Bayshire Yorba Linda Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Yorba Linda, California.
- Location
- 17803 Imperial Highway, Yorba Linda, California 92886
- CMS Provider Number
- 555768
- Inspections on file
- 21
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Bayshire Yorba Linda Post-acute during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies were identified when surveyors observed a dirty hood over the stove, damaged and worn utensils, multiple food-contact items with residue or watermarks, heavily marred cutting boards, a wet and dirty blender and storage containers stacked before drying, a can opener with crusted residue, and a Dietary Aide serving food with facial hair not covered by a hair restraint. The RD verified the beard restraint issue, and the DON was informed.
Pharmacy Consultant Failed to Identify Levothyroxine and PPI Medication Irregularities: The Consultant Pharmacist’s monthly MRR failed to identify medication irregularities for three residents whose orders and MARs showed levothyroxine scheduled at the same time as PPIs such as pantoprazole and lansoprazole. During med pass observations, an LVN administered the levothyroxine and PPI doses together for each resident, and the pharmacist initially stated there was no concern before later acknowledging levothyroxine should not be given within four hours of a PPI.
Food items were served at improper temperatures during tray line and test tray observations. The RD and DSS verified mashed potatoes and other hot items were below the facility's required hot-food range, while apple juice was above the required cold-beverage range. The DSS also verified roast beef and green peas were not hot and were below the recommended temperatures for a hot meal tray; 41 of 41 residents received food prepared in the kitchen.
The facility failed to keep resident records accurate and complete. For several residents, POLST forms and social services notes did not match regarding advance directives, one resident’s admission social services assessment was not completed, and one resident’s MAR did not reflect observed and reported behaviors during the shift. An SSD and DON were aware of the mismatched and missing documentation, and an LVN acknowledged the behavior charting was incorrect.
An LPN failed to perform hand hygiene during medication administration for multiple residents, did not disinfect the glucometer between uses for several residents, and used an alcohol swab that had been dropped on the floor during a blood glucose check on a resident on EBP isolation. The DON stated hand hygiene should occur before entering and after exiting resident rooms, the glucometer should be disinfected after each use, and the dropped swab should have been discarded.
Failure to Offer Advance Directive Information: A resident with intact cognition and decision-making capacity had no documented offer of advance directive information or assistance in the record. Although a POLST referenced an advance directive, the chart lacked a copy of it, and SSD notes did not show that the resident was offered information about formulating one until later, with no documentation in the earlier social service notes.
A resident's record showed PRN zolpidem tartrate for insomnia was ordered for 14 days, then extended for another 14 days after the physician was notified of the resident's request. However, the chart did not include an appropriate clinical rationale for continuing the psychotropic medication beyond the original order, and an RN verified the missing documentation during record review.
A resident’s care plan did not include the specific targeted behavior monitoring tied to psychotropic medication use. The resident had orders for zolpidem for insomnia and buspirone for anxiety, with monitoring for anxiety, insomnia, and ability to fall asleep, but the care plan did not address those behaviors. The DON verified the omission during interview and record review.
Improper PICC Dressing Care and Unlabeled IV Tubing: A resident receiving IV antibiotics and IV hydration through a PICC line was observed with a PICC dressing dated outside the required change interval and IV tubing that was initially unlabeled. The DON and RN later confirmed the dressing date and tubing labeling issues, and RN stated he added a label without replacing the tubing, which was not consistent with procedure.
Failure to provide humidifiers for continuous oxygen therapy. Two residents were observed receiving O2 at 2 L/min via nasal cannula without a humidifier bottle attached to the concentrator. Their records included orders for continuous oxygen and for staff to monitor the humidifier bottle every shift, and an RN verified that documentation was being completed even though no humidifier was present. The DON stated that residents on continuous oxygen need a humidifier to prevent nasal dryness.
Incomplete Dialysis Access Assessments: A resident with ESRD who required hemodialysis had a left upper extremity AVF that was not consistently assessed before and after treatments. Dialysis communication forms were missing documentation of bruit and thrill checks and other access site observations such as color, warmth, drainage, bleeding, and edema. An LVN confirmed licensed nurses were responsible for the documentation and stated the access site should have been assessed pre- and post-dialysis to ensure the AVF was working.
A resident with leg edema had a Lasix order entered with an incorrect indication for pain during urination instead of a diuretic use. The MAR reflected the wrong indication while the medication was administered by an LVN over several days, and the DON and LVN both confirmed the order should have been clarified before administration.
Medication administration errors resulted in a 20% error rate, with two of four LPNs observed making errors involving levothyroxine and pantoprazole or lansoprazole. An LPN gave levothyroxine together with stomach acid medications instead of separating them by at least four hours, and also crushed pantoprazole delayed release tablets for two residents despite no order to do so. Another LPN administered pantoprazole and levothyroxine together to a resident whose orders were for both medications before breakfast.
Unsafe medication storage was observed when an LPN left an insulin vial and a linaclotide bubble pack unattended on top of a med cart during med pass while staff, residents, and a maintenance vendor were present in the hallway. An inspection of another med cart also found an open foil packet of Sorbalgon Ag wound dressing stored inside, and the LPN verified it should have been discarded.
Menu items were not followed for three residents during lunch service. Two residents did not receive the bread or roll with margarine listed on their meal tickets, and one resident did not receive the scalloped potatoes from the menu or the mashed potatoes she requested as a replacement. The RD verified the missed items during observation.
Improperly Covered Dumpster Lids: The facility failed to keep garbage and refuse properly disposed of in three of seven dumpsters. During observation, three dumpsters were found with lids partially propped open by cardboard boxes and black trash bags, preventing the lids from fully closing. The Plant Operations Director verified the finding and stated the dumpster lids should be completely closed at all times for safety and infection control purposes.
A resident with orthostatic hypotension did not have orthostatic blood pressure and pulse checks completed in lying, sitting, and standing positions as ordered by the physician. Instead, only single readings were documented each day, and staff confirmed the required assessments were not performed or recorded.
Surveyors identified multiple failures in food labeling, dating, and storage, as well as unsanitary conditions of kitchen equipment and utensils. Food items in refrigerators were not properly labeled or dated, expired food was not discarded, and utensils and surfaces were found with stains, rust, and food debris. Additionally, utensils were not air-dried before storage, and a cutting board was heavily marred, all contrary to facility policy and professional standards.
A resident with a recent lumbar fusion and orders for spinal precautions and use of an LSO brace when out of bed did not have these interventions included in their care plan. Therapy staff confirmed the need for these precautions, but the care plan was missing the required details. CNAs demonstrated inconsistent knowledge and implementation of the necessary precautions, and facility leadership acknowledged the deficiency.
The facility did not update care plans for three residents to accurately reflect the use of side rails, instead documenting the same interventions for each and failing to include alternatives like adjustable beds or bedside mats that were considered. This resulted in non-individualized care plans regarding bed mobility and safety devices.
Three residents receiving continuous oxygen therapy did not receive care in accordance with physician orders and facility policy. One resident was given oxygen at a lower rate than prescribed, while two residents lacked required 'No Smoking/Oxygen in Use' signage at their room entrances. These deficiencies were confirmed by nursing staff and the DON during observations and interviews.
A resident did not receive insulin as ordered by the physician when blood sugar levels indicated it was needed, and the medication administration record was incorrectly coded. Additionally, narcotic shift count sheets for a medication cart were found to have multiple missing signatures from both incoming and outgoing licensed nurses over several months, contrary to facility policy and increasing the risk of medication errors and diversion.
A medication error rate exceeding 5% was identified when two nurses administered incorrect medications and dosages to a resident, failed to provide required education about not chewing extended-release medications to two residents, and did not assess for signs of bleeding before giving anticoagulants. Staff interviews confirmed these errors and lapses in protocol.
Medications were found stored on an open shelf in the central supply room, accessible to non-licensed staff, and a medication cart was left unlocked and unattended in a hallway near the nurses' station. The DON and an LVN confirmed these lapses, acknowledging that medications should be secured and carts locked when not in use.
Multiple deficiencies were identified in the facility's medical record documentation, including missing or mismatched signatures on psychotropic medication consent forms, incomplete staff job designations on MARs, and missing or incomplete consents for medication administration. Additionally, some residents' medication administrations and treatments were not properly documented, and advance directives were not always available in the active medical record. The facility also failed to document physician notifications and justifications for antibiotic use when residents did not meet clinical criteria.
Surveyors identified multiple infection control failures, including improper classification of infections in surveillance reports, lack of adherence to neutropenic precautions for a resident post-chemotherapy (such as an open door, presence of fresh flowers, and staff not wearing masks), and failure to follow enhanced barrier precautions for a resident with an indwelling device when a CNA did not wear a gown during a transfer. Additionally, the medication room sink was found dirty and in need of cleaning, contrary to facility policy.
Essential equipment, including a leaking sink faucet in a medication room, an improperly cleaned ice machine with black particle residue, and multiple freezers with significant ice build-up, were not maintained in safe and operable condition. Additionally, a digital thermometer used for food safety checks was not calibrated correctly by dietary staff, as confirmed by the CDM. These deficiencies were verified through direct observation and staff interviews, and were not in accordance with facility policy or manufacturer instructions.
Two residents with bed rails had documented gaps between the mattress and bed components, but maintenance staff did not perform timely or complete entrapment assessments after these risks were identified by nursing staff. Annual inspections were relied upon, and some required measurements were missing or not documented, resulting in unaddressed entrapment risks.
The facility did not make the most recent Recertification Survey's plan of correction easily accessible to residents and the public. Several residents stated they were unaware of where to find the latest survey results or their right to review them. A binder in the lobby contained the CMS 2567 but was missing the Plan of Correction, which the Administrator confirmed was not present.
A bag of dry cereal brought in by family was found on a resident's bedside table without a label or date, contrary to facility policy requiring all such food to be labeled and properly stored. An LVN stated only wet food was labeled, and the DON confirmed the dry cereal should have been labeled and dated.
A facility failed to create a care plan for a resident with severe cognitive impairment who was at risk of falls due to behaviors of getting up from a wheelchair. Despite being identified as a fall risk, the resident's care plan lacked specific interventions, leading to an incident where the resident was found on the floor. Interviews with staff confirmed the absence of a tailored care plan, highlighting a deficiency in care planning.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen during observations by surveyors. During the initial kitchen tour, the hood over the stove was observed with black, dirt residue, and the Cook acknowledged that it was cleaned weekly and also serviced by an outside company. The hood service sticker showed the last service date as 1/16/26. The report also documented that the facility’s kitchen utensils and equipment were not maintained in good repair, with multiple items observed damaged or worn, including spatulas with cracked or melted edges, a frayed basting brush, chipped and cracked rubber spatulas, and a deformed whisk. Surveyors also observed multiple kitchen items that were not clean to sight and touch. A clear plastic container used for storing utensils and kitchenware was dirty with fuzzy films, watermarks, and dry residue inside. Two ketchup pumps, several stainless steel scoops, a serving spoon, slotted spoons, a spoon, a ladle, a black peeler, and a knife with a black handle were all observed with dirt, fuzzy films, watermarks, or dry, crusted residue. The facility’s cutting boards were also observed in poor condition; the white, brown, green, blue, and yellow cutting boards were fuzzy, heavily marred, and had deep grooves, and the Culinary Director stated they should have been replaced. Additional observations showed food preparation equipment and utensils were not being properly air dried or stored in a sanitary manner. A heavy-duty blender was observed dirty, still wet, and with white residue inside and on the lid, and five clear rectangular bucket containers used for marinating meats and storage were wet and stacked on top of each other. The countertop mounted can opener had dry, crusted black and white residue on the blade. During lunch tray line observation, a Dietary Aide was serving food with facial hair not covered by a hair restraint, and the RD verified the finding and stated a beard guard was used. The DON was informed of the findings.
Pharmacy Consultant Failed to Identify Levothyroxine and PPI Medication Irregularities
Penalty
Summary
The facility’s Consultant Pharmacist failed to identify and make recommendations for medication irregularities during the monthly drug regimen review for three residents receiving levothyroxine together with proton pump inhibitor (PPI) medications. The facility’s Medication Regimen Review policy stated the Consultant Pharmacist conducts a monthly review for every resident receiving medications and reviews the medical record to prevent, identify, report, and resolve medication-related problems or other irregularities. For Resident 30, the physician ordered levothyroxine sodium 75 mcg daily before breakfast and pantoprazole sodium delayed release 40 mg daily before breakfast. The April 2026 MAR showed both medications scheduled for 0630, and the Consultant Pharmacist’s monthly MRR on 4/7/26 did not identify the irregularity. During a medication administration observation, an LVN administered the pantoprazole sodium delayed release and levothyroxine sodium at the same time. For Resident 17, the physician ordered levothyroxine sodium 88 mcg in the morning on an empty stomach and lansoprazole 30 mg daily before breakfast, with both medications scheduled for 0630 on the April 2026 MAR. The monthly MRR did not identify the irregularity, and an LVN administered both medications at the same time during observation. For Resident 19, the physician ordered levothyroxine sodium 100 mcg in the morning on an empty stomach and pantoprazole sodium delayed release 40 mg twice daily before breakfast and dinner, with both medications scheduled for 0630 on the April 2026 MAR. The monthly MRR also failed to identify the irregularity, and an LVN administered both medications at the same time during observation. During interview, the Pharmacy Consultant initially stated there was not a concern with levothyroxine being administered with lansoprazole or pantoprazole, then later stated levothyroxine should not be administered within four hours of any PPI and the order should be clarified.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food items were served at appetizing temperatures. Review of the facility's policy and procedure titled Trayline Setup and Service showed hot food should be 110-120 degrees Fahrenheit and cold food should be 45-50 degrees Fahrenheit. During a tray line observation with the RD and DSS, the mashed potatoes were checked and verified at 100 degrees Fahrenheit, and the apple juice was checked and verified at 54.8 degrees Fahrenheit. The RD acknowledged the apple juice was above the recommended temperature for a cold beverage and the mashed potatoes were below the recommended temperature for hot food. During a later test tray observation of the regular lunch menu, the DSS and RD checked and verified the roast beef was at 105.8 degrees Fahrenheit and the green peas were at 94 degrees Fahrenheit. The DSS verified both items were not hot and were below the recommended temperatures for a hot meal tray. The facility's Diet Type Report showed 41 of 41 residents consumed the food prepared in the kitchen, and the menu for the lunch meal included mixed green salad with dressing, artichoke chicken, red bliss potatoes, seasoned green peas, bread or roll with margarine, chocolate cake with caramel icing, choice of beverage, and herb roast beef for alternate.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for five sampled residents. Facility policies required social services assessments to be initiated upon admission and completed within seven days, advance directives to be maintained in the medical record, and documentation to be complete and accurate. Review of records showed that for Residents 2, 4, and 26, the POLST and social services documentation did not match regarding advance directive status, and in Resident 26’s record there was no copy of the advance directive even though the POLST indicated one existed. For Resident 10, the medical record did not show that the social services assessment was completed upon admission. The SSD stated she would try to complete social services assessments within 72 hours after admission, but verified that Resident 10’s assessment had not been completed after admission. Resident 10’s record therefore lacked the required admission social services assessment documentation. For Resident 15, the MAR documented no behaviors on the night shift, but the LVN who worked that shift stated the resident had multiple screaming episodes during the shift. The LVN later reviewed the MAR and verified it showed no behaviors, stating he had incorrectly documented it. Observations during the early morning hours also documented the resident yelling and screaming out, which was inconsistent with the MAR entry.
Infection Control Failures During Medication Pass and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration and blood glucose monitoring. During an observed medication pass, LVN 5 did not perform hand hygiene after leaving the medication cart area and returning to begin medication administration, and then administered medications to 12 residents without performing hand hygiene between residents or between medication administration and blood glucose checks. LVN 5 also did not disinfect the glucometer between blood glucose checks for seven residents. During a blood glucose check on Resident 35, who was on EBP isolation, LVN 5 placed supplies on the bedside table, dropped an unopened alcohol swab on the floor, picked it up with gloved hands, and used it during the procedure. After obtaining the blood sample, LVN 5 wiped the first drop of blood with his gloved finger and then used the alcohol swab that had been contaminated by contact with the floor to clean Resident 35's finger. The DON stated hand hygiene should be performed before entering a resident's room, upon exiting, and anytime hands are visibly soiled, that the glucometer should be disinfected after each use, and that the alcohol swab dropped on the floor should have been discarded.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information about the right to formulate an advance directive for one sampled resident. Resident 26 was admitted and later readmitted to the facility, and the medical record review showed the resident had the capacity to understand and make decisions. The resident’s H&P dated 3/20/26 showed capacity for decision-making, and the admission MDS showed a BIMS score of 15, indicating intact cognition. Review of the record showed a POLST dated 3/18/26 indicating an advance directive in Section D, but the medical record did not contain a copy of the advance directive. The Social Service Evaluation dated 3/20/26 documented that the resident had no advance directive and that information was only provided on the right to formulate one on 4/14/26. Social Services progress notes dated 3/19/26 and 3/23/26 did not document that the information and formulation of an advance directive was offered. During interview and concurrent record review, the SSD verified there was no documentation that an advance directive was offered, and the DON was informed and acknowledged the findings.
Missing Clinical Rationale for Continued PRN Zolpidem
Penalty
Summary
The facility failed to ensure that the prescriber documented an appropriate clinical rationale for the continued use of a psychotropic medication for Resident 15. Resident 15 was reviewed for unnecessary medications, and the record showed an order dated 3/21/26 for zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia with a 14-day duration. The medical record also showed a second order dated 4/7/26 for zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia with a 14-day duration. Nursing progress notes dated 4/6/26 at 2350 hours documented that the physician was notified of the resident's request to extend the PRN zolpidem tartrate medication and agreed to extend it for an additional 14 days. However, the record did not show an appropriate clinical rationale for continued use of zolpidem tartrate beyond the original 14-day order, and RN 1 verified this during an interview and concurrent record review.
Incomplete Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that the person-centered care plan for Resident 15 included the specific targeted behavior monitoring related to the resident’s psychotropic medication use. Resident 15 was admitted to the facility and had physician’s orders for zolpidem tartrate 5 mg by mouth at bedtime as needed for insomnia and buspirone HCl 15 mg by mouth twice a day for anxiety. The medical record also included behavior/side effects monitoring orders to monitor anxiety as manifested by verbalization of feeling anxious every shift for buspirone use, and to monitor insomnia and the ability to fall asleep every evening and night shift for zolpidem use. Review of the Care Plan Report showed that these specific targeted behaviors were not addressed in the resident’s care plan. The facility’s policy stated that a comprehensive person-centered care plan should include measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs, and should incorporate identified problem areas with treatment goals, timetables, and measurable outcomes. During interview and concurrent record review, the DON verified that Resident 15’s care plan failed to address the behavior monitoring for the zolpidem tartrate and buspirone HCl medication use.
Improper PICC Dressing Care and Unlabeled IV Tubing
Penalty
Summary
The facility failed to provide proper IV care for one resident receiving IV infusions through a PICC line. The resident was observed with two IV bags at the bedside, including a normal saline bag connected to unlabeled IV tubing and a cefepime-dextrose infusion connected to tubing with a green label. The resident stated he was receiving IV antibiotics and IV hydration through the PICC line. The PICC line dressing was observed with a handwritten date of 4/2/26, and the resident had a physician order for the PICC dressing site care and cap change every seven days and as needed. During follow-up observation and record review, the IV normal saline tubing was later found with a green label dated 4/12 at 0800 hours, while the bag remained dated 4/11. The DON stated the facility process was to date PICC dressings on the day they were changed and that IV lines should be labeled when changed or every 72 hours per facility policy. The DON verified the PICC dressing date was 4/2/26 and stated that if it was dated that day, then it had never been changed. RN 1 later stated he had observed the IV NS tubing was not labeled, added a label dated 4/12, and did not replace the tubing, acknowledging this was not following procedure because incorrectly dating the tubing could allow it to be used past the expiration date.
Failure to Provide Humidifiers for Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents receiving continuous oxygen therapy. Resident 52 was observed on the initial tour receiving oxygen at 2 liters per minute via nasal cannula, and the oxygen concentrator had no humidifier bottle attached. A follow-up observation the next day again showed no humidifier connected to the concentrator. The resident’s record showed orders for continuous oxygen at 2 liters per minute via nasal cannula/mask and to monitor the oxygen humidifier bottle every shift, changing it when close to empty. The DON stated that residents receiving oxygen continuously would need a humidifier to prevent dryness of the nostrils, regardless of oxygen concentration. Resident 17 was also observed in bed and later sitting in a chair receiving oxygen via nasal cannula at 2 liters per minute, with no humidifier bottle present on either observation. The resident’s record included orders to monitor the oxygen humidifier bottle every shift and to administer oxygen therapy continuously at 2 liters per minute via nasal cannula. During interview, RN 1 verified that Resident 17 did not have a humidifier connected to the continuous oxygen and stated nurses had been documenting the humidifier monitoring as completed even though no humidifier was present. The DON was made aware of these findings and acknowledged them.
Incomplete Dialysis Access Assessments
Penalty
Summary
The facility failed to ensure the necessary care of a resident's dialysis access site was consistently and accurately assessed before and after hemodialysis treatments. Resident 4 had end-stage renal disease and required hemodialysis through a left upper extremity AV fistula. The physician ordered that the AV shunt be checked every shift for the presence of bruit and thrill, with notification to the physician if negative. The resident's care plan also addressed the hemodialysis treatment and access site, including monitoring for redness, poor circulation, swelling, drainage, and changes in bruit and thrill. Review of the dialysis communication forms showed incomplete documentation of the access site assessment. On one treatment date, the access was assessed for bruit and thrill before dialysis, but the form did not show assessment for warmth, edema, drainage, or bleeding. On another treatment date, the access was not assessed for bruit and thrill or for color, warmth, and drainage after dialysis. On a later treatment date, the access was again not assessed for bruit and thrill or for color, warmth, drainage, bleeding, and edema after dialysis. During interview, an LVN confirmed that licensed nurses were responsible for completing the dialysis communication form and stated the dialysis site should have been assessed before and after dialysis to ensure the AVF was working. The DON was informed and acknowledged the findings.
Incorrect Lasix Indication on Medication Order
Penalty
Summary
Facility pharmaceutical services failed for one sampled resident when the Lasix order was not accurately reconciled and the medication indication was documented incorrectly. Resident 55 was admitted with capacity to understand and make decisions, and during an observation and interview on 4/12/26, she stated she was having trouble sleeping due to edema in her legs; her lower legs were observed with edema present. The medical record showed a physician's telephone order dated 4/10/26 for Lasix 20 mg by mouth daily for four days, but the MAR listed the medication as being ordered for pain during urination, including one entry for one-time use and another for one time a day for three days. The MAR showed Lasix was administered on 4/10/26 at 2154 hours and on 4/11, 4/12, and 4/13/26 at 0900 hours by LVN 3. Review of the record showed the telephone order did not have an indication for Lasix use, and the DON stated the medication was intended as a diuretic for excess fluid and was not indicated for urinary pain. The DON verified the indication was incorrect and stated the nurse should have called the physician to clarify the order. LVN 3 also stated Lasix was used as a diuretic and should have been questioned before administration.
Medication Administration Errors Involving Levothyroxine and Pantoprazole
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the observed error rate was 20 percent. During medication administration observations, two of four licensed nurses were found to have errors involving levothyroxine and pantoprazole or lansoprazole. The report states these failures created the risk for residents to have potential side effects or complications related to the medications. For one resident with low thyroid hormone and GERD, an LVN administered levothyroxine 88 mcg together with lansoprazole delayed release 30 mg, even though the levothyroxine order was for morning administration on an empty stomach and the stomach medication was ordered before breakfast. For another resident with low thyroid hormone and GERD, the same LVN administered levothyroxine 100 mcg together with pantoprazole 40 mg. The report cites online guidance stating stomach medicines such as lansoprazole and pantoprazole should be taken at least four hours before or after levothyroxine. The report also describes two instances in which pantoprazole delayed release 40 mg was crushed and mixed with applesauce for residents who had orders for pantoprazole delayed release in the morning for GERD. The LVN stated there was no physician order to crush the medication and acknowledged delayed-release medications should not be crushed. In a separate medication pass, another LVN administered pantoprazole sodium delayed release and levothyroxine sodium 75 mcg together to a resident whose orders were for both medications before breakfast. The consultant pharmacist stated levothyroxine should not be administered within four hours of any PPI, including pantoprazole, and the order should be clarified by the physician.
Unsafe Medication and Dressing Storage
Penalty
Summary
Medication storage was not maintained in a safe manner for two residents during medication administration and for one medication cart. During an observation of medication administration for one resident, an LVN prepared insulin and then left the vial on top of the medication cart unattended in the hallway while entering the resident’s room. During a separate observation for another resident, the same LVN prepared linaclotide and left the bubble pack on top of the medication cart unattended while entering the resident’s room. Several staff members, residents, and an outside maintenance vendor were observed in the hallway during this time. The facility’s policy stated the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide, and no medications are to be kept on top of the cart. An inspection of Medication Cart B also found an open foil packet of Sorbalgon Ag wound dressing stored in the cart. The dressing was individually wrapped in foil pouches, but one pouch was open with the dressing inside. The LVN who inspected the cart verified the open pouch and stated the dressing should have been thrown away and not stored in the cart.
Menu Items Not Served as Ordered
Penalty
Summary
The facility failed to ensure the menu was followed for three of 41 residents who consumed foods prepared in the kitchen. During a dining observation, Resident 30 was served mixed green salad with ranch dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, and diet cola, but was not served the bread or roll with margarine listed on the meal ticket. Resident 36 was observed eating lunch and was served mixed green salad, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, water, and tea, but was not served the bread or roll with margarine listed on his meal ticket. Resident 33 was observed eating lunch in her room and was served bacon meatloaf, soft sauteed broccoli florets, and diet cola, but did not receive the scalloped potatoes from the menu or the mashed potatoes she requested as a replacement. The RD verified that Residents 30 and 36 did not receive the bread or roll with margarine and stated it should have been provided, and also verified that Resident 33 requested mashed potatoes and did not receive them.
Improperly Covered Dumpster Lids
Penalty
Summary
The facility failed to ensure garbage and refuse were properly disposed of in three of seven garbage dumpsters. During an observation and concurrent interview with the Plant Operations Director, three dumpsters were seen with lids partially propped open by cardboard boxes and black trash bags, which prevented the lids from fully closing. The facility's policy titled Garbage and Rubbish Disposal stated that outside dumpsters are to be maintained in a clean and sanitary condition, that garbage and rubbish are to be placed in waste containers with tight-fitting lids or covers, and that outdoor trash receptacles are to be kept covered. The Plant Operations Director verified the observation and stated the dumpster lids should be completely closed at all times for safety and infection control purposes.
Failure to Obtain Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to provide necessary care and services as ordered for a resident diagnosed with orthostatic hypotension. The physician's order required that the resident's orthostatic blood pressure and pulse rate be checked daily in lying, sitting, and standing positions for three days. However, a review of the Medication Administration Record (MAR) for the specified period showed that only single blood pressure and pulse readings were documented each day, without specifying the required positions. Further review of the medical record confirmed that the orthostatic blood pressure measurements in all three positions were not obtained as ordered. During interviews, both the LVN and the DON acknowledged that the required assessments were not completed and verified the absence of documentation for the ordered positions. The failure to follow the physician's order was confirmed through both record review and staff interviews.
Sanitary Deficiencies in Food Storage, Labeling, and Kitchen Equipment
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items, failure to discard expired food, and lack of adherence to food storage policies. During an inspection, surveyors observed multiple food items in refrigerators that were not labeled or dated, including bags of cheese and containers of thickened juices. Additionally, a container with brown granules was found unlabeled on a kitchen shelf. The facility's own policies required all products to be dated upon receipt and when opened, and to include use-by dates, but these procedures were not followed. Food brought in by visitors for residents was also not consistently labeled with the resident's name, room number, and date received, contrary to posted facility instructions. Further observations revealed that kitchen equipment and utensils were not maintained in a sanitary condition. Inspectors found an ice machine with black particles on the deflector and groove, and several utensils and scoops were either chipped, corroded, stained, or had food debris. The can opener and peeler were rusted, and storage bins for scoops were stained. Cupcake pans and a microwave were also found with discoloration and food debris. These findings were verified by dietary staff and the Director of Maintenance, who confirmed the cleaning responsibilities and schedules. Additional deficiencies included the improper air-drying of utensils, as six scoops were found stored wet inside a storage bin, and a cutting board was observed to be heavily marred with knife marks, making it difficult to clean and sanitize. These failures were observed in areas where food was prepared for nearly all residents in the facility, as indicated by the Diet Type Report. The lack of adherence to professional standards and facility policies for food storage, labeling, and equipment sanitation had the potential to impact the safety of food served to a medically vulnerable population.
Care Plan Lacked Spinal Precautions and LSO Brace Interventions for Post-Lumbar Fusion Resident
Penalty
Summary
The facility failed to develop a care plan that addressed the specific needs of a resident who had undergone a lumbar fusion and required spinal precautions and the use of an LSO (lumbosacral orthosis) brace when out of bed. Medical record review showed that the resident was admitted with diagnoses including spinal stenosis and lumbar fusion, and both the history and physical examination and therapy notes indicated the need for spinal precautions and the LSO brace. A physician's order was also present for the use of the LSO brace when the resident was out of bed. However, the resident's care plan did not include interventions for spinal precautions or the use of the LSO brace. Interviews with OT and PT staff confirmed that the resident required spinal precautions and the LSO brace, and they acknowledged that these interventions were not included in the care plan. Observations and interviews with CNAs revealed inconsistent understanding and implementation of the required precautions, with one CNA stating that no other precautions were needed during transfers or in-bed mobility, and another CNA indicating no special precautions were necessary during transfers. The DON and Administrator were made aware of and acknowledged these findings.
Failure to Revise Care Plans for Side Rail Use
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents to accurately address the use of side rails. For each of these residents, the care plans documented the use of grab bars and quarter-sized side rails as the least restrictive interventions for bed mobility, turning, positioning, and transfers. However, the medical records and side/bed rail evaluations indicated that other alternatives, such as adjustable beds and bedside mats, were considered or attempted. The care plans did not reflect these alternatives or provide individualized interventions prior to the use of side rails. During interviews and medical record reviews, it was confirmed that the interventions related to the use of grab rails were the same across all three residents, and the care plans did not accurately document the least restrictive devices used. The admitting nurse initiated the care plans, but there was uncertainty regarding why the same interventions were applied to each resident and why the documentation did not align with the alternatives considered. This resulted in care plans that were not individualized to each resident's needs regarding side rail use.
Failure to Provide Safe and Appropriate Respiratory Care and Required Oxygen Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required continuous oxygen therapy. One resident did not receive oxygen at the rate ordered by the physician, as observations showed the oxygen was administered at 1.5 liters per minute instead of the prescribed 2 to 5 liters per minute. This discrepancy was confirmed by both a registered nurse and a review of the resident's medical orders, which specified the required oxygen flow rate to maintain adequate oxygen saturation levels. Additionally, two other residents who were on continuous oxygen therapy did not have the required 'No Smoking/Oxygen in Use' signage posted at the entrance to their rooms, as mandated by the facility's own policy and procedure for oxygen administration. Observations and interviews with nursing staff and the Director of Nursing confirmed the absence of these safety signs, despite the residents' ongoing use of oxygen. The lack of proper signage was noted during multiple observations and was acknowledged by facility staff as not being in compliance with established procedures.
Failure to Administer Insulin as Ordered and Incomplete Narcotic Shift Counts
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for one resident by not administering insulin as ordered by the physician. Medical record review showed that the resident had a physician's order for Humulin R insulin to be given subcutaneously before meals based on specific blood sugar levels. On two occasions, the resident's blood sugar was above the threshold requiring insulin, but the medication was not administered, and the medication administration record was incorrectly coded to indicate that no insulin was required. Both the LVN and RN involved acknowledged that insulin should have been given according to the physician's order. Additionally, the facility did not ensure proper accounting and safeguarding of controlled medications. Review of the Narcotic Shift Count sheets for one medication cart revealed multiple instances over several months where the required signatures from incoming and outgoing licensed nurses were missing. This failure to complete the narcotic count documentation was verified by staff and acknowledged as a risk for medication errors and drug diversion. The facility's policies required these counts and signatures to be completed at every shift change, but this was not consistently done.
Medication Administration Errors and Lack of Resident Education
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 22.58%. During medication administration, two licensed nurses were found to have made multiple errors. One nurse administered medications to a resident that did not match the physician's orders, including giving a tablet form of a multivitamin instead of the prescribed packet form due to a supply shortage, and provided the incorrect dosage of calcium. The nurse confirmed these errors during an interview and acknowledged that clarification with the physician should have occurred at the time of admission. Another nurse failed to provide necessary education to two residents regarding the proper administration of extended-release (ER) medications, specifically not instructing them not to chew the ER tablets. One resident was observed making chewing motions while taking ER nifedipine and potassium chloride, and the nurse did not intervene or provide guidance. Additionally, the same nurse did not assess or inquire about signs or symptoms of bleeding or bruising before administering apixaban, an anticoagulant, to both residents, despite physician orders requiring such monitoring. Interviews with staff confirmed the medication errors and lapses in protocol. The central supply process for reordering medications was described, and it was noted that nurses would request needed over-the-counter medications, with the central supply staff responsible for obtaining them. The errors were verified by nursing and administrative staff, who acknowledged that proper procedures were not followed in these instances.
Failure to Secure Medication Storage and Lock Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and in accordance with professional standards. During an observation of the central supply room, a CNA, who was the designated supply room designee, was found to have access to and dispense medications such as Thera Antifungal Body Powder, Hydrocortisone Cream, Zinc Oxide ointment, and Triple Antibiotic Ointments to nurses upon request. These medications were stored on an open metal shelf in the central supply room, accessible to non-licensed staff. The DON confirmed that these medications should not have been accessible to non-licensed staff and should have been stored in a locked cabinet accessible only to licensed nurses. Additionally, Medication Cart 1 was observed unlocked and unattended in a hallway near the entrance lobby and nurses' station, with residents, visitors, and staff passing by. The cart was not being attended to by any staff at the time of observation. An LVN confirmed that the cart was left unlocked because they had to check on a resident and acknowledged that the cart should be locked at all times when not in use.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing or mismatched signatures on informed consent forms for psychotropic medications, incomplete documentation of staff job designations on Medication Administration Records (MARs), and missing or incomplete consents for medication administration. For example, the informed consent for buspirone for one resident did not have signatures that matched the printed names, and the staff who signed the consent had not actually obtained the consent from the resident. Additionally, several MARs lacked the professional titles of staff who administered medications, and some consent forms were missing required physician signatures and dates. Documentation lapses were also found in the administration and monitoring of medications and treatments. One resident's MAR showed multiple instances of missing documentation for medication administration, treatments, and required monitoring, such as pain assessments, intake and output, and infection control measures. In some cases, staff admitted to forgetting to document or save entries after providing care. Another resident's advance directive was not available in the active medical record, and staff could not provide documentation that the advance directive had been offered or discussed upon admission. The facility also failed to properly document physician notifications and justifications for continuing antibiotic treatments for residents who did not meet McGeer's Criteria. The Infection Surveillance Monthly Report indicated that antibiotics were continued per physician direction, but the medical records did not include the name of the physician, the date and time of notification, or the name of the nurse who communicated with the physician. These documentation failures were verified by staff during interviews and were not in accordance with facility policies and accepted professional standards.
Infection Control and Precaution Failures Identified
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. The infection preventionist (IP) did not accurately classify residents according to McGeer's Criteria in the infection control surveillance reports for December 2024 and January 2025. This resulted in incomplete tracking of residents who did not meet the criteria for true infections, and the IP was unable to provide alternative documentation for this tracking. Additionally, the facility's antibiotic stewardship policies required review and notification of inappropriate antibiotic use, but the surveillance reports did not reflect this process. For a resident on neutropenic precautions following chemotherapy, the facility did not implement required measures. Despite a physician's order for neutropenic precautions, the resident's door was repeatedly observed open, and fresh flowers were present at the bedside, both of which are prohibited under the facility's policy. The IP was also observed entering the room without a mask, contrary to the stated requirements for staff and visitors to wear masks, keep the door closed, and restrict fresh flowers in the room. Another resident with an indwelling medical device was under enhanced barrier precautions, but a CNA was observed transferring the resident without wearing a gown, despite signage and orders indicating that PPE, including gowns, should be used during such care activities. Additionally, the sink in Medication Room A was found to be dirty, with visible discoloration and debris, and both the RN and DON confirmed that the sink required cleaning and maintenance, contrary to facility policy requiring medication preparation areas to be kept clean and sanitary.
Failure to Maintain and Properly Clean Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition as required by its policies and federal regulations. In Medication Room A, a leaking sink faucet was observed, with water pooling at the base and visible discoloration on the sink strainer and surrounding area. Both the RN and DON confirmed the ongoing leak and associated staining, and the Director of Maintenance acknowledged that the issue could have been addressed if it had been reported by nursing staff. In the main kitchen, the ice machine was found to have black particles on the deflector and grooves, despite records indicating recent cleaning by both an outside vendor and facility staff. The Director of Maintenance confirmed that dietary staff were not using the manufacturer-recommended cleaning and sanitizing products for the ice machine bin and exterior, contrary to both facility policy and manufacturer instructions. Additionally, significant ice build-up was observed in the walk-in freezer in the main kitchen, the freezer in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside. The Culinary Director and Director of Maintenance attributed the ice build-up in the main kitchen freezer to a faulty door, which was pending replacement, and cleaning logs indicated regular cleaning, though the issue persisted. The facility also failed to ensure that food temperature measuring devices were properly calibrated. During an observation, a Dietary Aide was seen incorrectly calibrating a digital thermometer, and the CDM confirmed the calibration was not performed according to manufacturer instructions. The thermometer was subsequently used to check food temperatures, raising concerns about the accuracy of temperature monitoring. These failures collectively demonstrate lapses in equipment maintenance, cleaning, and calibration protocols as outlined in facility policies and relevant regulatory standards.
Failure to Conduct Timely Bed Safety and Entrapment Assessments
Penalty
Summary
The facility failed to ensure that bed safety inspections and entrapment assessments were properly conducted for residents using bed rails, as required by facility policy and federal guidance. Specifically, for two residents, there were documented gaps between the mattress and the side/bed rail, headboard, and footboard, which were identified during initial nursing evaluations. Despite these findings, there was no evidence that maintenance staff performed follow-up inspections or entrapment assessments in response to these identified risks. For one resident, the initial evaluation noted gaps that could pose entrapment risks, but the Director of Maintenance confirmed that he did not conduct a new inspection or assessment after the resident's admission or after changes in the bed or mattress. The maintenance department relied on annual inspections and only performed additional checks if a low air loss mattress was used or if repairs were requested by nursing staff. Documentation provided by the Director of Maintenance showed that some entrapment zones were not assessed, and certain required measurements were left blank. For another resident, the initial evaluation also indicated gaps between the mattress and bed components, but the Director of Maintenance was unaware of these findings and could not provide documentation of a bed entrapment assessment for this resident. The facility's process did not ensure that entrapment risks identified by nursing staff were communicated to or addressed by maintenance, resulting in a lack of timely and comprehensive bed safety assessments for residents at risk.
Survey Results and Plan of Correction Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent Recertification Survey's plan of correction was readily accessible to residents and the public. During a residents' group meeting, five of nine residents reported they did not know where the latest survey results were located and were unaware of their rights to review these results. Upon review, a white binder containing the CMS 2567 from the last recertification survey was found in the lobby, but it did not include a copy of the Plan of Correction. The Administrator confirmed that the Plan of Correction was missing from the binder and acknowledged that it may have been removed.
Failure to Label and Date Family-Brought Food
Penalty
Summary
The facility failed to implement its policy and procedure regarding the labeling and storage of food brought in by family members for residents. During an observation, an unlabeled and undated resealable plastic bag of dry cereal was found on a resident's bedside table. The facility's policy required all food brought in by family or visitors and left with the resident to be labeled and stored in a manner that distinguishes it from facility-prepared food, with non-perishable foods stored in resealable containers with tightly fitting lids. An LVN stated that only wet food was labeled, not dry food, and the DON confirmed that the dry cereal should have been labeled and dated.
Failure to Develop Care Plan for Resident's Fall Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who exhibited behaviors of getting up from a wheelchair, posing a risk of falls. The resident, who was identified as a fall risk, showed behaviors such as being easily distracted, having altered perception, disorganized thoughts, restlessness, lethargy, and confusion. Despite these observations, the facility did not create a care plan with specific interventions to address the resident's behavior of getting up from the wheelchair, which led to an incident where the resident was found sitting on the floor. The medical records and interviews with facility staff, including an LVN and the DON, confirmed the absence of a care plan addressing the resident's behavior and fall risk. The resident's cognitive assessment indicated severe impairment, with a BIMS score of 3, further emphasizing the need for a tailored care plan. The facility's policy required comprehensive, person-centered care plans with measurable objectives, but this was not implemented for the resident in question, leading to a deficiency in care planning and risk management.
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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