.
Failure to Adhere to IV Therapy Protocols
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident receiving parenteral medication. Specifically, the resident's peripheral IV saline lock dressing was not dated, and there was no care plan developed for the IV saline lock. Additionally, there was no documentation of IV site care and flushing in the resident's medical record, and the IV saline lock was left in place for eight days, exceeding the recommended duration of seven days. The resident, who was admitted in Spring 2024, had diagnoses including a wedge compression fracture, low back pain, and osteoarthritis. During an observation, it was noted that the IV saline lock in the resident's left hand was covered with a transparent dressing without a date or nurse's initials. The facility's policy required transparent dressings to be changed every seven days and labeled with the date and nurse's initials. The Director of Staff Development confirmed the lack of documentation and adherence to policy, and the Director of Nursing stated that the policy should have been followed.
Failure to Properly Handle Controlled Medications for Deceased Resident
Penalty
Summary
The facility failed to ensure the proper handling and accounting of controlled medications for a deceased resident, identified as Resident 58. After the resident's death, the controlled medications, which included hydrocodone and lorazepam, were not removed from the medication cart, nor were they counted at shift change by the licensed nurses, LN 1 and LN 6. During an observation and interview, both nurses acknowledged that they forgot to count the controlled medications, which is a critical step to prevent medication errors or drug diversion. The facility's policies and procedures require that controlled medications be counted by two licensed nurses at each shift change and stored securely until they are destroyed or picked up by a hospice nurse. The Director of Nursing (DON) confirmed that the facility's policies and procedures were not followed in this instance. The policies stipulate that discontinued medications should be marked and stored in a designated secure area until they are destroyed. The DON stated that the controlled medications should have been given to her for destruction with the pharmacist, and that the ongoing and off-going nurses were responsible for counting the medications until they were properly disposed of. This oversight in following established protocols could have led to medication being administered incorrectly or diverted for unauthorized use.
Failure to Provide Recommended Dental Services
Penalty
Summary
The facility failed to ensure that a resident received recommended dental services, specifically a full mouth x-ray for a broken tooth identified months earlier. The resident, who experienced dental pain for about two months, reported the issue to multiple staff members but did not receive the necessary follow-up care. During interviews, the resident expressed frustration over not being heard and feeling neglected. The Social Services Director (SSD) confirmed that there were no referrals or notices for service from the nurses regarding the resident's complaint of tooth pain. The SSD also noted that the facility lacked a follow-up process for treatment recommendations, which contributed to the oversight. The Director of Nursing (DON) reviewed the resident's dental notes and confirmed the absence of follow-up orders for the recommended treatment. The DON acknowledged that the facility should have a system in place to ensure follow-up with outside dental services and that the four-month delay was excessive. The lack of follow-up posed a risk to the resident, as untreated dental issues could lead to further complications. The facility's policy on dental services indicated that routine and emergency dental services should be available to meet residents' oral health needs, but this was not adhered to in this case.
Missing Prosthetic Evaluation Notes in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that copies of evaluations for a prosthetic leg were included in the medical records of a resident, identified as Resident 12. This deficiency was identified during a review of Resident 12's clinical records, which revealed that the resident had been waiting for a prosthetic leg for a year. Despite having an order for a prosthetic evaluation, the facility did not have access to the evaluation notes, which were crucial for medical providers to review recommendations regarding the prosthetic leg. Interviews with the Medical Director, Director of Rehab, and Licensed Nurse confirmed that the evaluation notes were missing from the clinical record, and attempts to obtain them from the prosthetic company were unsuccessful. Resident 12, who had a left leg amputation and a diagnosis of Type 2 diabetes, expressed a strong desire to receive a prosthetic leg to improve her mobility and independence. The Prosthetic Representative confirmed that Resident 12 was highly motivated to have a prosthetic leg and had been assessed multiple times the previous year. However, the representative did not provide the facility with copies of the evaluation notes, stating it was not her practice to do so. The facility's policy on documentation required such information to be included in the resident's medical record, but this policy was not followed, as acknowledged by the Director of Nursing and the Administrator.
Infection Control Deficiencies in PPE Use, Water Distribution, and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control measures in several instances. A Certified Nurse Assistant (CNA) entered a room designated for Contact Isolation Precautions without wearing the necessary personal protective equipment (PPE) and exited without performing hand hygiene. The CNA was unaware of the isolation status of the room, which was confirmed by a Licensed Nurse who informed the CNA of the requirement for PPE. The Director of Staff Development and the Director of Nursing confirmed that the facility's policy required PPE and hand hygiene for such rooms, but these protocols were not followed. Another deficiency was observed when a CNA distributed clean water pitchers from a cart that also contained dirty water pitchers, a dirty cup, and a partially eaten food tray. This practice posed a risk of cross-contamination, as acknowledged by the CNA and the Director of Staff Development. The Director of Nursing confirmed that the procedure for distributing clean water pitchers was not adhered to, which increased the risk of infection. Additionally, a resident's urinary catheter bag was found resting on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor to prevent contamination. Both a CNA and a Licensed Nurse confirmed the improper placement of the catheter bag, and the Infection Preventionist and Director of Nursing acknowledged the infection risk associated with the bag being on the floor. The facility's policy on urinary catheter care was not followed, leading to potential cross-contamination and infection risk.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms met the minimum space requirement of at least 80 square feet per resident in seven shared rooms. This deficiency was identified during a recertification survey, where it was observed that rooms 1, 3, 5, 6, 8, 10, and 11, each housing three residents, did not meet the required space per resident. The room sizes ranged from 229 to 238 square feet, which is below the required 240 square feet for three residents. Interviews with the Administrator and Maintenance Director confirmed the measurements of these rooms. Despite the deficiency, interviews with staff and residents revealed that there were no complaints regarding the room sizes. Licensed nurses and the Director of Nursing stated that they had not received any complaints from residents about the room sizes affecting their ability to perform their duties safely. Residents interviewed expressed that they had enough space for their personal belongings and were comfortable, although one resident mentioned a preference for sharing the room with only one other resident. The Department recommended the continuation of the room size waiver for the affected rooms.
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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