Westview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 12225 Shale Ridge Lane, Auburn, California 95602
- CMS Provider Number
- 055776
- Inspections on file
- 85
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Westview Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple respiratory and cardiac conditions, including respiratory failure, COPD, and RSV, had physician orders and a care plan for continuous O2 at 2 L/min via nasal cannula with titration allowed only during activity or therapy to maintain O2 sats above 90%. Nursing documentation on the morning of the incident reflected O2 at 2 L/min with an O2 sat of 96%, but later observation found the resident’s O2 concentrator set at 3.5 L/min while the resident remained in bed without increased activity. An LN, the DON, and a nurse supervisor all confirmed there was no documentation of a drop in O2 saturation or any clinical indication or progress note explaining the increase in liter flow, despite facility policies requiring adherence to MD orders and recording of O2 flow rate and route after adjustments.
A resident with dementia and severe cognitive impairment was in a hallway near the dining room when another cognitively impaired resident in a wheelchair came up from behind and grabbed her breasts with both hands. The ADON directly observed the contact, and the affected resident later stated that someone had touched and squeezed her breasts in the hallway. Staff reported that the resident who initiated the contact had a history of prior inappropriate behavior toward a female resident and was being closely monitored. The facility’s abuse prevention policy required that residents be protected from abuse by anyone, including other residents, but this incident occurred despite that requirement.
A resident who lacked decision-making capacity had an RP/POA spouse and a physician order requiring that any change in medications, treatments, diagnoses, behaviors, or care plan be approved by the spouse. The RP had arranged for the resident’s psychiatric care through an outside psychiatrist and, during a care conference, verbally and in writing withheld consent for any psychiatric, psychological, or mental health services from the facility’s contracted psychiatrist (PD) or other contracted mental health providers, requesting that they be removed from the resident’s provider list. Despite this, the resident’s profile and face sheet continued to list the contracted PD, the ADON acknowledged the RP’s request but did not remove the PD’s name or notify the PD, and the PD later arrived at the resident’s room with a list that included the resident, prompting the RP to intervene. Surveyors found no evidence that the facility acted on the RP’s request or prevented the PD’s access to the resident’s information, contrary to the facility’s resident rights and privacy policies.
A resident with type 2 DM on Jardiance and scheduled insulin, and with a history of stroke and DKA, had only PRN blood glucose monitoring initially and later an order for routine AM and HS checks. Documentation showed multiple blood glucose readings above 200 mg/dL, including several over 400 mg/dL on consecutive days, but there was only one documented MD notification despite these elevations. The resident was later transferred to the hospital with worsening hypoxemia and was found to have blood glucose greater than 500, requiring ICU treatment. The DON reported that blood sugars were expected to be monitored regularly and that MD notification was expected for readings above 200 mg/dL, and the facility’s diabetes protocol called for twice-daily monitoring for residents on insulin and practitioner notification for repeated readings above 250 mg/dL with a change in condition.
A resident with post-stroke hemiplegia, aphasia, and DM with ketoacidosis was admitted for short-term care, with the daughter identified as the responsible party. Social services staff documented voicemail and phone contact to invite the responsible party to a care conference and noted that the party would attend by phone, but there was no follow-up documentation confirming that the conference occurred with the representative’s participation. An IDT conference note later indicated a care conference was held with SSD, ADON, and DOR, but the Nursing Services section was left incomplete and there was no record that the representative was involved. The MDSC confirmed the resident was nonverbal, tube-fed, and bedbound, that SSD schedules conferences within the first week of admission, and that there was no documentation of contact with the representative, contrary to facility policy requiring resident/representative participation and documented notification for care planning.
A document containing residents’ protected health information (PHI), including names, room numbers, cognitive (A&O) status, code status, diagnoses, and medication administration details, was observed left on top of a medication cart in a hallway. A nurse admitted he had left the document there and acknowledged it violated residents’ rights to privacy and confidentiality. When shown photos of the document on the cart, the DON confirmed it should not have been there. Facility policy on PHI requires all personnel to manage and protect resident information to prevent unauthorized disclosure.
A resident with multiple chronic conditions and moderate cognitive impairment had an Advance Health Care Directive (AD) designating two individuals as Power of Attorney for Health Care (POA). The facility failed to maintain the current AD in the electronic record and instead relied on emergency contacts not named in the AD for notifications and decision-making. As a result, the designated agents were not notified of the resident's death by the facility, learning of it only through the mortuary. Staff later confirmed the AD was not uploaded or referenced as required by facility policy.
A resident with significant physical disabilities and intact cognition was struck in the face by another resident with severe cognitive impairment and a history of aggressive behavior. The incident occurred in the smoking area, resulting in physical injury and psychosocial distress for the victim. Witnesses and staff confirmed the altercation, and facility records indicated that preventive measures to monitor and separate residents with aggressive tendencies were not effectively implemented prior to the event.
Care plans were not updated and documentation was incomplete for three residents after two were involved in a physical altercation and another reported abuse by a CNA. Despite the incidents being reported, the required care plan updates and clinical documentation were not completed as per facility policy.
A resident with normal cognition and a history of stroke was physically abused by a roommate with moderate cognitive impairment, who threw a hard plastic cup of thickened liquid at the resident's face during an argument over cigarettes. The incident resulted in the resident being covered in fluid and sustaining a red mark on the cheek, and was confirmed by both residents and the DON. This event represents a failure to protect a resident from physical abuse as required by facility policy.
A cognitively impaired resident with diabetes was subjected to sexual abuse when another resident, known for prior inappropriate behaviors, grabbed and placed the resident's hand on his groin. This incident, witnessed and reported by another resident, was not the first occurrence, and previous inappropriate actions by the perpetrator had not been properly reported or addressed by staff.
Staff failed to report an allegation of abuse involving two residents to enforcement agencies within the required two-hour timeframe. Despite being notified of the incident, the Administrator delayed reporting for three days, contrary to facility policy and federal regulations. The resident involved had a documented history of inappropriate behavior that had not been previously reported or addressed.
A resident with dementia and moderate memory impairment was inappropriately touched by another resident, also with moderate memory impairment, in a hallway after an activity event. The incident was witnessed by staff, and the affected resident was unable to communicate well but showed visible signs of distress. Facility records confirmed the incident, and the DON acknowledged it occurred, but there was no evidence of consent. This resulted in a failure to protect the resident from abuse, contrary to the facility's abuse prevention policy.
Discontinued controlled medications, including a bottle of lacosamide and several blister packs, were found improperly stored with non-controlled and active medications, lacking required count sheets and not secured in the DON's office as per facility policy. Nursing staff confirmed these medications should have been removed from active storage and properly documented until destruction.
Surveyors found expired medications, loose pills, and a misplaced blister pack in medication carts, as well as unlabeled creams left at the bedside of two residents. LNs and the DON confirmed these practices were not in line with facility policies, which require proper labeling, timely disposal of expired drugs, and secure storage of all medications.
Surveyors identified multiple infection control deficiencies, including an unlabeled G-tube water flush bag for a resident with severe cognitive impairment, a medication cart not cleaned of residue from a previously crushed medication, and a CNA providing high-contact care to a resident on Enhanced Barrier Precautions without wearing a gown, despite facility policy and posted signage.
A resident with mild memory impairment was inaccurately assessed as a non-smoker in the MDS and related documentation, despite self-reporting cigar use and staff confirmation. The MDS Coordinator acknowledged the inconsistency between the resident's actual tobacco use and the documented assessments.
A resident with diagnoses of unspecified psychosis and major depressive disorder was not provided with a required PASRR Level II evaluation after readmission. The DON was unaware of the need for the evaluation, and no follow-up was conducted, resulting in the resident not receiving the necessary assessment as indicated by the facility's screening process.
Four residents did not have comprehensive care plans addressing their needs, including three residents who smoked and one with rashes. In several cases, staff confirmed the absence of required care plans or failed to implement existing plans, such as not storing smoking materials as directed. These deficiencies were identified through interviews, record reviews, and direct observation.
A resident with cognitive impairment and hearing loss did not receive needed assistance with hearing aids, which remained unused for two months. The resident repeatedly requested help and education on using and charging the devices, but staff failed to provide support due to unclear communication and lack of documented orders, despite facility policy requiring such assistance.
A resident with severe cognitive deficits and total dependence on staff for ADLs was observed with long, dirty fingernails on her left hand. Despite care plan requirements and facility policy mandating daily grooming and nail care, staff failed to provide this assistance, as confirmed by both a nurse and the DON.
Two residents with severe cognitive and physical impairments were found without accessible call lights, despite care plans and facility policy requiring call lights to be within reach. Staff confirmed the call lights were not positioned appropriately, leaving the residents unable to request assistance as needed.
Several rooms did not meet the required minimum square footage per resident, with some providing only 65 to 78.12 square feet instead of the mandated 80 or 100 square feet. Observations showed the rooms were clutter-free and accessible for residents with mobility aids, and neither residents nor staff reported issues related to space or care delivery.
A resident with long-term kidney disease and breathing problems was not allowed to return to the facility after hospitalization due to the interference of her POA, her daughter, with medical care. Despite the facility's policy allowing return within the bed-hold period, the resident was discharged on the same day she was sent to the hospital, as confirmed by the Administrator and DON.
A resident with COPD and kidney failure was prescribed Prednisone for five days post-hospital discharge, but the LTC facility continued the medication for 17 additional days. This oversight led to severe oral thrush and fluid retention. Despite family communication and multiple NP visits, the error was not corrected, and the facility's policies on medication orders were not followed.
A resident with cognitive impairment was injured during an altercation with another resident who was cognitively intact. The incident involved one resident striking the other with a wheelchair armrest, causing a skin tear. The altercation was witnessed by staff, and the resident admitted to the act. The facility's abuse prevention policy was not effectively implemented to protect the resident from harm.
A facility failed to provide a resident's legal representative with timely access to medical records. The representative requested the resident's vaccination records, but the facility did not provide them within the 72-hour timeframe as per policy. The records were requested on August 2, 2024, but were not provided until August 9, 2024, resulting in a deficiency.
A resident with multiple health issues was discharged without a 30-day notice, limiting their ability to appeal. The discharge was ordered and executed on the same day, with the Social Services Director confirming the notification and discharge times. The DON acknowledged the facility's practice of not issuing 30-day notices, and no documentation of a discharge notice was found.
A resident did not receive routine baths as per their schedule, leading to feelings of discomfort and dissatisfaction. Despite being scheduled for showers twice a week, the resident only received one partial bath in a month. Facility staff confirmed the lack of documentation and adherence to the bathing schedule, contrary to the facility's policy.
The facility failed to maintain effective pest control and sanitary conditions in the kitchen, with flies and worm-like creatures observed in the food preparation area. The Dietary Manager acknowledged the presence of flies and mentioned monthly pest control visits, but live flies were still found near the stove, sink, and storage room. Deteriorating floor tiles and an opening in the wall were noted, with numerous worm-like creatures present. Pest control logs indicated significant insect activity in previous months.
The facility failed to store foods according to professional standards for food safety. Opened and unlabeled food items were found, a stained cutting board was not properly maintained, and brownish puffy substances were observed on storage racks. These issues were acknowledged by the Dietary Manager and had the potential to increase the risk of foodborne illnesses for 164 residents.
The facility failed to protect residents' personal and medical information when dietary tray tickets containing sensitive details were discarded in the general trash. The Dietary Manager and Registered Dietitian acknowledged the issue, recognizing it as a potential HIPAA violation. Facility policies mandate that such information should be kept confidential and disposed of properly.
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the MAR and CDR. The DON confirmed these discrepancies and stated that staff are expected to document in both records when administering controlled medications, as per the facility's P&P.
The facility failed to consistently monitor and document side effects and behaviors associated with psychotropic medication use for a resident. The resident, admitted with depression and a psychotic disorder, was not monitored for 50 shifts over several months. The DON confirmed the lack of monitoring, which is required by the facility's policy on psychotropic medication use.
The facility failed to ensure that opened biologicals, eye drops, and ear drops were dated once opened, appropriately labeled, and not available for resident use past their expiration date. Inspections revealed multiple medications either past their use-by dates or without appropriate labeling across various medication carts. Staff confirmed these deficiencies and emphasized the importance of proper labeling and timely removal of expired medications.
The facility failed to maintain effective infection control, with issues including a dusty vent and water collection in the laundry room, unlabeled urinals in shared bathrooms, an unlabeled jug of distilled water in a resident's room, and staff personal belongings in medication carts. These deficiencies were confirmed by staff and pose a risk of cross-contamination and infection.
The facility failed to protect a resident's property during a room transfer when the inventory sheet was not signed or verified for accuracy. The resident's phone was lost, and staff confirmed that inventories were not typically done during room changes, leading to the resident feeling sad and isolated.
The facility failed to update a resident's care plan to include an order for nectar thick fluid consistency, despite the resident's severe cognitive impairment and documented dietary requirements. The DON confirmed the care plan should have been developed within seven days and revised as needed.
A resident with a terminal diagnosis and history of depression expressed suicidal thoughts, but the facility's LNs failed to report this to the physician, DON, and ADON as required by policy. Immediate actions were taken to ensure the resident's safety, but necessary notifications and follow-up actions were not completed.
The facility failed to ensure that a resident was turned and repositioned every two hours as ordered, leading to potential skin breakdown. Despite having orders and being dependent on two-person assistance for bed mobility, documentation showed that the task was not consistently completed or recorded. Observations confirmed redness on the resident's ankle, and the DON verified the lapse in documentation.
The facility failed to implement physician orders for two residents. One resident with severe cognitive impairment was served regular thin coffee instead of nectar-thick liquids, and another resident with bilateral lower extremity edema received more fluids than prescribed, with staff unaware of the fluid restriction order.
The facility failed to follow the physician's order to change the oxygen cannula for two residents with acute respiratory failure and hypoxia. Observations revealed that the oxygen tubing for both residents had not been changed as scheduled, leading to potential contamination and bacterial growth. Staff confirmed the discrepancies and acknowledged the failure to comply with the physician's orders.
The facility failed to monitor and communicate the fluid intake for a dialysis-dependent resident with a fluid restriction, leading to discrepancies in documentation and noncompliance with the prescribed limit. The resident had access to an uncontrolled water bottle, and there was no notification to the physician or nurse practitioner about the noncompliance, increasing the risk of fluid overload.
A resident was prescribed an antibiotic for a UTI, and the order was extended without documented clinical rationale. Both the Pharmacy Consultant Supervisor and the Attending Physician confirmed the lack of documentation, which is against the facility's policy on antibiotic stewardship.
The facility failed to ensure resident rights were maintained when a resident's responsible party was not given the opportunity to consent for a PPD skin test and the addition of D-Mannose to the resident's medication profile. Despite the resident's incapacity to understand rights and responsibilities, the facility proceeded with medical treatments without explicit consent from the RP, contrary to the facility's policy requiring notification of any changes to the resident's plan of care.
The facility failed to provide the required 80 square feet of space per resident in several rooms, housing two residents each with only 65 to 78.12 square feet per resident. Despite no complaints or safety concerns from staff and residents, the facility did not meet regulatory space requirements. The Administrator requested a continuance of the room size waiver, which the Department recommended.
The facility failed to provide adequate supervision for a resident with a history of falls, as outlined in her care plan. The resident was found unattended in her room, unable to reach her call light, despite the care plan requiring her to be at the nurse's station for increased supervision. This was confirmed by multiple staff members and the DON.
The facility failed to provide a resident's medical records via email as requested by the resident's Responsible Party (RP). Despite confirming the request and having the records ready for pick-up, the facility could not provide evidence of the email being sent, violating their policy and state regulations.
Undocumented Increase in Oxygen Flow Rate Contrary to Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy according to physician orders and to document the rationale for changing the oxygen liter flow for one resident. The resident was admitted with multiple respiratory and cardiac diagnoses, including respiratory failure with hypoxia, COPD, acute and chronic respiratory failure with hypercapnia, diabetes, heart failure, and RSV. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Physician orders dated 3/27/26 directed continuous oxygen at 2 L/min via nasal cannula related to acute and chronic respiratory failure and bronchitis due to RSV, with a goal to maintain oxygen saturation above 90%. A separate order allowed titration of oxygen up or down as indicated during activity and/or therapy, with instructions to call the MD if more than 5 L/min was needed. The care plan also specified administering oxygen at 2 L/min via nasal cannula as ordered. On 4/9/26 at 7:00 a.m., the resident’s oxygen saturation was documented as 96% with oxygen via nasal cannula, and the nursing skilled charting form recorded continuous oxygen at 2 L/min. However, during an observation at 12:10 p.m. the same day, the resident was seen receiving oxygen via nasal cannula from a concentrator set at 3.5 L/min. The resident stated he used supplemental oxygen continuously. When the LN reviewed the chart, she stated the resident was ordered 2 L/min continuously and acknowledged the concentrator was set at 3.5 L/min, but she was unsure why it had been increased and noted the resident had not had increased activity. The DON and Nurse Supervisor both confirmed that the record contained no documentation of a drop in oxygen saturation or any indication or progress note explaining why the oxygen was titrated to 3.5 L/min, despite facility policies requiring verification of physician orders and documentation of oxygen flow rate and route after any adjustment, and requiring that prescribed treatment orders be carried out as written.
Failure to Protect Resident from Inappropriate Sexual Contact by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when one resident inappropriately touched another resident’s breasts in a public hallway. Resident 1, who had dementia, dysphagia, and a BIMS score of 7 indicating severe cognitive impairment with significant memory problems and need for substantial supervision, was in a wheelchair in the hallway next to the dining room. The Assistant Director of Nursing (ADON) documented that Resident 2, also in a wheelchair, came up behind Resident 1 and was seen touching and grabbing Resident 1’s breasts with both hands. In a subsequent interview, Resident 1 reported that somebody touched and squeezed her breasts in the hallway, and identified the touching as occurring to her “tits,” while denying feeling scared or mad at that time. Resident 2 had dementia with severe behavioral disturbance, a history of a cerebral infarction, and a BIMS score of 5, also indicating severe cognitive impairment and need for substantial supervision. A licensed nurse (LN 1) stated that this was the first time she was aware of Resident 2 inappropriately touching another resident, but also stated that Resident 2 had been closely monitored by staff because of a past inappropriate incident toward a female resident. In an interview, Resident 2 claimed he was “putting her boobs back” and fixing Resident 1’s clothes because her breasts were showing. The Social Services Director (SSD) reported assessing both residents after the incident and stated that neither showed changes in behavior and that Resident 1 appeared happy. The facility’s undated Abuse Prevention Program policy stated that residents had the right to be free from abuse and that the facility was required to make every attempt to protect residents from abuse by anyone, including other residents, which did not occur in this incident.
Failure to Honor Resident’s Choice of Psychiatric Provider and RP Authority
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose his attending physician and to follow the directions of the resident’s Responsible Party (RP) and Power of Attorney (POA). The resident, admitted in 2016 with multiple diagnoses including aftercare for cerebral infarction, lacked capacity to make health-care decisions. The clinical record identified the resident’s wife as RP/POA, and a physician order dated 6/12/24 directed staff to call the spouse with any changes to medications, treatments, diets, diagnoses, behaviors, or care plan, and to obtain her approval for any and all changes. The resident’s depression care plan also included an intervention to encourage family to actively participate in the resident’s care. During a care conference in December 2025, the RP told the Social Services Assistant (SSA) that she did not want the resident to be seen by the facility’s contracted psychiatrist (PD) or any other psychiatric provider associated with or contracted by the facility, stating that the resident had been followed by an outside psychiatrist through his medical insurance for years. The RP provided a written letter addressed to the DON, Administrator, and nursing staff withholding consent for consultation or evaluation by any psychiatric, psychological, or mental health practitioner associated with or contracted by the facility and requested that such providers be removed from the resident’s list of care providers. Despite this, the resident’s profile and face sheet continued to list the contracted PD as a provider, and there was no documentation that the facility took steps to accommodate the RP’s request or to notify the PD of the restriction. In March 2026, the RP again raised her concerns with the Assistant DON (ADON), who acknowledged that the RP made all treatment decisions and that the resident was managed by an outside psychiatrist selected by the RP. The ADON told the RP that the PD’s name would be removed from the resident’s profile but admitted she did not do so and did not communicate the RP’s request to the PD. Later that same day, the PD came to the resident’s room with a list of residents to see, which included this resident’s name, and the RP intervened to prevent any evaluation. On review of the record on 3/27/26, surveyors confirmed that the PD’s name remained on the resident’s profile and that the facility’s own Resident Rights policy guaranteed the right to choose a physician and treatment, participate in care planning, and to have privacy and confidentiality, and prohibited unauthorized access or disclosure of resident information.
Failure to Monitor and Report Elevated Blood Glucose Levels per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident with type 2 DM, prior DKA, hemiplegia/hemiparesis following cerebral infarction, and aphasia. The resident was admitted in mid-January 2026 with orders for Empagliflozin (Jardiance) via PEG tube once daily and Insulin Glargine 8 units subcutaneously every 12 hours. An order dated 1/18/26 for PRN fingerstick blood glucose testing for hypo/hyperglycemia was present, but there were no blood glucose results documented on the January 2026 MAR. On 2/4/26, a new order was written for blood sugar monitoring every morning and at bedtime. Review of the Blood Sugar Summary showed that 9 of 14 recorded readings were above 200 mg/dL, including multiple readings over 400 mg/dL. Despite these elevated readings, there was only one documented physician notification on 2/2/26 when the blood sugar was 445 mg/dL, and no other evidence of physician notification when blood sugars were over 200 mg/dL or when they exceeded 400 mg/dL on consecutive days (2/4/26 and 2/5/26). An SBAR dated 2/6/26 documented a blood sugar of 405 mg/dL on the night of 2/5/26 and noted that the resident’s O2 saturation remained in the low 80s on 5 liters of oxygen, prompting transfer to the hospital. The hospital discharge summary for the stay from 2/7/26 to 2/18/26 indicated the resident was found to have blood glucose greater than 500 and was treated in the ICU with IV fluids and antibiotics. The DON stated that the resident’s blood sugar order was initially PRN, that an order for AM and HS monitoring was later obtained, and that her expectation was for licensed nurses to notify the physician when blood sugar was above 200 mg/dL. The facility’s diabetes clinical protocol, revised March 2025, indicated that residents receiving insulin who are well controlled should have blood glucose monitored twice daily and that staff should notify the practitioner when there are two or more readings higher than 250 mg/dL within 24 hours accompanied by a new medical problem or change in condition.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident representative was involved in the development and implementation of a person-centered care plan when a scheduled care plan conference was not conducted as planned. The resident was admitted in mid-January 2026 with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and type 2 diabetes mellitus with ketoacidosis. The admission record identified the resident’s daughter as the responsible party (RP). An IDT note dated 1/19/26 by Social Services Assistant (SSA) 1 documented a voicemail left for the RP requesting a return call. A social service note dated 1/20/26 by SSA 2 documented that the RP was called and asked to attend a care conference at 2:30 p.m. and that the RP would participate over the phone. There was no subsequent social services documentation confirming that the care conference occurred or that the RP participated. An IDT conference note initiated 2/5/26 stated that a care conference was conducted that day with the Social Services Director (SSD), Assistant DON (ADON), and Director of Rehabilitation (DOR), and that the resident planned to discharge home with support; this note was signed by SSA 1 on 2/18/26. SSA 2 later stated she did not know if the RP attended the care plan conference, and SSA 1 stated that SSD 1 had created the IDT care conference note on 2/5/26 and that she completed it on 2/18/26 because SSD 1 had not finished her notes. The Minimum Data Set Coordinator (MDSC) confirmed that the SSD schedules care plan conferences, that the conference should be done within the first week of admission, and that the resident was nonverbal, on tube feeding, and bedbound. The MDSC acknowledged that the IDT conference note for this resident had sections completed by Dietary, Therapy, Activities, and Social Services, but the Nursing Services section was not filled out and there was no documentation that Social Services had spoken with the resident’s representative. The facility’s policy stated that residents and/or representatives are encouraged to participate in care plan development and that the SSD or designee is responsible for notifying them and maintaining records of such notices, including input if they are unable to attend.
Unsecured PHI Document Left on Medication Cart
Penalty
Summary
A deficiency occurred when a document containing residents’ personal and medical information was left unsecured on top of a medication cart in Station 3 hallway during a survey observation. The document included residents’ names, room numbers, cognitive status (A&O status), code status, diagnoses, and information about how they take medications (such as whether they take pills whole). During an interview, a licensed nurse acknowledged that he had left this document on top of the medication cart and stated that he was not supposed to do so and that it was a violation of residents’ rights. Later, when shown photographs of the document on the cart, the DON confirmed that the document should not have been there. The facility’s policy on Protected Health Information (PHI), revised April 2014, states that all personnel with access to resident and facility information are responsible for managing and protecting such information to prevent unauthorized release or disclosure. This failure to secure the document containing PHI for a census of 167 residents had the potential to compromise the privacy of residents, as noted in the survey findings.
Failure to Maintain and Honor Advance Directive Results in Improper Notification of Resident's Death
Penalty
Summary
The facility failed to maintain and utilize the current Advance Health Care Directive (AD) for a resident, resulting in the designated agents for Power of Attorney for Health Care (POA) not being notified of the resident's death. The resident, who had multiple diagnoses including multiple sclerosis, epilepsy, and dysphagia, was admitted in 2012 and had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The resident's AD, dated 2011, named two individuals as designated agents for health care decisions, but the facility's records listed other individuals as emergency contacts and responsible parties. Upon the resident's decline and subsequent death, the facility notified the first emergency contact, who was not listed as a designated agent in the AD, and coordinated post-mortem arrangements with this individual. The actual designated agents, as specified in the AD, were not contacted by the facility and only learned of the resident's death through the mortuary. Interviews revealed that the facility was unable to locate the AD in the electronic record at the time of the incident, despite the document having been faxed to the facility in 2013 and later found in past files. Facility staff, including the DON, Social Services Director, and Medical Records Assistant, confirmed that the AD was not uploaded into the electronic record when the system changed in 2022, and that the staff had been relying on the emergency contact rather than the designated agents for decision-making and notifications. The facility's policy required that advance directives be maintained in a readily retrievable location in the medical record and that the resident's wishes be communicated to direct care staff and physicians, but this was not followed in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis, dysphagia, and cachexia, who was cognitively intact but physically dependent and used a wheelchair, was struck in the face by another resident in the facility's smoking area. The incident was reported by the affected resident, who stated that the other resident approached, used expletives, and slapped her on the left side of her face. Documentation indicated that the resident experienced swelling and redness to the left side of her face and a sore to her lower lip that reopened after the slap. The resident expressed psychosocial distress, fear, and a sense of being unsafe in the facility following the incident. The resident who committed the act had a history of hemiplegia, hemiparesis, diabetes, aphasia, and severe cognitive impairment. This resident was unable to provide a clear account of the incident due to communication difficulties. Witnesses, including another resident, confirmed observing the physical altercation, stating that the aggressor willfully struck the victim on the cheek. Staff interviews corroborated that the incident took place in the smoking area and that the aggressor had previously exhibited aggressive behavior. Facility records and staff interviews revealed that, prior to the incident, there were no effective measures in place to prevent the altercation or to monitor the residents for aggressive or inappropriate behaviors as outlined in the facility's abuse prevention and resident-to-resident altercation policies. The affected resident reported ongoing fear and discomfort, noting that the aggressor continued to be present in areas near her room after the incident, which contributed to her distress. The facility's failure to protect the resident from physical abuse resulted in both physical and psychosocial harm.
Failure to Update Care Plans and Document Incidents After Resident Altercations and Abuse Allegation
Penalty
Summary
The facility failed to ensure that care plans were updated and documentation was complete for three residents following significant incidents. Two residents were involved in a resident-to-resident altercation in the smoking area, where one resident, who was cognitively intact and had diagnoses including ALS and dysphagia, reported being struck in the face by another resident. The other resident involved had severe cognitive impairment, hemiplegia, and aphasia, and was unable to provide a personal account of the incident. Despite the altercation being reported and documented in progress notes and communication forms, neither resident had a care plan initiated or updated to address the incident. Additionally, another resident with moderate cognitive impairment, COPD, bipolar disorder, and adult failure to thrive, reported being pushed against the wall by a CNA during a brief change. This incident was reported as suspected abuse, but there was no documentation in the clinical record regarding the event, and no care plan was initiated to address the situation or the resident's needs following the report. Interviews with facility leadership confirmed that these incidents were not reflected in the residents' care plans and that documentation in the clinical records was incomplete or missing. Facility policies require that care plans be updated and incidents documented when there is a significant change in a resident's condition or following an altercation or abuse allegation, but these procedures were not followed for the residents involved.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident's right to be free from physical abuse was not protected. One resident, who had a history of stroke and difficulty speaking but demonstrated normal cognition, was subjected to physical abuse by his roommate. The roommate, who had a seizure disorder, stroke, and moderate cognitive impairment, threw a hard plastic cup filled with thickened liquid at the first resident's face during an argument. This incident resulted in the resident being covered in fluid and left a red mark on his cheek. The event was witnessed and documented by nursing staff, and both residents confirmed the altercation during interviews. The facility's policy states that residents have the right to be free from abuse, neglect, and exploitation. Despite this, the incident occurred following a disagreement between the two residents, with the aggressor stating the action was in response to a dispute over cigarettes. The Director of Nursing confirmed the details of the incident and acknowledged the resulting injury. The report identifies this as a failure to protect the resident from physical abuse as required by facility policy.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with a history of inappropriate behavior towards female residents was observed grabbing and placing another resident's hand on his groin area. This incident was witnessed by a third resident, who reported the event to staff. The resident who was subjected to this behavior was cognitively impaired and had multiple diagnoses, including diabetes mellitus. The resident who committed the act was noted in previous records to have engaged in inappropriate behaviors, such as being found in a female resident's room and touching another resident's arm in the hallway. These prior incidents were not reported or addressed with interventions to prevent further occurrences. Staff interviews confirmed knowledge of the resident's history of inappropriate conduct, and facility documentation acknowledged the abusive nature of the incident. The facility's policy states that residents have the right to be free from abuse, including sexual abuse by other residents. Despite this, the facility failed to implement measures to protect the cognitively impaired resident from abuse, resulting in a violation of the resident's rights.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse within the required regulatory timeframe for two residents. One resident, who had a history of inappropriate behaviors towards female residents and diagnoses including dementia, was reported by another resident to have grabbed and placed a female resident's hand on his groin. The incident was witnessed and reported to the Social Services Assistant, who then notified the Administrator. However, the Administrator did not report the allegation to the California Department of Public Health until three days after being notified, despite facility policy and federal regulations requiring reporting within two hours if the alleged violation involves abuse. Record review and staff interviews confirmed that the Administrator was aware of the incident but delayed reporting, and the Director of Nursing acknowledged that previous inappropriate behaviors by the same resident had not been reported or addressed with interventions. The facility's policy clearly stated that all reports of resident abuse must be promptly reported to the appropriate authorities, but this was not followed in this case.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia and moderate memory impairment was subjected to inappropriate sexual contact by another resident, who also had moderate memory impairment. The incident took place in a hallway after an activity event, where a staff member witnessed one resident fondling the other's breasts without consent. The affected resident was unable to communicate well and appeared surprised and distressed during the incident, as observed by the staff member. The facility's records, including the admission record and Minimum Data Set, confirmed the cognitive impairments of both residents involved. The Interdisciplinary Team note documented the incident based on the staff witness report, but there was no evidence that the affected resident had given consent for any physical contact. When interviewed, the resident who committed the act declined to participate and asked to be left alone. The Director of Nursing confirmed the incident and acknowledged that it was witnessed by staff. The facility's abuse prevention policy states that all residents have the right to be free from abuse, including sexual abuse, by anyone. Despite this policy, the facility failed to protect the resident from abuse by another resident, resulting in a violation of the resident's rights.
Improper Storage and Handling of Discontinued Controlled Medications
Penalty
Summary
The facility failed to maintain consistent pharmacy services for its residents, as evidenced by improper handling and storage of controlled medications. During an inspection, a discontinued bottle of lacosamide, a controlled substance, was found stored with non-controlled medications in the medication storage room and lacked a required count sheet. Licensed nursing staff confirmed that discontinued controlled medications should have been taken to the DON's office for secure storage with proper documentation, in accordance with facility policy. The DON also stated that all discontinued controlled medications were expected to be brought to her office for secure storage until destruction with the facility's pharmacist. Additionally, an inspection of a medication cart revealed seven blister packs of discontinued controlled medications stored alongside active medications. Licensed nursing staff acknowledged that discontinued controlled medications should not remain in the medication cart and should be given to the DON. Facility policies reviewed indicated that all unused controlled substances must be securely locked and documented until disposal, and discontinued drugs should be placed in designated bins for destruction. These findings demonstrate a failure to follow established procedures for the handling and storage of controlled medications.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and handling practices. Expired pharmaceutical products, including a multi-dose vial of Humulin R insulin and two multi-dose inhalers, were found in medication carts at both the front and back stations. Licensed nurses confirmed the presence of these expired medications and acknowledged that they should have been discarded according to facility policy and manufacturer guidelines. Facility policies reviewed indicated that staff are required to check expiration dates prior to administration and to place outdated drugs in designated bins for destruction. Additionally, loose pills were discovered in two medication carts, and a blister pack was found behind a drawer in one of the carts. Licensed nurses confirmed these findings and stated that loose pills and misplaced blister packs should not be present in the carts. The Director of Nursing reiterated that medication carts are expected to be free of loose medications and maintained in a clean, safe, and sanitary manner, as outlined in the facility's storage policy. Further deficiencies were observed in resident rooms, where unlabeled medicine cups containing creams were found at the bedside of two residents. Staff interviews confirmed that these creams were intended for the residents' use but should not have been left at the bedside and should have been discarded after use. Facility policy requires that all drugs and biologicals be stored in locked compartments, and the Director of Nursing confirmed that medications should not be left at the bedside.
Infection Control Program Deficiencies Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In one instance, a resident with severe cognitive impairment and a history of dysphagia and gastrostomy was receiving enteral feeding via a G-tube. The water flush bag used for this resident was found hanging at the bedside without a label, contrary to facility policy and staff expectations, which require labeling with the resident's name and the date and time the bag was started. Both the licensed nurse and the Director of Nursing confirmed that the bag should have been labeled. During a medication administration observation, a licensed nurse was seen using a medication cart that had not been cleaned of white powder residue from a previously crushed medication. The nurse acknowledged that the residue was from a crushed acetaminophen tablet and that medication cart surfaces should be cleaned prior to medication administration. The Director of Nursing also stated that the expectation was to keep medication preparation areas clean and sanitary, as outlined in the facility's policy. Additionally, a certified nursing assistant provided high-contact care to a resident on Enhanced Barrier Precautions (EBP) without wearing a gown, despite clear signage and policy requirements. The resident had an indwelling catheter and was identified as requiring EBP due to risk factors. The CNA admitted to not wearing a gown during activities such as teeth brushing, brief changing, and dressing, and acknowledged awareness of the requirement. The facility's infection preventionist confirmed that gowns and gloves are required during high-contact care for residents on EBP, as specified in the facility's policy.
Inaccurate Assessment of Resident's Tobacco Use
Penalty
Summary
The facility failed to accurately assess a resident's tobacco use during the Minimum Data Set (MDS) assessment process. The resident, who was admitted with diagnoses including high blood pressure and generalized muscle weakness, had a BIMS score indicating mild memory impairment. The MDS documented that the resident was not a smoker, and the smoking observation/assessments also indicated the resident denied smoking or using tobacco products. However, during interviews, the resident stated that he smoked cigars and that the facility was aware of his smoking status, which was confirmed by a licensed nurse. Upon review, the MDS Coordinator acknowledged that both the MDS and the smoking observation/assessment inaccurately reflected the resident's tobacco use. This discrepancy demonstrated that the facility did not conduct a comprehensive and accurate assessment of the resident's health status as required.
Failure to Complete Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to follow up with the required Preadmission Screening and Resident Review (PASRR) Level II evaluation for one resident. The resident was initially admitted in February 2023 and readmitted in November 2024 with diagnoses including unspecified psychosis and major depressive disorder. A review of the resident's PASRR Level I Screening Result, dated 11/19/24, indicated that a Level II evaluation was required. However, the Director of Nursing (DON) confirmed during an interview and record review that she was unaware of the need for a PASRR Level II evaluation for this resident, and acknowledged that no follow-up was conducted for the required evaluation. The facility's policy, revised in March 2023, states that all new admissions and readmissions are to be screened for mental disorders, and if the Level I screen indicates possible mental disorder, the individual should be referred for a Level II evaluation. In this case, the lack of follow-up resulted in the resident not receiving the necessary PASRR Level II evaluation as indicated by the screening process.
Failure to Develop and Implement Comprehensive Care Plans for Smoking and Skin Conditions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, resulting in unmet physical and psychosocial needs. For one resident with a history of orthopedic aftercare and gas gangrene, there was no care plan addressing his smoking habits, despite documentation and staff interviews confirming his regular, unsupervised smoking in the designated area. The Minimum Data Set Coordinator and Medical Records Director both confirmed the absence of a smoking care plan for this resident, even though the resident was identified as a smoker in the assessment. Another resident with acute on chronic congestive heart failure and documented rashes on her upper arms, chest, and back did not have a care plan addressing her skin condition. Physician orders for topical and oral medications to treat the rashes were present, and the resident reported ongoing itching. The Minimum Data Set Coordinator confirmed that no care plan was created for the rashes, despite the presence of skin observations and medication orders. Additionally, a resident with chronic pulmonary lung disease had a care plan stating that cigarettes and lighters should be stored at the nurse's station, but staff interviews and observations revealed that the resident kept these items on his person, and staff did not follow the care plan. Another resident with high blood pressure and mild memory impairment, who smoked cigars daily, also lacked a care plan for smoking. Staff and the Director of Nursing confirmed the absence of a smoking care plan for this resident, despite facility policy requiring documentation of smoking-related privileges and restrictions in the care plan.
Failure to Assist Resident with Hearing Aid Use Due to Communication and Documentation Gaps
Penalty
Summary
The facility failed to provide necessary assistance with the use of hearing aids for one resident who had a cognitive communication deficit and muscle weakness. The resident was admitted with hearing aids for both ears and required help with their use, as documented in the resident's records and assessments. Despite this, the resident reported not receiving any assistance or education on how to charge or use the hearing aids, which remained unused in their box for two months. Multiple observations and interviews confirmed that the resident continued to experience difficulty hearing and repeatedly requested help from staff. Interviews with facility staff revealed a lack of clear communication and documentation regarding the resident's need for hearing aid assistance. There was no physician order for the hearing aids, and staff were unclear about whose responsibility it was to enter such orders or provide the necessary support. The facility's policies required staff to assist residents with hearing aids and ensure competency in their use, but these procedures were not followed for this resident, resulting in unmet care needs.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident with a history of an anoxic brain injury, severe cognitive deficits, and a right hand contracture was found to have long fingernails with a brownish substance underneath the fingernails on her left hand. The resident was non-verbal, dependent on staff for all activities of daily living (ADLs), and unable to make her needs known. Her care plan required staff to provide extensive to total assistance with all personal care, including daily grooming and nail care, as she was unable to participate in her own care. During observation, staff noted the resident's left hand fingernails were dirty and confirmed that nail care should have been performed. Both a licensed nurse and the DON verified that the resident had not refused nail care and that staff were expected to ensure nails were clean as part of routine hygiene and infection control. Facility policy also required staff to provide appropriate grooming for residents unable to perform ADLs independently. The failure to provide nail care resulted in the resident having visibly dirty fingernails, contrary to her care plan and facility policy.
Call Lights Not Within Reach for Residents with Severe Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with severe cognitive and physical impairments. One resident, admitted after an anoxic brain injury and noted to be non-verbal and dependent on others for all mobility and care needs, was observed sitting in a wheelchair next to her bed with her call light left in the bed, out of her reach. Staff confirmed that the call light was not accessible and acknowledged that the expectation was for call lights to always be within reach, especially for non-verbal residents who cannot call out for help. The resident's care plan specifically indicated that the call light should be within reach due to her inability to verbalize needs and poor mobility. Another resident, admitted with dysphagia following a stroke and requiring maximal assistance for mobility, was also found with her call light out of reach on multiple occasions. Staff interviews confirmed that the call light was not positioned appropriately and should have been within the resident's arm reach. The resident's care plan included an intervention to encourage the use of the call light for assistance, and facility policy required call lights to be within easy reach when residents are in bed or confined to a chair. These observations and staff confirmations demonstrate that the facility did not consistently follow care plans or policy regarding call light accessibility for residents with significant care needs.
Failure to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the required minimum room size of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms, as specified by regulations. Specifically, rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314 were identified as not meeting these requirements, with several rooms providing only 65 to 78.12 square feet per resident. This deficiency was identified through document review, which included a letter to the California Department of Public Health, and was confirmed by direct observation of the rooms and interviews with residents and staff. Despite the deficiency in room size, observations noted that the rooms were clutter-free and allowed for the movement of residents using walkers and wheelchairs. Residents and staff interviewed did not report any issues or complaints related to the lack of space, and there were no validated safety concerns or problems with the delivery of care due to room size. The Director of Maintenance confirmed that no alterations had been made to these rooms since the last recertification survey.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to protect a resident's right to return to the facility following hospitalization, resulting in an unanticipated discharge. The resident, who had long-term kidney disease and breathing problems, was admitted to the facility in the fall of 2024. On December 20, 2024, the resident experienced an acute change in mental status and was sent to the hospital due to extreme lethargy and low blood sugar. Despite the resident having the capacity to make her own decisions, her Power of Attorney (POA), her daughter, was involved in all healthcare and financial decisions. The facility's policy required that residents be allowed to return following hospitalization within the bed-hold period. However, the facility did not permit the resident to return, citing the daughter's interference with care as the reason. The Administrator and Director of Nursing confirmed that the daughter's actions, which included withholding consent and interfering with medical procedures, hindered the facility's ability to provide care. Consequently, the facility discharged the resident on the same day she was sent to the hospital, without taking any bed-hold money, and informed the POA of the discharge after it occurred.
Failure to Follow Prednisone Orders Leads to Resident Complications
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was prescribed Prednisone following a hospital discharge. The resident, who had a history of chronic obstructive pulmonary disease and kidney failure requiring dialysis, was readmitted to the facility with a prescription for Prednisone 60 mg daily for five days. However, the facility continued administering the medication at the same dosage for an additional 17 days beyond the prescribed period. The resident experienced significant side effects due to the prolonged use of Prednisone, including severe oral thrush and fluid retention, which were not addressed by the facility. Despite multiple visits from a Nurse Practitioner, the issue with the Prednisone dosage was not identified or corrected. The resident's family member expressed concern over the facility's failure to follow the physician's orders and provided documentation to the facility's management, which was not acted upon. The facility's Director of Nursing acknowledged the oversight, stating that the stop date for the Prednisone was not entered into the resident's orders upon readmission. Additionally, there was no documented evidence that the Prednisone order was verified with the resident's physician. The facility's policies on medication orders and therapy were not followed, leading to the resident's prolonged exposure to high doses of Prednisone and subsequent health complications.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse during an altercation between two residents. Resident 1, who was cognitively intact and had a history of hemiplegia and hemiparesis, struck Resident 2 on the arm with a wheelchair armrest, resulting in a skin tear. Resident 2, who had moderate cognitive impairment and a history of paraplegia and an unruptured cerebral aneurysm, was engaged in a conversation with Resident 1 when the incident occurred. The altercation was reported by the facility's administrator, and the injury was documented in Resident 2's nurse's notes. Interviews and observations revealed that Resident 1 admitted to hitting Resident 2 after being called a liar and insulted. The Director of Staff Development witnessed the verbal exchange and confirmed that Resident 1 admitted to the physical altercation. Resident 2 expressed feeling both safe and unsafe in the facility due to the incident, indicating a potential emotional impact. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, including from other residents, highlighting a failure to adhere to this policy in this instance.
Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with timely access to the resident's medical records. Resident 1 was admitted in May 2021, and a family member was designated as the resident's representative. The representative submitted a written request for the resident's complete vaccination records on August 2, 2024, at 2:45 p.m. According to the facility's policy, medical records should be provided within 72 hours of a request, excluding weekends and holidays. However, the facility did not provide the requested records until August 9, 2024, which was beyond the stipulated timeframe. During an interview and documentation review on August 12, 2024, the Medical Record Director confirmed that the facility received the request on August 2, 2024, and acknowledged that the records were provided electronically on August 9, 2024. This delay in providing the medical records was a deviation from the facility's policy, resulting in a deficiency.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day discharge notice to a resident, which compromised the resident's ability to appeal the discharge. The resident was admitted with multiple diagnoses, including diverticulitis, gastrointestinal hemorrhage, breast cancer, difficulty in walking, and muscle weakness. On the same day as the discharge, the resident received a physician's order for discharge with home health services, physical and occupational therapy, and an aide. The Social Services Director confirmed that the resident was notified of the discharge on the same day at 3:12 p.m., and the discharge occurred at 5 p.m. The Director of Nursing admitted that the facility does not issue 30-day notices, and there was no documented evidence of a written or verbal notice of intent to discharge provided to the resident.
Failure to Adhere to Resident's Bathing Schedule
Penalty
Summary
The facility failed to ensure the dignity of a resident by not adhering to the resident's bathing schedule, resulting in the resident feeling upset, angry, and dirty. The resident, who was admitted in 2021 with diagnoses including a leg fracture, hypertension, and cancer, reported not receiving a bath for three weeks. The resident expressed dissatisfaction with their appearance and hygiene, stating that their hair was dirty and matted, which made them feel uncomfortable. A review of the resident's bathing task sheet revealed that the resident had only received one partial bath in a 30-day period, with several scheduled bathing days missed. The care plan indicated that the resident was supposed to receive showers at least twice a week. Interviews with facility staff, including a licensed nurse and the assistant director of nursing, confirmed the lack of documentation and adherence to the bathing schedule. The facility's policy required staff to document bathing and notify supervisors if a resident refused a bath, which was not consistently followed in this case.
Pest Control and Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program and sanitary conditions in the kitchen, as evidenced by the presence of several flies and small worm-like creatures in the food preparation area. During an interview, the Dietary Manager (DM) acknowledged the presence of flies, noting that they were more prevalent in the summer. The DM mentioned that a pest control company visited monthly to replace fly trappers and spray outside the facility, and additional visits were arranged if serious issues arose. However, during a kitchen tour, live flies were observed near the stove, sink, and dry storage room. The DM admitted that flies should not be present in the kitchen and hoped they would be caught in traps overnight. Further inspection revealed deteriorating floor tiles under the sink, with a white plastic substance and blackish residue on the tiles. An opening was noted where the sink pipe entered the wall, and the floor was wet and cluttered with food debris and numerous black worm-like creatures. The DM and Kitchen Staff confirmed the presence of these creatures, which were approximately 1 cm long. The DM was unable to identify them but suggested they might be small worms from beneath the tiles. The Infection Control Nurse also observed the creatures and acknowledged their presence, along with a fly on the wet floor. Pest control logs from previous months indicated significant flying insect activity, and the facility's policies emphasized the importance of pest control and sanitation in the kitchen.
Failure to Store Foods According to Professional Standards
Penalty
Summary
The facility failed to store foods according to professional standards for food safety. During an initial kitchen tour, the Dietary Manager (DM) acknowledged several opened and unlabeled food items, including a gallon of milk in the refrigerator, an opened box of cookie dough in the freezer, and three cans of vegetable oil spray in the cooking area. The facility's policy requires all food items to be labeled with an opened date and used by date, which was not followed in these instances. Additionally, a yellow cutting board was found stained with black markings from the rubber stand, which the DM acknowledged. According to the FDA Food Code, cutting surfaces that can no longer be effectively cleaned and sanitized should be resurfaced or discarded, which was not adhered to in this case. Furthermore, the DM acknowledged the presence of brownish puffy substances at the bottom of four metal storage racks in the dry storage room, identified as dust. The facility's policy mandates routine cleaning, which was not followed. The FDA Food Code emphasizes that food contact surfaces must be clean to sight and touch to prevent contamination. These failures had the potential to increase the risk of foodborne illnesses for the 164 residents who received food from the kitchen.
Improper Disposal of Dietary Tray Tickets Compromises Resident Confidentiality
Penalty
Summary
The facility failed to ensure the protection of residents' personal and medical information when dietary tray tickets containing sensitive information were discarded in the general trash. During a kitchen tour, tray tickets with residents' names, ID numbers, room numbers, diet orders, food preferences, and allergies were found in the general trash bin. The Dietary Manager acknowledged the issue and recognized it as a potential HIPAA violation. The Registered Dietitian confirmed that tray tickets should be disposed of in a shred box to maintain confidentiality. Facility policies on confidentiality and residents' rights were reviewed, indicating that access to personal and medical records should be limited to authorized staff and that unauthorized disclosure of resident information is prohibited.
Failure to Ensure Accurate Accountability of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for three residents, resulting in discrepancies between the Medication Administration Record (MAR) and the Controlled Drug Record (CDR). For Resident 30, the MAR indicated that Morphine was administered, but the CDR did not reflect this, and there was an inconsistency in the tablet count. For Resident 119, the MAR and CDR did not match on multiple occasions, with the MAR showing administration of Norco that was not recorded in the CDR and vice versa. Similarly, for Resident 120, the MAR indicated Norco was administered, but the CDR did not reflect this. During an interview and record review, the Director of Nursing (DON) confirmed these discrepancies and stated that the expectation is for staff to document in both the MAR and CDR when administering controlled medications. The facility's Policy and Procedure (P&P) on Controlled Medications, revised in April 2023, requires that the date, time, amount administered, and the nurse's signature be recorded in both the MAR and CDR. The failure to follow this procedure resulted in the facility not having accurate accountability of controlled medications, raising concerns about whether the medications were administered as ordered.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to consistently monitor and document side effects and behaviors associated with psychotropic medication use for one resident. Resident 91, who was admitted in the winter of 2021 with diagnoses including depression and a psychotic disorder, was prescribed multiple psychotropic medications. The Medication Administration Record (MAR) indicated that Resident 91 was not monitored for the listed behaviors and side effects for a total of 50 shifts from February 2024 to May 2024. This lack of monitoring was confirmed by the Director of Nursing (DON), who stated that if the monitoring was not signed, it was not done. The facility's policy requires staff to observe, document, and report the effectiveness of interventions and any side effects or adverse consequences of psychotropic medications to the attending physician or nurse practitioner. During an observation and interview, Resident 91 was found calm and conversant in his room, with his call light within reach. However, the DON verified that several shifts of behavior and side effects monitoring were not signed, indicating that the monitoring was not performed. The facility's policy on psychotropic medication use, revised in October 2023, mandates that nursing staff monitor and report any side effects and adverse consequences of psychotropic medications. The failure to adhere to this policy had the potential for unnecessary use of psychotropic medications for Resident 91.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that opened biologicals, eye drops, and ear drops were dated once opened, appropriately labeled to correctly identify which resident they were for, and were not available for resident use past their expiration date. During an inspection of the Station 4 Back Hall Medication Cart, it was found that a bottle of Artificial Tears eye drops and a bottle of LubriFresh P.M. Nighttime eye ointment were past their recommended use-by dates. Licensed Nurse (LN) 6 confirmed these observations and stated that both medications were only good for 60 days after opening and were past their recommended use-by dates. Further inspections revealed additional deficiencies. At Station 2 Back Hall Medication Cart, a bottle of GoodSense Eye Drops, Mucus-ER tablets, and an Iron Supplement liquid were found either past their use-by dates or without appropriate labeling. LN 9 confirmed these findings and stated that medications without labels or open dates would not be administered. Similarly, at Station 2 Front Hall Medication Cart, several medications including Ayr Nasal gel, sunscreen lotion, Visine eye drops, and Tetrahydrozoline HCL eye drops were found without appropriate labeling. LN 10 confirmed these observations and emphasized that each resident should have their own labeled medications. At Station 3 Back Hall Medication Cart, multiple medications including Zinc tablets, Senna tablets, Loratadine tablets, Micro-Guard antifungal powder, Tetrahydrozoline HCL eye drops, Systane lubricant eye drops, and Carbamide Peroxide ear drops were found either past their expiration dates or without appropriate labeling. LN 11 confirmed these findings. The Infection Prevention Nurse (IP) and the Director of Nursing (DON) both acknowledged the deficiencies, with the DON stating that expired medications should be removed and destroyed before they expire. The facility's policies and procedures were reviewed and indicated that medications should be checked for expiration dates and labeled appropriately before administration.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. In the laundry room, a dusty vent was observed above a table with clean laundry, and water was found collected behind the washers. The Maintenance Director confirmed these observations and acknowledged the potential for cross-contamination. Additionally, the wall in the clean clothing room had peeled paint and stains from old water leakage, further indicating unsanitary conditions. The Infection Prevention Nurse and Infection Preventionist Consultant confirmed these issues during their inspection, noting that the laundry room should not be in such a state and that the vent should be clean. In shared bathrooms, unlabeled urinals were found, which could lead to cross-contamination. In Resident 15's shared bathroom, two unlabeled urinals were observed on top of the toilet bowl tank. Licensed Nurses confirmed that these urinals should be labeled and dated to prevent cross-contamination. Similar observations were made in other shared bathrooms, where used urinals with dried brownish substances were found without labels. The Director of Nursing confirmed that urinals should be labeled and placed appropriately to avoid cross-contamination and infection. In Resident 119's room, an unlabeled and undated jug of distilled water was found on the floor beside the nightstand. The resident confirmed that the jug was used for his CPAP machine. Licensed Nurses and the Infection Prevention Nurse confirmed that the jug should be labeled, dated, and not placed on the floor to prevent contamination. Additionally, staff personal belongings and a cigarette lighter were found in medication carts, which were confirmed by Licensed Nurses and the Director of Nursing as inappropriate and a potential source of contamination. The facility's policies and procedures were not followed, leading to these deficiencies in infection control and prevention.
Failure to Protect Resident's Property During Room Transfer
Penalty
Summary
The facility failed to protect Resident 106's property from loss when the resident's inventory sheet was not signed and not verified for accuracy. Resident 106, who was admitted in November 2021 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, reported that her phone was lost during a room transfer. The inventory sheet dated 11/2/21 listed the phone but lacked signatures from staff and the resident's representative, verifying the accuracy of the list. The facility did not conduct an inventory during the room transfer, and the last inventory was done upon admission in 2021. Interviews with staff, including LN 6, the Social Services Director, and the Director of Nursing, confirmed that inventories were not typically done during room changes and that the inventory sheet for Resident 106 was incomplete and unsigned. The facility's policy required that personal belongings be inventoried and documented upon admission, but this procedure was not followed during the room transfer, leading to the loss of Resident 106's phone and her subsequent feelings of sadness and isolation.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for one resident when the care plan did not address the order for nectar thick fluid consistency when it was initiated. Resident 126, who was admitted with diagnoses including cerebral infarction with residual effects and seizures, had a diet order for finger food regular chopped meat texture with thickened liquids nectar consistency. Despite this order being documented in the resident's clinical record and nutritional risk review, the care plan was not updated to reflect this dietary requirement. The Director of Nursing confirmed that the care plan should have been developed within seven days and revised as the resident's condition changed, as stipulated by the facility's policy and procedure on care plans.
Failure to Report Suicidal Ideation
Penalty
Summary
The facility failed to meet professional standards of quality for a resident who expressed suicidal ideation. Resident 59, admitted under hospice services with a terminal diagnosis including cognitive deficits, dementia, bipolar disorder, and depression, verbalized a desire to commit suicide to a CNA. Licensed Nurses 12 and 13 documented the resident's suicidal thoughts and took immediate actions such as removing sharp objects and conducting frequent checks. However, they failed to report the incident to the facility's physician, Director of Nursing (DON), and Assistant Director of Nursing (ADON), as required by the facility's policy and procedure on suicide threat management. Interviews with the ADON, DON, and Social Services Director (SSD) confirmed that the appropriate notifications and follow-up actions, including creating a care plan and documenting a change of condition, were not completed. The facility's policy mandates immediate reporting of suicidal threats to the charge nurse, who should then notify the attending physician and responsible party. The failure to follow these procedures had the potential to adversely affect the safety of Resident 59.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to ensure that Resident 43 received care in accordance with professional standards when the resident was not turned and repositioned every two hours as ordered. Resident 43, who was admitted with diagnoses including contractures of the upper extremities, hips, and ankles, and a history of a left ankle pressure ulcer, was observed lying flat on his back with both legs bent to the side on multiple occasions. The Minimum Data Set (MDS) indicated that Resident 43 was dependent on two-person assistance for bed mobility. Despite having orders for turning and repositioning every two hours, documentation showed that this task was not consistently completed or recorded as required. During an observation and interview, Licensed Nurse 3 (LN 3) acknowledged that the left posterior of Resident 43's ankle had developed redness again, indicating potential skin breakdown. The Director of Nursing (DON) confirmed that the documentation for turning and repositioning was not done as ordered. The facility's policies and procedures for repositioning and carrying out physician orders were not followed, leading to this deficiency. The failure to adhere to these orders increased the risk of skin breakdown for Resident 43.
Failure to Implement Physician Orders for Fluid Consistency and Restriction
Penalty
Summary
The facility failed to provide necessary care and services for two residents. For Resident 126, who had severe cognitive impairment and was unable to make her own healthcare decisions, the facility did not implement the physician's order for thickened fluid consistency. Despite the order for nectar-thick liquids, Resident 126 was served regular thin coffee by a Certified Nurse Assistant (CNA). This was confirmed by both the CNA and a Licensed Nurse (LN), and later verified by the Director of Nursing (DON), who acknowledged that the staff should have followed the doctor's order to prevent accidents. For Resident 153, who was admitted with bilateral lower extremity edema and fluid retention, the facility did not maintain and accurately monitor the fluid restriction order. The resident was observed receiving more fluids than prescribed, and the CNA assigned to her was unaware of the fluid restriction order. The Licensed Nurse confirmed that the resident's fluid intake exceeded the physician's order, and the DON noted that the nursing staff should have monitored and documented the fluid intake accurately. Additionally, a care plan for non-compliance should have been developed if the resident refused to follow the doctor's order.
Failure to Change Oxygen Cannula as Ordered
Penalty
Summary
The facility failed to follow the physician's order to change the oxygen cannula for two residents, Resident 27 and Resident 99. Resident 27 was admitted with acute respiratory failure with hypoxia and had a physician's order to change the nasal cannula every Sunday night and as needed. However, observations on 5/21/24 revealed that Resident 27's oxygen tubing was last changed on 5/12/24, indicating non-compliance with the order. The Licensed Nurse confirmed the discrepancy and acknowledged that the tubing should have been changed weekly as per the physician's order. The Infection Prevention Nurse also confirmed that failing to change the tubing as scheduled could lead to contamination and bacterial growth. Similarly, Resident 99, who was also admitted with acute respiratory failure with hypoxia, had an order for continuous oxygen use via nasal cannula, with the tubing to be changed every Sunday night and as needed. Observations on 5/21/24 showed that Resident 99's oxygen tubing, which had yellowish discoloration and water inside, was last changed on 5/12/24. The Certified Nurse Assistant and Licensed Nurse both confirmed the tubing change date and acknowledged the failure to follow the physician's order. The Director of Nursing stated that staff are expected to follow physician orders accurately and on time. The facility's policy and procedure also indicated that oxygen tubing should be changed at least weekly and labeled with the date it was changed.
Failure to Monitor and Communicate Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to accurately monitor and communicate the fluid intake for a resident with end-stage renal disease who was dependent on renal dialysis. The resident had a physician's order for a fluid restriction of 1 liter per day, broken down into specific amounts for each shift. However, observations and interviews revealed that the resident had access to a water bottle at the bedside, which was not controlled by the staff, leading to noncompliance with the fluid restriction. The resident was readmitted to the facility after a hospital stay for acute respiratory failure secondary to fluid overload, indicating the severity of the issue. Interviews with Certified Nursing Assistants (CNAs) and the Nurse Supervisor (NS) confirmed discrepancies in the documentation of the resident's fluid intake. The CNAs and Licensed Nurses (LNs) documented different amounts of fluid intake, and there was no communication between them to reconcile these differences. Additionally, there was no notification made to the resident's Attending Physician (AP) or Nurse Practitioner (NP) regarding the resident's noncompliance with the fluid restriction, as required by the facility's policy. The facility's policy on encouraging and restricting fluids mandates that staff verify physician's orders for fluid restrictions, record fluid intake accurately, and inform the physician or NP if the resident is noncompliant. The failure to adhere to this policy resulted in the resident's fluid intake exceeding the prescribed limit on multiple occasions, increasing the risk of fluid overload and related complications. The NS acknowledged the discrepancies and the lack of communication and documentation regarding the resident's fluid intake and noncompliance.
Failure to Ensure Resident's Drug Regimen was Free from Unnecessary Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication. Resident 10, who was admitted with multiple diagnoses including overactive bladder, chronic kidney disease, and a urinary tract infection (UTI), was prescribed Macrobid, an antibiotic, for the UTI. The initial order for Macrobid was for 7 days, but the order was later extended without documented clinical rationale. The extension of the antibiotic was not supported by any documented symptoms or clinical criteria, which is against the facility's policy on antibiotic stewardship. During interviews, both the Pharmacy Consultant Supervisor and the Attending Physician confirmed that there was no documented reason for extending the antibiotic. The facility's policy requires documentation of specific criteria supporting the use of antibiotics, which was not followed in this case. This failure resulted in Resident 10 receiving unnecessary medication, potentially increasing the risk of antibiotic resistance and exposure to side effects associated with prolonged antibiotic use.
Failure to Obtain Proper Consent for Medical Treatment
Penalty
Summary
The facility failed to ensure resident rights were maintained for one resident when the responsible party (RP) was not given the opportunity to consent for a placement of a PPD skin test and the addition of D-Mannose to the resident's medication profile. The resident, who was incapable of understanding rights and responsibilities, received medical treatment without proper consent from the RP. The resident's medical history included hemiparesis, hemiplegia, dysphagia, and functional quadriplegia following a cerebral infarction. Despite the RP's previous indication that the resident was a known reactor to tuberculin skin tests, the facility proceeded with the PPD skin test without obtaining explicit consent from the RP. Interviews with various staff members, including the Infection Prevention Nurse (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed that the facility relied on the general consent to treatment signed during admission. However, the facility's policy and the resident's care profile required notifying the RP of any changes to the resident's plan of care. The DON confirmed that the RP was not contacted regarding the addition of D-Mannose, and the expectation was that the RP should be notified of any changes in treatment or medication. The facility's policy on resident rights emphasized the resident's right to be informed of and participate in their plan of care and treatment, which was not upheld in this case.
Failure to Provide Adequate Room Space
Penalty
Summary
The facility failed to provide the required 80 square feet of space per resident in rooms 302, 303, 304, 305, 306, 307, 309, 310, 312, and 314. Each of these rooms housed two residents but only provided between 65 to 78.12 square feet per resident, which is below the regulatory requirement. Despite the rooms being uncluttered and having sufficient space for personal effects, entrance, egress, and maneuvering of equipment, the facility did not meet the minimum space requirements. Interviews with staff and residents indicated no issues or complaints regarding the room sizes, and no safety concerns were reported. The Maintenance Director confirmed that there had been no alterations in the rooms, and measurements taken during the survey confirmed the insufficient space. The facility's Administrator requested a continuance of the room size waiver, noting that there had been no complaints from residents or issues raised in Resident Council meetings. The Department recommended continuing the room size waiver for the specified rooms.
Failure to Provide Adequate Supervision for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for Resident 7, who had a history of multiple falls and was identified as a fall risk. Despite the care plan indicating that Resident 7 should be out of bed and at the nurse's station during the day for increased supervision, she was found unattended in her room, sitting in a Geri chair and unable to reach her call light. This situation was observed by a Certified Nursing Assistant (CNA) and confirmed by a Licensed Nurse (LN) and the Director of Nursing (DON), all of whom acknowledged that Resident 7 should not have been left alone in her room and that her call light should have been within reach at all times. Resident 7's clinical records indicated she required assistance from two or more staff members for transfers and had a history of repeated falls. On two separate occasions, Resident 7 had fallen while attempting to self-transfer. The facility's policies on fall risk management and comprehensive person-centered care plans were not followed, as evidenced by the failure to keep Resident 7's call light within reach and to ensure she was supervised as required by her care plan. This lack of adherence to the care plan increased the risk of falls for Resident 7.
Failure to Provide Medical Records via Requested Method
Penalty
Summary
The facility failed to provide a copy of medical records for one resident when the resident's Responsible Party (RP) did not receive the medical record via electronic mail as requested. The admission record indicated that the resident was initially admitted with diagnoses including chronic respiratory failure with hypoxia. The resident had a Responsible Party and Power of Attorney (POA) who authorized the disclosure of health information via email. Despite the request being received and confirmed by the Social Services Director, the facility was unable to provide documented evidence of the email being sent to the RP. The Medical Records staff stated that the medical chart was copied and ready for pick-up, but this did not align with the RP's request for electronic delivery. The facility's policy indicated that residents could access their records within two working days of a written request. However, the facility failed to comply with this policy, as there was no documented evidence of the email being sent. This failure decreased the facility's potential to provide resident medical records consistent with state laws and regulations.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
