Apple Valley Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Apple Valley, California.
- Location
- 11959 Apple Valley Rd, Apple Valley, California 92308
- CMS Provider Number
- 555476
- Inspections on file
- 34
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Apple Valley Care Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a femur fracture, gout, COPD, and HTN, activated the call light for incontinence care but remained in a soiled brief for over 40 minutes while lunch was served. A CNA entered the room without knocking, turned off the call light, initially ignored the resident, and stated she could not provide peri-care because the roommate was eating. The CNA later claimed she had been told not to provide such care when someone in the room was eating, while the CN and DSD denied giving such instructions and referenced expectations for immediate response and use of privacy curtains. Review of the facility’s dignity policy and the DON’s statements confirmed that required practices for prompt toileting assistance, respect, and privacy were not followed.
A resident with diabetes, gait difficulty, and muscle weakness was admitted with documented discoloration on the lower back, but staff did not further assess, monitor, or care plan this finding, nor notify the physician or responsible party as required by the facility’s Changes in Residents Condition policy. The same resident had a PT order and repeatedly refused to ambulate on multiple occasions; the PT documented the refusals but did not notify nursing, and no change in condition process or care plan for treatment refusal was initiated, contrary to facility policy requiring action after two or more consecutive refusals.
Two residents with significant mobility limitations were found without accessible call lights, as one had the device placed out of reach above the pillow and another had it wrapped around a bedrail and hanging to the floor. Both residents were unaware of their call light locations, and staff failed to verify accessibility during routine checks, contrary to facility policy.
A resident with a history of pulling out a surgical drainage tube following cholecystectomy was admitted without the facility obtaining key surgical details or follow-up instructions. Despite repeated incidents of the resident attempting to remove the tube, there was no care plan addressing this behavior, and the physician was not notified. The resident ultimately removed the tube, requiring hospital transfer, and the facility did not follow its own policies for care planning and change of condition notification.
A resident with systemic lupus erythematosus and mobility issues experienced an assisted fall, which was not documented according to facility policy. The CNA reported the incident to the LVN, but no immediate assessment or documentation was completed. The facility's fall protocol requires such incidents to be documented and investigated, which was not followed in this case.
The facility failed to address grievances from residents regarding noise at night and staff not returning after responding to call lights. Despite a policy requiring prompt resolution of grievances, these issues persisted due to high staff turnover. The Activity Director did not consider concerns raised during resident council meetings as grievances, leading to ongoing unresolved issues documented from May to October 2024.
A facility failed to ensure the accuracy of a discharge MDS for a resident, incorrectly documenting the discharge location. The resident was discharged home, but the MDS indicated a discharge to a hospital. Interviews with the MDS Coordinator and DON confirmed the error, and the facility lacked a specific policy for MDS completion, relying on RAI guidelines.
The facility failed to notify physicians of pharmacy recommendations for two residents, leading to unaddressed medication issues. One resident had an incorrect morphine order that was not clarified, while another had inappropriate use of lorazepam and ABHR cream/gel for anxiety and agitation. The DON and Consultant Pharmacist had differing expectations for follow-up timeframes, but neither was met, resulting in a lack of documented physician response.
The facility exceeded the acceptable medication error rate, reaching 6.45% due to errors involving two residents. One resident received a multivitamin with minerals instead of the prescribed multivitamin without minerals, while another received a multivitamin without minerals instead of the prescribed multivitamin with minerals. The errors were acknowledged by the LVNs involved, and the importance of verifying medication labels against orders was emphasized by the DON and Administrator.
A resident was administered Haloperidol without proper informed consent from their representative. The facility's policy requires written consent for psychotropic drugs, but the consent form was incorrectly filled out, with the hospice nurse's name in the representative's space. The DON acknowledged the error, noting the lack of proper documentation of verbal consent from the resident's wife.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to honor a resident’s dignity and comfort. Resident 1, who had diagnoses including a left femur fracture, gout, COPD, hypertension, and a history of falling, reported that she activated her call light at 11:00 AM because she needed a diaper change. She stated that a CNA brought her lunch at 11:30 AM but refused to assist with the diaper change. At 11:41 AM, the resident was observed in bed stating she had been waiting since 11:00 AM for incontinence care. At 11:43 AM, while the surveyor was present, the resident again activated her call light. CNA 1 entered the room in less than a minute without knocking or announcing her presence, turned off the call light, ignored the resident, checked only on the roommate, and was about to leave the room until the visibly distressed resident requested assistance, stating she would not eat while soiled. CNA 1 told the resident she could not change the diaper because the roommate was eating. In a subsequent interview, CNA 1 stated she had been on lunch break from 10:40 AM to 11:20 AM, believed another staff member had answered the earlier call light, and claimed she had been instructed by the DSD not to provide peri-care if someone in the room was eating, and that the charge nurse had told her she could not do it. The charge nurse denied instructing CNA 1 not to change the resident and stated she had told CNA 1 to pull the privacy curtain and assist with the diaper change. The DSD denied ever instructing staff to delay care due to a roommate eating and stated staff were expected to attend to residents’ needs immediately and use privacy curtains during personal care. Review of the facility’s “Dignity” policy showed requirements that residents be treated with dignity and respect, that staff knock and request permission before entering rooms, promote and protect privacy, and promptly respond to toileting requests. The DON acknowledged that the policy was not followed when staff did not provide necessary personal care and left the resident in a soiled diaper for more than 40 minutes, in violation of facility standards and CMS regulations.
Failure to Address Skin Discoloration and Repeated Therapy Refusals as Changes in Condition
Penalty
Summary
The facility failed to implement its policy on Changes in Residents Condition or Status for a resident admitted with multiple diagnoses, including type 2 diabetes mellitus, difficulty in walking, and muscle weakness. On the admission skin assessment, the Wound Care Nurse documented discolorations on the resident’s lower back. However, there was no documentation in the clinical record that this discoloration was further assessed, monitored, or addressed. The Wound Care Nurse acknowledged that no change of condition monitoring was done, no care plan was initiated, and the skin condition was not assessed or documented prior to the resident’s transfer out of the facility. The DON stated that the discoloration should have triggered a change of condition notification to the primary physician and responsible party on admission, and that it should have been monitored and documented according to facility policy. The facility also did not follow its policy regarding refusals of treatment. The resident had a physician’s order for Physical Therapy evaluation and treatment, and Physical Therapy notes showed that the resident refused to ambulate on four documented occasions. There was no evidence in the clinical record that these repeated refusals were addressed by the facility. The Physical Therapist stated that the resident often refused to get out of bed and walk with a walker on more than two occasions and that these refusals were only documented in therapy notes without notifying the licensed nurse. The DON stated that the resident’s refusal to get out of bed should have been communicated to the licensed nurse and that a care plan should have been initiated after more than two refusals, consistent with the facility’s policy requiring physician notification and care plan review or revision for significant changes in condition and repeated refusals of treatment.
Failure to Ensure Call Light Accessibility for Residents with Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents, both of whom had significant mobility impairments. For one resident with a right femur fracture and difficulty walking, the call light was observed placed above the pillow and out of reach. The resident was unaware of the call light's location. A Licensed Vocational Nurse confirmed the call light was not accessible and subsequently placed it in the resident's hand. The Certified Nursing Assistant (CNA) responsible for this resident admitted she had not checked the call light's accessibility during her last round, despite facility policy requiring her to do so each time she entered the room. For another resident with hemiplegia and hemiparesis following a stroke affecting the right side, the call light was found wrapped around the right bedrail, hanging down and touching the floor, making it unreachable. This resident also did not know where the call light was. The CNA responsible for this resident stated she had not checked the call light's location during her last check, mistakenly believing it had been removed by maintenance. Maintenance staff clarified that call lights should not be wrapped around bedrails and should be accessible, and the Minimum Data Set Nurse confirmed that facility policy requires call lights to be within reach, especially for residents with weakness on one side.
Failure to Address Resident's Repeated Tampering with Surgical Drainage Tube
Penalty
Summary
The facility failed to provide appropriate care and services for a resident admitted after a cholecystectomy with a surgical drainage tube in place. The facility was unaware of the date of the resident's surgery and did not have information regarding necessary follow-up visits or treatments from the resident's surgeon. There was no documentation of the facility seeking this information from the hospital, family, or other sources, and the care plan did not address the resident's previously identified behavior of attempting to pull out the drainage tube. Multiple nursing notes documented that the resident had a history of pulling on the drainage tube, including specific incidents where the resident was observed attempting to remove it. Despite this, there were no interventions or care plan updates to address this behavior, and the physician was not notified of these incidents. Staff interviews confirmed that the resident frequently tampered with the tube and that this was a known issue upon admission, but no formal documentation or care planning was completed to mitigate the risk. Ultimately, the resident pulled out the drainage tube, resulting in redness and edema at the site, and was transferred to the hospital. The facility's own policies required prompt notification of changes in condition, comprehensive care planning, and measures to ensure resident safety and supervision, but these were not followed in this case. The lack of care planning, physician notification, and follow-up on the surgical procedure directly contributed to the deficient practice.
Failure to Document Assisted Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an assisted fall. The resident, diagnosed with systemic lupus erythematosus and difficulty in walking, was admitted to the facility and later reported a fall incident. The Case Manager was unable to locate the incident report or a Change of Condition (COC) report in the resident's records, indicating a lapse in documentation according to the facility's policy. The Certified Nursing Assistant (CNA) involved in the incident stated that the resident slipped while attempting to stand and was assisted to the floor. Although the CNA informed the Licensed Vocational Nurse (LVN) of the incident, no assessment was conducted, and the incident was not documented immediately. The Director of Nursing confirmed that a COC report should have been completed for the assisted fall. The facility's fall protocol requires documentation and investigation of such incidents, which was not adhered to in this case.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances voiced by five residents who attended a resident council meeting. The facility's grievance policy, revised in April 2017, states that residents and their representatives have the right to file grievances, and the facility staff must make prompt efforts to resolve them. However, during a resident council meeting, residents reported that the facility did not always follow up on their grievances. They expressed concerns about noise at night in the hallways and staff responding to call lights but not returning to provide services. These issues were reportedly communicated to the facility, but due to high staff turnover, the problems persisted. The Activity Director (AD) stated that concerns raised during the resident council meetings were not considered grievances and were only discussed in subsequent meetings if not addressed. The Resident Council Minutes from May 2024 to October 2024 documented ongoing concerns about unanswered call lights and staff not returning to provide services.
Inaccurate Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the discharge Minimum Data Set (MDS) for a resident, specifically regarding the location of disposition at the time of discharge. The resident was admitted to the facility and later discharged home, as indicated by the admission record and physician orders. However, the discharge MDS inaccurately recorded the resident as being discharged to a short-term general hospital. Interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed the error, with the DON stating that the facility did not have a specific policy for MDS completion but followed the Resident Assessment Instrument (RAI) guidelines. The Administrator also expressed the expectation that the MDS should be accurate.
Failure to Notify Physician of Pharmacy Recommendations
Penalty
Summary
The facility failed to notify the physician of pharmacy recommendations and did not ensure a specified time frame for physician response to these recommendations for two residents. Resident #40, who was admitted with severe cognitive impairment and chronic pain syndrome, had an incorrect morphine sulfate order that was not clarified despite a pharmacy recommendation to do so. The Director of Nursing (DON) acknowledged forgetting to follow up on the recommendation, which was initially discussed with an unidentified charge nurse. The DON expected the physician to be notified within 48 hours, but this did not occur, leaving the morphine order unclarified. Resident #85, also with severe cognitive impairment and on hospice care, had orders for lorazepam and ABHR cream/gel for anxiety and agitation. The pharmacy recommended limiting lorazepam use to 14 days and discontinuing the ABHR cream/gel, as the reasons for their use were deemed insufficient. The DON stated that the hospice nurse was informed of the recommendations, who then spoke to the hospice physician, but there was no documentation of physician notification. The Consultant Pharmacist expected follow-up within two weeks, while the DON expected it within one week, but neither timeframe was met, resulting in a lack of documented physician response.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.45% during a survey. This deficiency was identified through observations, record reviews, and interviews. Two residents were involved in the medication errors. Resident #66, who was admitted with a diagnosis of generalized muscle weakness, was prescribed a multivitamin without minerals. However, during medication administration, LVN #6 administered a multivitamin with minerals instead. The nurse acknowledged the mistake during an interview, and the Director of Nursing confirmed that the nurse should have verified the medication label against the physician's order. Similarly, Resident #23, with a history of chronic obstructive pulmonary disease, was prescribed a multivitamin with minerals. LVN #7 administered a multivitamin without minerals, contrary to the physician's order. The nurse admitted to the error during an interview, and the Director of Nursing reiterated the importance of comparing the medication label with the medication administration record. The facility's Administrator also emphasized that the nurses should have verified the medication orders and sought clarification if there were any doubts.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from a resident's representative before administering a psychotropic medication, Haloperidol, to the resident. The resident, who was admitted with diagnoses including senile degeneration of the brain, unspecified dementia, anxiety, and delirium, was given the medication without the proper consent documentation. The Physician Telephone Order for Haloperidol was signed, but the consent form was incorrectly filled out, with the hospice nurse's name appearing in the space designated for the resident's representative. During an interview, the Director of Nursing (DON) acknowledged that the hospice nurse claimed to have obtained verbal consent from the resident's wife, but the documentation did not reflect this. The facility's policy requires written informed consent for psychotherapeutic drugs, and the consent form should have included the name of the person who gave consent and the date. The failure to follow this policy resulted in a violation of the resident's representative rights, as the necessary consent was not properly documented in the resident's medical record.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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