Arcadia Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arcadia, California.
- Location
- 1601 S Baldwin Ave., Arcadia, California 91007
- CMS Provider Number
- 555729
- Inspections on file
- 33
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Arcadia Care Center during CMS and state inspections, most recent first.
Surveyors found that two CNAs did not have timely, fully documented annual performance evaluations, and one CNA lacked a complete pre-employment background check. One CNA had no evaluation for the most recent year, and another’s evaluation was completed late; both evaluations lacked supervisor comments on new goals, objectives, and commitments. The same CNA’s file contained only a limited county criminal search without required abuse registry and OIG LEIE exclusion checks, despite facility policies requiring comprehensive background screening and annual performance reviews to support ongoing CNA competency.
A resident with asthma and a history of acute respiratory failure was allowed to self-administer a Fluticasone Furoate-Vilanterol inhaler unsupervised over several months without an IDT assessment, despite facility policies requiring such evaluation before self-administration. Physician orders and MARs documented daily unsupervised self-use of the inhaler, while the IDT care conference form left the self-medication section unaddressed and contained no assessment of self-administration capability. Nursing notes later showed the resident was using the inhaler on a PRN basis instead of as ordered, and staff interviews revealed that no formal self-medication assessment had been completed and that key team members were unaware the resident was self-administering. Facility P&Ps required the attending physician and IDT to assess mental and physical abilities and specific medication-management skills before permitting self-administration, which was not done in this case.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required this intervention due to fall risk and functional limitations. One resident with hemiplegia, hemiparesis, generalized weakness, COPD, moderate cognitive impairment, and dependence in multiple ADLs was observed in bed with the call light pad hanging under the bed, and both the resident and a CNA stated the resident could not reach it. Another resident with prostate cancer, bone metastases, difficulty walking, generalized weakness, type 2 DM, and intact cognition was observed sitting on one side of the bed while the call light lay on the floor on the opposite side; the resident and an LVN confirmed it was out of reach. The DON and facility policies required that call lights be kept within easy reach of residents to accommodate their needs and support safe functioning.
A deficiency occurred when a physician-ordered Nystatin powder for treatment of scrotal MASD was found stored at a resident's bedside rather than in a locked medication area, contrary to facility policy. The resident, who had multiple serious diagnoses and required extensive assistance with ADLs, had an active order for Nystatin application every shift, documented on the TAR and OSR. During observation, the Nystatin bottle with its label was seen on the bedside drawer, and the resident and family member reported it was kept there and accessible to anyone. A review of the treatment cart with a treatment nurse confirmed the medication was not stored there, and both the TN and DON stated medications should be kept locked and accessed only by licensed nurses, as required by the facility's medication storage policy.
A resident with hemiplegia, hemiparesis, DM, and recent right thigh tumor surgery was admitted with a right thigh JP drain and an abdominal wound VAC, but staff did not obtain physician orders on admission to monitor, drain, and record JP output or to monitor and change the wound VAC canister. Documentation showed no monitoring of the JP drain, its stoma sites, or the wound VAC on the evening and night shifts following admission, and TAR entries for JP and wound VAC monitoring did not begin until the next day. In interviews, the admitting RN and LVNs confirmed they did not secure appropriate orders or perform and document required monitoring, and the DON referenced facility policy requiring the admitting nurse to contact the physician, review assessment findings, and obtain and record admission orders based on those findings.
A resident with neuromuscular bladder dysfunction and extrarenal uremia underwent a bladder scan performed by an LVN, who then contacted the physician and received an order for PRN straight catheterization. Although the SBAR form reflected that the scan was done and an order was obtained, the electronic order summary contained no physician order for either the bladder scan or the straight catheter. The LVN acknowledged that the order was not entered into the medical record, and the DON confirmed that such an order should have been documented, resulting in inaccurate clinical documentation.
A resident with dementia and mobility needs was left alone at an outside medical appointment without a facility escort present, despite facility policy requiring staff to remain with cognitively impaired residents until family arrives. The resident was found by family unaccompanied, raising concerns about safety and adherence to established protocols.
A resident with hypertension and other conditions was provided with salt packets despite a physician's order for no added salt. The dietary supervisor gave the resident salt upon request, did not document communication with the family or physician, and did not follow facility policy for handling declined therapeutic diets.
A facility failed to notify a resident's representative when the resident was transferred to a hospital due to a respiratory infection. The resident, who had multiple diagnoses and was dependent on staff, was transferred without documented notification to their representative, violating the facility's policy. The LVN responsible did not recall the notification time, and the transfer form lacked this documentation.
A facility failed to document the notification to a resident's representative about the resident's transfer to a General Acute Care Hospital. The resident, with conditions including encephalopathy and acute respiratory failure, was transferred due to a respiratory infection. The LVN did not remember the notification time, and the DON confirmed that if it was not documented, it was not done, violating the facility's charting policy.
A facility failed to notify a resident's responsible party when the resident's antibiotic treatment was discontinued, contrary to policy. The resident, admitted for IV antibiotics for a complicated UTI, did not receive alternative treatment, leading to increased confusion and pain. Staff assumed the physician had informed the responsible party, resulting in a communication breakdown.
A resident admitted with a UTI did not receive prescribed IV antibiotics due to cost concerns, and no alternative treatment was provided. The facility also failed to conduct a timely urinalysis to guide treatment, leading to the resident's rehospitalization with altered mental status.
A resident with a UTI did not receive timely laboratory services, leading to a delay in antibiotic treatment. The facility failed to collect a urine sample for urinalysis with C&S as ordered, resulting in the resident experiencing altered mental status and requiring transfer to a hospital for further evaluation and treatment.
The facility failed to provide written Medicare Advance Beneficiary Notices (ABN) to the responsible parties of two residents, despite notifying them by phone. Both residents had significant cognitive impairments and required substantial assistance. The ABNs indicated that Medicare coverage for skilled services would end, necessitating out-of-pocket payments. The Business Office Manager confirmed the lack of written notification, which was against facility policy.
The facility failed to implement fall safety interventions for two residents, leading to potential fall risks. One resident, with conditions like osteoarthritis and cerebral palsy, was left to ambulate alone due to delayed staff response. Another resident, at high risk for falls, had their bed in a raised position without required floor mats, contrary to their care plan.
A facility failed to monitor and document fluid intake and output for a resident on dialysis, as per physician's orders. The resident, with severe cognitive impairment and dependent on staff, had a fluid restriction due to heart failure and end-stage renal disease. Interviews confirmed missing documentation on multiple dates, violating the facility's policy for intake and output recording, and preventing verification of compliance with the fluid restriction.
A facility failed to implement proper infection control measures, as evidenced by a CNA entering a resident's isolation room without PPE and an LVN using potentially contaminated toilet paper during eye drop administration. These actions violated facility policies and CDC guidelines, increasing the risk of infection spread.
The facility failed to maintain resident dignity by not responding to call lights promptly, standing while feeding residents, and not respecting private spaces. Two residents experienced long waits for assistance, leading to frustration and potential incontinence. Staff were observed standing while feeding, against policy, and entering rooms without knocking, violating privacy and dignity.
The facility failed to educate the representatives of two residents on their rights to formulate Advance Directives. One resident, with COPD and other conditions, lacked decision-making capacity, and their representative did not receive complete information. Another resident, with lung cancer and cognitive impairment, had documents signed by staff not legally recognized as decision-makers. The facility did not involve its Bioethics Committee as required, risking unwanted life-sustaining treatment.
A resident's representative was not properly informed of the facility's bed hold policy during a transfer, as the Bedhold Notification form lacked the necessary signature. The resident, who was dependent on staff and had multiple diagnoses, had their consent obtained over the phone without proper documentation. The facility's policy requires documentation and witness signatures for phone consents.
A resident with type 2 diabetes had a blood sugar level of 420 mg/dL recorded, but the facility staff failed to notify the physician as required. The resident's MAR indicated a need to inform the MD for levels above 400 mg/dL. The LVN could not recall notifying the MD, and there was no documentation of such action. The DON confirmed that the facility's policy required notifying the physician of changes in the resident's condition.
A resident with End Stage Renal Disease and hypertension used a shared restroom not designated for them, potentially invading the privacy of other residents. The resident, who had intact cognition, was directed by a staff member to use the restroom across the hallway due to an urgent need. Facility staff confirmed that this practice violated privacy policies.
A resident with multiple health conditions, including dementia and diabetes, was served fish despite a documented preference against it. The oversight occurred during lunch tray line service, where the resident's meal tray card indicated 'No Fish'. The Dietary Services Supervisor emphasized the importance of adhering to food preferences, as outlined in the facility's policies.
The facility failed to follow its dishwashing and standard precautions policies, as a dishwasher improperly handled sanitized trays, risking cross-contamination. The Dietary Services Supervisor confirmed the error, noting that another staff member was responsible for handling sanitized items. Facility policies required proper sanitization and handling of tableware.
A facility failed to ensure a responsible party understood a binding arbitration agreement before signing. The resident, with dementia and requiring substantial assistance, had an agreement signed electronically by their representative without a clear explanation of its terms. The Admissions Coordinator communicated via email and phone but did not provide adequate information, despite facility policy allowing refusal or rescission of the agreement.
Failure to Complete Annual CNA Evaluations and Full Background Screening
Penalty
Summary
Surveyors identified that the facility did not ensure required annual performance evaluations were completed and properly documented for two of four CNAs reviewed, and did not complete a full pre-employment background check for one CNA. Personnel file review showed CNA 2, hired on 9/28/23, had a performance evaluation dated 9/28/24 but no evaluation for 2025, and the existing evaluation lacked supervisor comments regarding new goals, objectives, and commitments. CNA 4’s performance evaluation was dated 7/20/25, although the CNA’s hire date of 6/1/19 indicated the annual evaluation was due on 6/1/25, and this evaluation also lacked supervisor comments on new goals, objectives, and commitments. During interview, the DSD confirmed there was no 2025 performance evaluation for CNA 2 and stated that performance evaluations should be completed annually and that annual reviews of CNA skills are important to ensure safe resident care. Record review further showed that CNA 4’s personnel file did not contain a full background check as required by facility policy. The file only included a 7-year criminal court record search for Los Angeles County and lacked documentation of an abuse registry check and an exclusion list database check, including the OIG LEIE. Facility policies titled “Background Screening Investigations,” “Hiring,” “Staff Development Program,” and “Performance Evaluations” indicated that background and criminal checks must be initiated within two days of an employment offer and completed prior to employment, including checks of the state nurse aide registry and applicable licensing boards, and that each employee’s job performance must be reviewed at least annually. The policies also stated that CNAs must complete at least 12 hours of annual in-service training to ensure continuing competency and address weaknesses identified in performance evaluations and the facility assessment.
Failure to Assess Resident Before Allowing Unsupervised Self-Administration of Inhaler
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary team (IDT) assessment was completed before allowing a resident to self-administer medication, as required by facility policies. The resident was admitted and readmitted with diagnoses including acute respiratory failure with hypoxia and asthma, and was prescribed a Fluticasone Furoate-Vilanterol inhaler for asthma as an unsupervised self-administered medication. Physician orders and MARs for multiple months documented that the resident was self-administering this inhaler daily and unsupervised. However, the IDT care conference record for the resident’s admission showed that the self-medication administration section was left unmarked, and there was no documentation in the conference summary that an IDT assessment for self-administration had been conducted. Further record review showed that the resident’s MDS indicated intact cognition for daily decision-making but dependence or need for assistance with several ADLs, including toileting hygiene, dressing, footwear, personal hygiene, and bathing. Nursing progress notes later documented that the resident reported taking the inhaler on an as-needed basis, despite the physician’s order specifying daily administration. The nurse documented reviewing proper inhaler technique with the resident and seeking clarification from the physician regarding whether the medication should remain a daily routine or be changed to PRN, and the physician confirmed it should be administered once daily as ordered. A care plan for self-administration of medication was initiated and revised later, indicating that the resident self-administers the inhaler and that reassessments would occur periodically, but this was not in place during the earlier period of self-administration. Interviews with staff and family further highlighted the lack of required assessment and oversight. A family member stated that the resident did not receive the inhaler for approximately two and a half months starting from the time of the order. An LVN reported that the resident had been self-administering the inhaler from December through March and stated that there should be a self-medication assessment in the electronic medical record completed by an RN supervisor or charge nurse, but confirmed that she had not completed such an assessment. The MDS nurse stated that residents who self-administer medications should have both a physician’s order and an IDT assessment of their ability to self-medicate, and reported having no knowledge that this resident was self-administering until preparing the quarterly MDS. Review of facility policies confirmed that residents may self-administer medications only if the attending physician and IDT determine, through assessment of mental and physical abilities and specific medication-related skills, that it is clinically appropriate and safe, which had not been documented for this resident during the period in question.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to keep call lights within reach of residents in accordance with its Call Light and Accommodation of Needs policies. The policies require that when a resident is in bed or confined to a chair, the call light must be within easy reach, and that staff behaviors support residents in maintaining safe independent functioning and that individual needs and preferences are accommodated. The Director of Nursing confirmed that the facility should ensure call lights are always kept within residents’ reach. For one resident admitted with hemiplegia and hemiparesis following a cerebral infarction, generalized muscle weakness, and COPD, the care plan identified the resident as a fall risk and specified interventions to maintain the call light within reach and to place the call light and frequently used items within reach to improve functional ability in bed. The resident’s history and physical indicated capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills and dependence for multiple ADLs, including eating, toileting hygiene, bathing, dressing, and personal hygiene. During observation and interview, the resident was awake in bed with the call light hanging on the left bedrail and the call light pad hanging under the bed; the resident stated being barely able to move hands and arms and unable to reach the call light pad. A CNA confirmed during the same observation that the resident could not touch the call light pad under the bed and acknowledged staff should have placed it within reach. For another resident admitted with prostate cancer, secondary malignant neoplasm of bone, difficulty in walking, generalized muscle weakness, and type 2 DM, the care plan also directed staff to place the call light and frequently used items within reach to improve functional ability in bed and to maintain the call light within reach due to fall risk. The history and physical documented that this resident had capacity to understand and make decisions, and the MDS indicated intact cognitive skills, with partial/moderate assistance needed for toileting hygiene, bathing, and dressing, and supervision or touching assistance for eating, oral hygiene, and personal hygiene. During observation and interview, the resident was sitting on the left edge of the bed with feet on the floor, while the call light was on the floor on the opposite side of the bed; the resident stated being unable to use the call light because it could not be reached. An LVN present at the time confirmed the call light was on the floor on the other side of the bed and that the resident could not reach it, acknowledging staff should have kept it within reach.
Improper Bedside Storage of Nystatin Powder
Penalty
Summary
Surveyors identified a deficiency related to medication storage when a physician-ordered Nystatin powder for treatment of scrotal moisture-associated skin damage (MASD) was found stored at a resident's bedside instead of in a locked medication area. The resident, admitted with diagnoses including muscle wasting and atrophy, generalized muscle weakness, liver cell carcinoma, secondary malignant neoplasm of the nervous system, and type 2 DM, had an active treatment order dated 2/26/2026 to cleanse the scrotum with normal saline, pat dry, and apply Nystatin powder every shift for 14 days, documented on the Treatment Administration Record and Order Summary Report. The resident's MDS indicated intact cognitive skills but dependence or substantial/maximal assistance with toileting, bathing, dressing, footwear, and personal hygiene. During observation at the bedside, surveyors saw a bottle of Nystatin powder with the pharmacy label on top of the bedside drawer, and both the resident and a family member stated the Nystatin was kept at the bedside and accessible to everyone. A subsequent observation of the treatment cart with the treatment nurse showed that the Nystatin powder ordered for this resident was not stored in the cart. The treatment nurse stated the Nystatin should have been stored in the treatment cart and that only licensed nurses should obtain and apply it. The DON stated that all ordered medications should be kept in a locked place with access limited to licensed nurses. Review of the facility’s “Storage of Medications” policy, revised April 2019, showed that all drugs and biologicals are to be stored in locked compartments, with nursing staff responsible for maintaining safe and secure medication storage areas, which was not followed in this instance.
Failure to Obtain Orders and Monitor JP Drain and Wound VAC After Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement physician orders and to monitor a resident’s right thigh Jackson Pratt (JP) drain and right lower quadrant (RLQ) abdominal wound vacuum following admission. The resident was admitted with a history of hemiplegia and hemiparesis following cerebral infarction and diabetes mellitus, and had recently undergone surgery on a right thigh tumor. The admission assessment documented the presence of a wound vacuum from the RLQ abdomen to the perineal area and a JP drain on the right thigh, and the physician’s plan included wound care for the right thigh ulcer with monitoring for drainage. However, the Order Summary Report on the admission date showed no physician orders to monitor, empty, and record JP drain output, and no orders to monitor or change the wound vacuum canister. Record review showed no evidence that the JP drain and wound vacuum were monitored on the evening shift of the admission date or on the subsequent night shift. The Treatment Administration Record for that month confirmed that monitoring and recording of JP drainage every shift did not begin until the day after admission and that there was no monitoring of the JP drain or its stoma sites on the evening and night shifts of the admission date. Similarly, orders and documentation for continuing and monitoring the wound vacuum every shift began the day after admission, with no such monitoring documented for the evening and night shifts immediately following admission. In interviews, treatment nurses and LVNs acknowledged that there were no orders on the admission date to monitor, drain, and record JP drainage or to monitor, continue, and change the wound vacuum canister, and they confirmed that they did not perform or document these tasks on the evening shift. The admitting RN stated that although the resident was admitted with a JP drain and wound vacuum, the RN did not verify and obtain orders from the physician to monitor, drain, and record JP output or to monitor and change the wound vacuum on the admission date. The DON stated that the facility should monitor, drain, and record JP drainage and monitor, continue, and change the wound vacuum canister after admission for residents with these devices, and the facility’s admission assessment policy required the admitting nurse to contact the attending physician, review assessment findings, and obtain admission orders based on those findings, documenting them in the medical record.
Failure to Document Physician Orders for Bladder Scan and Straight Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident who had neuromuscular dysfunction of the bladder and extrarenal uremia. The resident was admitted in mid-November 2025 and required varying levels of assistance with activities of daily living, including toileting and personal hygiene. Review of the resident’s Order Summary Reports for November and December 2025 showed no physician’s order for a bladder scan or for insertion of a straight catheter on an as-needed basis. However, an SBAR Communication Form dated December 8, 2025 documented that an LVN performed a bladder scan on the resident, notified the physician, and received a physician’s order to insert a straight catheter as needed at 12:45 PM that day. During interview and concurrent record review, the LVN confirmed performing the bladder scan and obtaining a physician’s order for straight catheterization to drain urine as needed, but acknowledged that there was no documented order in the medical record for either the bladder scan or the straight catheter on that date and stated that this documentation should have been completed. The DON also stated that the nurse should have obtained and documented a physician’s order to perform the straight catheter. Facility policies on Charting and Documentation required that all services provided and changes in condition be documented in the resident’s clinical record, and the Electronic Signatures and Electronic Orders policy required that the time and date of orders entered or changed in electronic records be recorded. The lack of a documented physician’s order for the bladder scan and straight catheterization on December 8, 2025 resulted in inaccurate documentation in the resident’s medical record and had the potential for delaying interventions and services for the resident.
Resident with Dementia Left Unescorted at Medical Appointment
Penalty
Summary
A resident with diagnoses including hypertension, epilepsy, and unspecified dementia was admitted to the facility and assessed as cognitively intact but requiring substantial to maximal assistance with walking and being dependent for transfers. The resident had an outside medical appointment, and according to family interview, was found alone at the appointment site with their wheelchair and medical documents, without a facility escort present. The family member expressed concern for the resident's safety due to the dementia diagnosis. Facility staff interviews revealed that the protocol is to send an escort with residents, especially those with cognitive impairment or dementia, unless family is present to assume responsibility. Documentation and staff statements indicated that the expectation was for an escort to remain with the resident until the family arrived. However, the escort left the resident at the appointment before the family arrived, contrary to facility policy and procedure, which requires staff to accompany residents with cognitive impairment when family is not available. This resulted in the resident being left unsupervised at the appointment site.
Failure to Follow Physician-Ordered Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a therapeutic diet was served as ordered for one resident. The resident had a physician's order for a controlled carbohydrate diet with no additional salt due to medical conditions including hypertension, epilepsy, and dementia. Despite this order, the resident was provided with salt packets upon request. The dietary supervisor confirmed that the resident frequently asked for additional salt and was given salt packets, even though the order specified no added salt. Mrs. Dash, a salt-free seasoning, was offered as an alternative but was refused by the resident. There was no documentation that the dietary supervisor communicated with the resident's family or the physician regarding the resident's requests for additional salt or the provision of salt packets. The facility's policy required collaboration with the resident or representative if a therapeutic diet was declined, but there was no evidence that such collaboration or communication occurred in this case. The failure to follow the physician's diet order and lack of documentation led to the deficiency.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding notifying a resident's representative of changes in the resident's condition or status. Specifically, the facility did not notify the representative of a resident when the resident was transferred to a General Acute Care Hospital due to a respiratory infection. The resident, who had been admitted with diagnoses including encephalopathy, acute respiratory failure with hypoxia, and pneumonitis, was dependent on staff for various activities of daily living and was rarely understood by others. The facility's policy required prompt notification of the resident's representative in such situations, but there was no documentation indicating that this notification occurred. Interviews and record reviews revealed that the Licensed Vocational Nurse responsible for the transfer did not remember the time of notification, and the transfer form did not document the notification to the resident's representative. The Director of Nursing confirmed that if the notification was not documented, it was considered not done, as per the facility's policy. The failure to document the notification violated the resident's and the representative's right to be informed of changes in the resident's condition or status.
Failure to Document Notification of Resident Transfer
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Charting and Documentation' by not documenting the notification to a resident's representative regarding the resident's transfer to a General Acute Care Hospital (GACH). The resident, who was originally admitted on January 13, 2025, and readmitted on February 6, 2025, had diagnoses including encephalopathy, acute respiratory failure with hypoxia, and pneumonitis due to inhalation of food and vomit. The resident was rarely/never understood by others and was dependent on staff for various personal care activities. On January 29, 2025, the resident was transferred to GACH due to a respiratory infection, but the time of notification to the resident's emergency contact was not documented. During interviews and record reviews, it was revealed that the Licensed Vocational Nurse (LVN) responsible for the transfer did not remember the time of notification to the resident's representative. The Director of Nursing (DON) confirmed that if the notification was not documented in the resident's Progress Notes or Transfer Form, it was considered not done. The facility's policy required that all services provided to the resident, including notifications of changes in the resident's condition, be documented in the medical record. The lack of documentation of the notification to the resident's representative was identified as a deficiency.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to promptly notify the responsible party of a resident when there was a change in the resident's condition, specifically when the resident's primary care provider discontinued the antibiotic Avycaz. This failure was contrary to the facility's policy and procedure, which mandates notifying the resident's representative of significant changes in the resident's medical condition. The resident was admitted to the facility with a diagnosis of a complicated urinary tract infection and was supposed to receive intravenous antibiotics therapy. The physician order dated January 8, 2025, indicated the discontinuation of Avycaz, but the responsible party was not informed until four days later. During this period, the resident did not receive any alternative treatment for the urinary tract infection, leading to increased confusion and pain. The facility staff assumed that the physician had notified the responsible party, which was not the case, resulting in a communication breakdown. Interviews with the facility's administrator, licensed vocational nurse, and director of nursing revealed that there was no documentation of notification to the responsible party regarding the discontinuation of Avycaz. The responsible party expressed concern over the lack of communication and the facility's failure to follow the hospital's instructions for the resident's care. The resident also reported feeling neglected and uninformed about their treatment plan.
Failure to Administer Prescribed Antibiotics and Conduct Timely Urinalysis
Penalty
Summary
The facility failed to provide appropriate care and services for a resident, identified as Resident 2, according to the facility's policy and procedures on antibiotic stewardship and urinary tract infection management. Resident 2 was admitted to the facility with a diagnosis of a urinary tract infection (UTI) and was supposed to continue intravenous antibiotic therapy with ceftazidime-avibactam (Avycaz) as recommended by the discharging hospital. However, the facility did not ensure that the primary care provider continued this therapy or provided an alternative treatment. The resident's physician, MD 1, discontinued the Avycaz order due to its high cost without ordering an alternative antibiotic treatment. This decision was made without prior authorization for the medication, which was necessary due to its expense. As a result, Resident 2 did not receive any antibiotics from 1/8/2025 to 1/12/2025, leading to a deterioration in the resident's condition, including altered mental status, which necessitated a transfer back to the hospital for further evaluation and treatment. Additionally, the facility failed to carry out a physician's order for a urinalysis with culture and sensitivity on 1/9/2025, which was intended to guide alternative antibiotic therapy. The delay in obtaining this test contributed to the lack of appropriate treatment for the resident's UTI. Interviews with facility staff, including the Director of Nursing and the admitting nurse, revealed that the facility did not follow the discharge instructions from the hospital, resulting in a delay in care and the resident's rehospitalization.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for a resident, resulting in a delay in treatment for a urinary tract infection (UTI) caused by Pseudomonas aeruginosa. The resident was admitted with a diagnosis of UTI and was a carrier of Carbapenem-resistant Enterobacterales (CRE). A physician order dated 1/8/2025 required a urinalysis with culture and sensitivity (C&S) to be conducted on 1/9/2025 to determine the appropriate antibiotic treatment. However, the facility staff did not collect the urine sample as ordered, leading to a lack of antibiotic therapy from 1/8/2025 to 1/12/2025. On 1/13/2025, the resident experienced altered mental status (AMS) and was transferred to a general acute care hospital (GACH) for further evaluation and treatment. The emergency department provider note indicated that the resident was brought in due to increased confusion and abnormal laboratory test results. The resident was started on ceftazidime-avibactam, an antibiotic that had been discontinued earlier due to its high cost, and was discharged back to the skilled nursing facility (SNF) to continue the antibiotic therapy. Interviews with the facility's registered nurse (RN), licensed vocational nurse (LVN), and the director of nursing (DON) confirmed that the urinalysis with C&S was not carried out as ordered, resulting in a delay in care. The physician also confirmed that the delay in obtaining the urine sample caused a delay in the resident's treatment, leading to rehospitalization. The facility's policy and procedures required that diagnostic and lab tests be processed and arranged promptly, which was not adhered to in this case.
Failure to Provide Written Medicare ABN to Residents' Representatives
Penalty
Summary
The facility failed to provide written notification to the responsible parties of two residents regarding the Medicare Advance Beneficiary Notice (ABN), which informs beneficiaries of services that Medicare may not cover. For Resident 178, who was admitted with serious medical conditions including intracerebral hemorrhage and chronic kidney disease, the facility did not provide a written ABN to the responsible party, despite notifying them by phone. The resident had moderate cognitive impairment, and the ABN indicated that Medicare coverage for skilled services would end, requiring out-of-pocket payment if no other insurance covered the costs. Similarly, for Resident 179, who had severe cognitive impairment and required significant assistance with daily activities, the facility also failed to provide a written ABN to the responsible party. The ABN for this resident indicated that Medicare coverage for skilled services would end, necessitating out-of-pocket payment. The responsible party could not recall receiving any written notification, and the Business Office Manager confirmed that no written ABN was provided, which was against the facility's policy.
Failure to Implement Fall Safety Interventions
Penalty
Summary
The facility failed to implement fall safety interventions for two residents, leading to potential fall risks. Resident 279, who was admitted with conditions such as osteoarthritis, cerebral palsy, and hyperlipidemia, required assistance for transferring and ambulating due to a history of falls. However, the resident reported waiting 45 minutes for staff assistance during the night shift, resulting in the resident walking to the bathroom unassisted. Observations confirmed that Resident 279 was walking alone in her room without staff supervision, and interviews with staff indicated a lack of communication regarding the need for assistance. Resident 55, with a history of falls and conditions including a wedge compression fracture, malignant neoplasm of the stomach, and hypertension, was assessed as high risk for falls. The care plan required the bed to be in the lowest position and floor mats to be placed on both sides of the bed. However, during an observation, the bed was found in a raised position without floor mats, contrary to the care plan. The Director of Nursing acknowledged the purpose of the floor mats was to minimize injuries in case of a fall, indicating a failure to adhere to the facility's fall prevention protocol.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document fluid intake and output for a resident requiring dialysis care, as per the physician's orders. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was on a fluid restriction of 1000 milliliters per 24 hours due to conditions including heart failure and end-stage renal disease. The facility's records showed no documentation of the resident's fluid intake or output on multiple dates, despite an active order for fluid restriction. Interviews with the Licensed Vocational Nurse and the Director of Nursing confirmed the absence of documentation for the specified dates, indicating a failure to adhere to the facility's policy and procedure for intake and output documentation. This lack of documentation meant the facility could not verify compliance with the fluid restriction, which was crucial for the resident's health management. The facility's policy required nursing staff to document intake and output each shift, but this was not followed, leading to the deficiency.
Infection Control Lapses in PPE Use and Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control measures as evidenced by two specific incidents. In the first incident, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation precautions without donning the required personal protective equipment (PPE). The resident, who was diagnosed with enterocolitis due to Clostridium difficile, required isolation to prevent the spread of infection. Despite the presence of signage and an isolation cart with PPE at the room entrance, the CNA did not wear the necessary gown and gloves, stating that PPE was not needed for merely delivering a meal tray. In the second incident, a Licensed Vocational Nurse (LVN) attempted to use toilet paper from a shared bathroom while administering eye drops to another resident. The resident had severe cognitive impairment and required assistance with medication administration. The LVN acknowledged that using toilet paper from the restroom was inappropriate due to potential contamination, as the restroom was shared and the toilet paper could have been touched by multiple individuals. These incidents were in violation of the facility's policies and procedures, as well as national health guidelines. The facility's policies required the use of PPE for contact precautions and specified the use of cotton balls for drying eyelids during eye drop administration. The Centers for Disease Control and Prevention (CDC) guidelines also mandated the use of PPE upon room entry for residents on contact isolation. The facility's failure to adhere to these protocols increased the risk of infection transmission within the facility.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity of six residents by not responding to call lights in a timely manner, standing while feeding residents, and not respecting residents' private spaces. Residents 120 and 279 experienced significant delays in having their call lights answered, with Resident 279 waiting 45 minutes and Resident 120 waiting up to 2 hours during nighttime shifts. These delays forced Resident 279 to attempt to use the bathroom independently, risking incontinence, while Resident 120 experienced frustration due to the inability to move their legs without assistance. Additionally, staff members were observed standing while feeding Residents 13 and 15, which is against the facility's policy that requires staff to be seated to maintain eye-level contact and dignity. The Director of Nursing confirmed that standing while feeding is degrading to residents. This practice was observed during dining times, where staff did not adhere to the policy, potentially impacting the residents' sense of dignity and respect. Furthermore, the facility staff failed to knock before entering residents' rooms, as observed with Residents 13, 75, and 86. LVNs entered rooms and restrooms without knocking, startling residents and violating their privacy. The facility's policy mandates knocking and introducing oneself before entering to maintain dignity and respect. These actions led to residents feeling embarrassed and disrespected, as confirmed by interviews with the Director of Nursing and affected residents.
Failure to Educate on Advance Directives
Penalty
Summary
The facility failed to ensure that the representatives of two residents were provided with complete and accurate education regarding the residents' rights to formulate an Advance Directive (AD). Resident 4, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and heart failure, did not have the capacity to understand or make decisions. The Admission Record indicated that the Advance Directive Acknowledgement was not properly completed, as there were no check marks to confirm that the resident's representative understood the provided materials or the resident's rights concerning medical care decisions. Similarly, Resident 19, who was admitted with diagnoses including lung cancer, muscle weakness, and COPD, was severely impaired in cognitive skills and dependent on staff for daily activities. The facility's staff, specifically RN 1 and RN 3, signed the resident's documents as representatives, despite not being legally recognized decision-makers. The facility's Administrator acknowledged that if a resident did not have a representative and lacked decision-making capacity, the facility should refer to its Bioethics Committee, which was not done in this case. The facility's policies and procedures on Advance Directives and Bioethics were not followed, as the residents' rights to participate in medical decisions were not upheld. The Bioethics Committee, which should have been involved in decision-making for residents without representatives, was not utilized. This oversight resulted in the potential for residents to receive life-sustaining care and/or treatment against their will, as the necessary steps to ensure informed decision-making were not taken.
Failure to Notify Resident's Representative of Bed Hold Policy
Penalty
Summary
The facility failed to notify the representative of a resident, who lacked decision-making capacity, about the facility's bed hold policy during a hospital transfer or therapeutic leave. The resident, who had been diagnosed with type 2 diabetes mellitus, liver cirrhosis, and hyperlipidemia, was dependent on staff for personal hygiene and toilet use. The Admission Coordinator stated that the bed hold notification was part of the admission packet and required a signature upon readmission. However, during the review, it was found that the Bedhold Notification form was incomplete, lacking the representative's signature. Licensed Vocational Nurse 4 admitted to obtaining verbal consent over the phone from the resident's representative but failed to document it properly. The Director of Nursing confirmed that if consent is obtained over the phone, it should be documented with the name of the person giving consent and witnessed by two staff members. The absence of proper documentation and signature on the Bedhold Notification form indicated a failure to inform the resident's representative of their rights, as required by the facility's policy.
Failure to Notify Physician of Elevated Blood Sugar
Penalty
Summary
The facility staff failed to notify the physician of a resident's elevated blood sugar level, which was recorded at 420 mg/dL. This incident involved a resident with a history of type 2 diabetes mellitus, liver cirrhosis, and hyperlipidemia. The resident's Medication Administration Record (MAR) indicated that the blood sugar level was recorded on 7/1/2024, and there was a standing order to notify the medical doctor if the blood sugar exceeded 400 mg/dL. However, the Licensed Vocational Nurse (LVN) responsible could not recall notifying the physician, and there was no documentation to confirm that the notification occurred. The Director of Nursing (DON) confirmed that according to the facility's policy, the physician should have been notified of the change in the resident's condition. The policy, titled 'Change in a Resident's Condition or Status,' required the nurse to inform the attending physician of any specific changes in the resident's condition. The DON acknowledged that if it was not documented, it was not done, emphasizing the importance of notifying the physician to determine if the resident's insulin needed adjustment and to decide on the appropriate care.
Resident Privacy Breach Due to Shared Restroom Use
Penalty
Summary
The facility failed to provide a homelike environment for a resident by not allowing them to use a shared restroom, which could potentially invade the privacy of other residents. The incident involved a resident who was admitted with End Stage Renal Disease and essential hypertension. The resident had intact cognition and the capacity to make decisions. During an observation, a Licensed Vocational Nurse (LVN) found the resident using a shared restroom that was not designated for them, as they were from another room. Interviews with staff, including the Infection Preventionist and the Director of Nursing, confirmed that residents from different rooms should not use shared restrooms to maintain privacy and dignity. The resident explained that they used the restroom because their designated restroom was occupied, and they had an urgent need due to an appointment. A staff member had directed the resident to use the restroom across the hallway. The facility's policy on providing a homelike environment emphasizes the importance of privacy and the use of personal belongings, which was not adhered to in this case.
Failure to Follow Resident's Food Preferences
Penalty
Summary
The facility failed to adhere to the food preferences of a resident during the lunch tray line service. The resident, who was admitted with multiple diagnoses including dementia, type 2 diabetes mellitus, and various vitamin deficiencies, had a documented preference against fish. Despite this, the resident was initially served a meal containing fish, contrary to the instructions on their meal tray card which indicated 'No Fish' under dislikes. This oversight was observed during a tray line observation, where it was noted that the resident should have been served chicken instead of fish. The Dietary Services Supervisor acknowledged the importance of reviewing meal tray cards to ensure residents' food preferences are respected and adequate nutrition is provided. The facility's policies and procedures require that food preferences be adhered to and that substitutes be provided for disliked foods. However, in this instance, the cook did not initially provide the appropriate substitute, leading to a failure in meeting the resident's dietary needs as documented.
Dishwashing and Standard Precautions Deficiency
Penalty
Summary
The facility failed to adhere to its Policies and Procedures regarding dishwashing and standard precautions, as observed in the kitchen. During an observation, a dishwasher (DW 1) was seen washing and rinsing dirty pans and trays in the sink and then touching sanitized metal trays, which were supposed to be handled by another staff member to prevent cross-contamination. The Dietary Services Supervisor (DSS) confirmed that DW 1 was not supposed to touch the sanitized trays, as another staff member, Dietary Aide 2 (DA 2), was assigned to handle them. The facility's policy, dated 2018, required all dishes to be properly sanitized through the dishwasher, and the policy on standard precautions, dated 6/25/2024, indicated that all tableware must be treated as contaminated and sanitized according to facility protocol.
Failure to Ensure Informed Consent for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the Responsible Party (RP 85) for Resident 85 understood the binding arbitration agreement (BAA) before signing it. Resident 85, who was originally admitted to the facility in June 2022 and readmitted later, had diagnoses including dementia and adult failure to thrive, indicating significant cognitive and physical impairments. The Minimum Data Set (MDS) assessment showed that Resident 85 required substantial assistance with daily activities and had increased confusion, lacking the capacity to make decisions. Despite these conditions, RP 85 signed the arbitration agreement electronically without a clear understanding of its purpose or terms. The Admissions Coordinator (AC) communicated with RP 85 via email and telephone, sending the arbitration agreement electronically and instructing RP 85 to call with any questions. However, RP 85 did not receive an explanation of the agreement's purpose or terms, nor did they contact AC for clarification. The facility's policy stated that signing the arbitration agreement was not a condition for admission and that residents had the right to refuse or rescind the agreement within 30 days. Despite this policy, the AC was unable to explain the details of the arbitration process, including the selection of a neutral arbitrator or venue, contributing to the deficiency in ensuring RP 85's informed consent.
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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