Carmel Hills Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monterey, California.
- Location
- 23795 W. R. Holman Highway, Monterey, California 93940
- CMS Provider Number
- 056055
- Inspections on file
- 17
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Carmel Hills Care Center during CMS and state inspections, most recent first.
Daily staffing information was not posted correctly for residents, families, and visitors. The DON found no current staffing posting at nurse station AA and located a posting in the lobby dated 1/9/2025; a later observation at nurse station BB also showed staffing information dated 1/9/2025. The ADM stated the staffing information should have been updated daily and posted in the lobby.
Missing Qualified F&NS Leadership: The facility did not employ a director of food and nutrition services after the dietary manager resigned, and the part-time RD worked about 24 hours per week. The Head temporarily oversaw kitchen operations without a formal assignment or dietary manager’s degree, and the administrator could not provide inservice records for dietary tasks. The RD’s role was limited mainly to menu coordination, resident meetings, dietary profiles, and resident assessments.
Ice Machines Had Buildup Around Dispenser and Discharge Chutes: Two ice machines, one in a utility room and one in a hallway near Station 2, had white, yellow, orange, black, and gray buildup around the ice dispenser chutes and ice discharge chutes. The DES stated the machines were maintained by a contracted company every 90 days and wiped externally daily, but the buildup was observed during surveyor rounds, and the contracted technician described it as hard-water scale on aging equipment.
Visible care instructions were posted in several resident rooms and on a room door, including directions about dentures, brief changes, transfers, feeding, shampoo use, fluid restriction, and hearing aid care. Residents involved included individuals with dementia, cognitive impairment, ESRD on dialysis, CKD, CHF, and post-stroke conditions. Staff confirmed the postings were visible and that some should not have been openly displayed. One resident also had an exposed urine drainage bag without a privacy bag, and staff confirmed it should have been covered.
Advance directive and POLST documentation was incomplete for multiple residents. Several residents had no documented AD or evidence that assistance was offered to complete one, while other residents had POLST forms with blank AD sections or missing required signatures from the provider or decisionmaker. Facility leaders confirmed the omissions in the records.
Unnecessary psychotropic medication use was identified for three residents. One resident with dementia and anxiety had a PRN lorazepam order without the required 14-day limit, while another resident with dementia and behavioral disturbance received Seroquel without documented attempts at non-pharmacological interventions beyond a general care plan entry. A third resident with major depressive disorder received citalopram and zolpidem ER without documented implementation of non-drug interventions in the record, MAR, or care plan.
A resident with limited ROM and mobility needs did not have consistent RNA documentation for ordered PROM/ROM services. Staff interviews and record review showed only a few charted ROM entries, a refusal entry, and missing notes for expected service days, while RNAs stated the resident should be seen multiple times per week and that documentation should be completed whether services were provided or refused. QAPI review also showed multiple residents were frequently missed for RNA services, and the resident had a history of contractures and not liking to get out of bed.
Incomplete Dialysis Follow-Up Documentation: Two residents with ESRD and dependence on dialysis had incomplete Dialysis Follow Up Information forms for multiple treatment days. Documentation was missing vital signs, signatures/titles, and other entries by the dialysis nurse and upon return to the facility, and the DHIM and an LVN confirmed the incomplete records and the expected communication between the facility and the dialysis center.
Medication administration and disposal errors were observed during med passes. An RN did not correctly prime an insulin pen for a resident with DM, another RN placed held meds in the sharps container instead of a designated waste bin, spironolactone was prepared from an outdated 25 mg card despite an order for 12.5 mg, and alendronate for a resident with GERD, hypothyroidism, and osteoporosis was scheduled and given with other morning meds instead of being separated by at least 30 minutes as ordered and per manufacturer labeling.
A resident with osteoporosis and GERD was receiving long-term omeprazole along with alendronate and three psychotropic meds that increase fall risk. Surveyors found no documented R/B assessment or clinical rationale supporting continued PPI use, and the DON, ADON, and CP could not locate documentation justifying the ongoing therapy.
Food was served below appetizing temperature for multiple residents, with several residents reporting hot foods were cold, lukewarm, or not warm and coffee was not hot. During tray observation, surveyors measured regular and puree tray items ranging from 109.8 F to 127.8 F, while the Head [NAME] stated hot food should not be below 140 F and noted the plate base and cover were not warmed.
A resident with dementia and an anxiety disorder received PRN lorazepam for agitation without documented informed consent. The MAR showed five doses were given, and the DON and ADON verified the record lacked consent; the ADON stated the nurse who received the order did not obtain it and thought hospice would.
Uneven hallway flooring created tripping hazards. Surveyors observed an uneven carpet-to-wood transition in one hallway and missing, broken tile pieces in another hallway near resident rooms. These areas were frequently used by residents using walkers, W/Cs, and by residents ambulating independently. The DES confirmed both conditions and stated the flooring transition lacked a threshold strip and that the broken tile pieces had not been replaced.
Fluid restriction was not followed for one resident with ESRD on dialysis when a cup of water was left within reach and the resident reported staff refilled it throughout the day, despite an 1800 ml/day order and a care plan for daily fluid restrictions. Another resident with CKD and CHF also had an 1800 ml/day fluid restriction order, but the care plan did not address restricted fluids, and staff confirmed the omission.
Missing CNA Annual Performance Evaluation: The facility failed to complete and maintain the annual performance evaluation for one CNA. The CNA's file had no current evaluation, and the DSD and DON stated the review should have been done annually, including when the CNA returned from leave and light duty. The employee handbook stated staff generally receive performance evaluations and that work during the year is evaluated by the supervisor.
Medication administration errors resulted in a 6.06% error rate after two errors were observed during med pass for two residents. An LVN gave metformin without a meal to a resident with diabetes, and another LVN crushed olanzapine ODT for a resident with agitation related to neurocognitive disorder, even though the ODT was intended to dissolve on the tongue and should not be crushed.
A facility medication cart contained inhalers and insulin pens labeled with expiration dates longer than the manufacturers’ instructions, and one expired Lispro pen remained in the cart even though the resident no longer had an order for it. Two LPNs stated staff used a pharmacy reference guide that listed longer dating for the inhalers and 28 days for insulin pens, but the products in the cart were still labeled beyond the required timeframes.
Improper Storage of Respiratory Equipment and Resident Care Items: Multiple residents had NCs, nebulizer masks, and C-PAP masks left uncovered, unlabeled, or exposed when not in use. Staff also observed a wet wash cloth and bath towel on the floor and unlabeled wash basins in shared bathrooms. A resident with COPD and acute respiratory failure had an uncovered nebulizer mask left on the machine after treatment, and staff confirmed these items were not being stored as required.
Kitchen staff were exposed to a buckled and cracked concrete floor in the walk-in freezer, with condensed ice observed on the floor and ceiling. The HC stated the floor had been in this condition for about 3 years and was slippery and not safe for staff. The ADM acknowledged the damage had been identified in a prior survey, and the DES stated the floor was supposed to be even and smooth.
The facility failed to follow its policies on food handling and kitchen maintenance, affecting all residents receiving food. Utensils were not stored inverted, meats were improperly thawed, and a significant crack was noted in the kitchen floor. The ice machine had a build-up, and the dish machine drain was filled with debris. Expired food was found in the refrigerator, and staff interviews confirmed these practices were not in line with policies.
The facility failed to implement a comprehensive water management program to prevent Legionella bacteria growth, as outlined in their policy. Despite the policy's requirements for a detailed water system diagram, the facility lacked such documentation. Interviews with staff, including the Administrator and Maintenance Supervisor, confirmed the absence of a water flow diagram, potentially affecting all 91 residents.
A medication cart was left unlocked and unattended by an LVN during medication administration, contrary to facility policy. The LVN admitted to not locking the cart, and both the DON and Administrator confirmed the expectation for carts to be locked when out of sight.
Daily Staffing Information Not Updated
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted was for the current day. During a concurrent observation and interview with the DON on 4/15/2026 at 9:48 a.m. at nurse station AA, there was no daily staffing information posted. The DON confirmed the observation and looked around nurse station AA, then went to the lobby's glass-covered cork board and found staffing information posted there that was dated 1/9/2025. During a later observation on 4/15/2026 at 9:53 a.m. at nurse station BB, daily staffing information was posted, but it was also dated 1/9/2025. During an interview with the ADM on 4/15/2026 at 10:07 a.m., the ADM was informed that the staffing information found in the lobby and at nurse station BB was dated 1/9/2025, and stated that the daily staffing information should have been updated daily and posted in the lobby. The facility policy titled, Posting Direct Care Daily Staffing Numbers, revised 8/2022, stated that staffing data is to be posted on a daily basis within two hours of the beginning of each shift in a prominent location accessible to residents and visitors.
Missing Qualified Food and Nutrition Leadership
Penalty
Summary
The facility failed to employ a director of food and nutrition services when the registered dietician was only employed part-time. During a concurrent observation and interview in the kitchen on 4/13/2026, the Head [NAME] stated the prior dietary manager had resigned about 2 months earlier and that the facility was in the process of recruiting a new one, while the Head temporarily managed the kitchen. The administrator later stated the dietary manager had resigned since 2/12/2026 and that the facility only had a part-time registered dietician working about 24 hours per week. During subsequent interviews, the administrator stated that both the administrator and Head oversaw the overall operation of the kitchen, and that the registered dietician’s responsibilities were mainly to coordinate the menu, meet with residents, complete dietary profiles, and resident assessments. The Head stated he was temporarily helping oversee dietary services and had been taught dietary tasks by the previous dietary manager. The administrator also stated there was no formal assignment for the Head to manage dietary tasks and that he did not have a dietary manager’s degree. When inservice training related to dietary tasks was requested during record review, the administrator could not provide the records. A review of the job description for Director of Food & Nutrition Services listed responsibilities including supervising staff, food preparation and service, sanitation, inventory, menu adjustments, resident diet cards, ordering food and supplies, nutritional screening, and attending weight variance meetings.
Ice Machines Had Buildup Around Dispenser and Discharge Chutes
Penalty
Summary
The facility failed to ensure proper sanitation of two ice machines, one located in the utility room near Station 2 and one located in the hallway near Station 2. During observation and interview, the Director of Environmental Services stated the two ice machines were under maintenance services, were cleaned internally by a contracted company every 90 days, and were wiped externally daily by maintenance staff with sanitizer. However, the utility room ice machine was observed with white, yellow, orange, and gray buildup around the ice dispenser chute, and the hallway ice machine was observed with white, yellow, and black buildup around the ice dispenser chute. The Director of Environmental Services stated the buildup looked like corrosion, was not clean, and should be replaced. Record review showed a contracted company invoice documenting internal cleaning of the ice machines, including flushing evaporators, dumping ice, cleaning machines, replacing water filters, and testing operation, with a note about rust buildup on and around the bin metal housing and a request for a quote for two new machines. The Director of Environmental Services agreed the report did not state whether the ice dispenser chutes were cleaned. The contracted company technician later observed black, yellow, white, and orange buildup on the top of the ice discharge chutes and around the dispenser chutes, describing the buildup as scale from hard water and noting the machines were old. The technician and company staff then observed that the buildup could be removed from some areas, but rough surfaces and stains remained around the chutes.
Visible care instructions and uncovered urine bag
Penalty
Summary
The facility failed to maintain resident dignity by visibly posting care instructions in multiple resident rooms and on room doors instead of keeping them discreet. For Resident 61, who had polyneuropathy, type 2 DM, and mild cognitive impairment with a BIMS score of 7, a posted instruction above the head of bed directed CNAs to assist with dentures before breakfast and remove them at night. The same type of visible posting remained in the room during repeated observations. Similar visible postings were observed for Resident 69, who had unspecified dementia and a BIMS score of 10, including an instruction to use only soap and warm water for brief changes and no wipes. Visible care instructions were also observed for Resident 19, who had dementia and a BIMS score of 6, stating that the patient was a Hoyer lift transfer. Resident 95, who had hemiplegia/hemiparesis following CVA and epilepsy and was cognitively intact with a BIMS score of 14, had posted instructions stating that the patient was a feeder and used medicated shampoo on shower days. When interviewed, Resident 95 stated, after being told what a feeder meant, that he could feed himself. Resident 90, who had senile degeneration of the brain, vascular dementia, and a history of TIA and cerebral infarction, had multiple care instructions visibly posted in the room, including directions to ask if he was hungry or thirsty, information about post stroke regression, and a daily wake-up plan. Staff confirmed the postings were visible and stated nurses were the ones who posted them. Additional visible postings were observed for Resident 3, who had ESRD and was on renal dialysis, and Resident 93, who had hearing aid care instructions posted on the wall and on a storage unit in front of the bed. Resident 54, who had CKD and CHF, also had a fluid restriction breakdown posted on the front door. In another room, Resident 39 had an exposed urine drainage bag tied to the side of the bed without a privacy bag. Staff confirmed the urine bag was not covered and stated that a privacy bag must be used. The facility policy on dignity stated that signs indicating a resident's clinical status or care needs are not openly posted in the resident's room and that urinary catheter bags should be covered.
Advance Directive and POLST Documentation Incomplete
Penalty
Summary
The facility failed to follow its advance directive policy for multiple residents by not documenting whether advance directives existed or whether assistance was offered to complete them. For Residents 1, 9, 118, and 121, the clinical records contained no documented evidence of an advance directive and no verification or offer of assistance to execute one. The director of social service stated that social service staff did not verify, offer, or provide assistance with advance directives for these residents and acknowledged that they should have done so. Resident 6’s record also showed no advance directive in the admission record or attached EMR documents. During record review, the director of social service confirmed that Resident 6 had no advance directive and stated that advance directives had not been discussed during previous care conferences. She stated that families and residents should have been encouraged to complete an advance directive while still capable of making health care decisions. The facility also had incomplete POLST forms for several residents. Resident 3’s POLST left section D unanswered, with all three advance directive-related options blank, and Resident 7’s POLST had the same section left blank despite documented advance directives in their charts. Resident 19’s POLST was missing the physician or nurse practitioner signature, and Resident 95’s POLST was missing the resident, decisionmaker, or conservator signature even though the physician had signed it. Facility staff, including the DHIM, ADON, DSS, and MDSC, confirmed these forms were incomplete and stated that the missing sections should have been completed.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure three sampled residents were free from unnecessary psychotropic medication use. One resident with dementia and anxiety disorder had an order for PRN lorazepam 0.5 mg every 1 hour for agitation that was written without a 14-day end date or specified duration. During review with the DON and ADON, both acknowledged that PRN psychotropic orders are limited to 14 days, and the facility policy also stated that PRN psychotropic orders are limited to 14 days. A second resident with dementia with other behavioral disturbance was receiving Seroquel 25 mg twice daily, but the clinical record contained no documented evidence that nursing staff attempted non-pharmacological interventions while the medication was being given. Although the care plan included a general intervention for non-pharmacological interventions for residents on psychotropic medication, the DON stated the interventions were documented only in the care plan and nowhere else, and the MDSC confirmed there was no documented evidence that licensed staff attempted or documented non-pharmacological approaches. A third resident with major depressive disorder had orders for citalopram 20 mg daily and zolpidem ER 12.5 mg at bedtime, but the record, nursing progress notes, and MAR contained no documented evidence that licensed nurses implemented non-pharmacological interventions for depression or difficulty sleeping; the care plan for citalopram only directed staff to offer emotional support, and the care plan for hypnotics contained no non-pharmacological interventions.
Missing Documentation for Restorative ROM Services
Penalty
Summary
The facility failed to provide restorative nursing services for a resident with limited range of motion and mobility needs, and documentation of those services was missing or incomplete. Review of the restorative nursing assistant (RNA) records showed only a few entries for active and passive ROM, including one entry for ROM on 3/17/26 and a refusal entry on 4/1/26, with no documentation found for other expected service dates. The resident was listed for PROM to both upper and lower extremities and was scheduled for exercise three times per week. During interview, the director of staff development stated that RNAs document in alert listing reports and that there was no documentation for some date ranges, meaning the resident either refused or was not seen. RNA staff stated the resident should be receiving RNA services 2-3 times per week, that documentation should be completed every time whether the resident receives ROM or refuses, and that the resident may be missed because staff are not able to get through the full list of residents who should receive services. Another RNA stated the resident refuses often and that missing documentation could be from the resident not being worked with or refusing. The record review also showed no progress note for a scheduled RNA day after the facility began documenting in progress notes, and the QAPI report identified multiple residents who were frequently not seen by an RNA. Facility staff stated the resident had been transitioned to RNA services after skilled care and had a long-standing history of not liking to get out of bed, with contractures noted in the chart. The facility policy stated residents with limited ROM and mobility should receive treatment and services to increase or prevent further decrease in ROM and that documentation should include attempts to address changes or decline in condition or needs.
Incomplete Dialysis Follow-Up Documentation
Penalty
Summary
Safe, appropriate dialysis care and services were not provided for two residents who required renal dialysis. Resident 121 was admitted with end stage renal disease and dependence on renal dialysis and was scheduled for dialysis every Monday, Wednesday, and Friday. Review of the Dialysis Follow Up Information forms showed incomplete documentation for 5 of 7 dialysis treatment days, including missing vital signs, missing signature and title upon return to the facility, and no documented evidence for some treatment days. The director of health information management and an LVN confirmed the incomplete forms and stated nursing staff were responsible for completing and verifying the documentation before and after dialysis visits. Resident 3 was also admitted with end stage renal disease and dependence on renal dialysis and was scheduled for dialysis every Tuesday, Thursday, and Saturday. Review of the Dialysis Follow Up Information forms showed incomplete documentation for 7 of 10 dialysis treatment days, including missing information by the dialysis nurse, missing documentation upon return to the facility, and missing signature and title on one form. The director of health information management and the LVN confirmed the incomplete documentation and stated the licensed nurse should complete, verify, and follow up on the dialysis follow-up information for each dialysis treatment day. The facility policy for end-stage renal disease stated that the contracted ESRD facility and the facility would exchange information regarding how the resident's care would be managed.
Medication administration and disposal errors
Penalty
Summary
Accurate medication administration and disposal were not ensured during multiple observed medication passes. During an observation for one resident with diabetes who had an order for Humalog 17 units with meals and to prime 2 units before each injection, an RN prepared the insulin pen by placing it sideways, dialing to 2 units, and pressing the button without confirming insulin at the needle tip. The RN later acknowledged she had not held the pen upright and did not observe insulin at the needle tip during priming. During another medication pass for a resident with congestive heart failure, an RN prepared spironolactone 25 mg, Entresto 24-25 mg, and metoprolol ER 25 mg, then checked the resident's BP at 105/60 mmHg and stated the medications would be held because the BP was below parameters. The RN then placed the held medications in the sharps container instead of a designated pharmaceutical waste container. In a separate review of the same resident's medication pass, the RN stated he had prepared spironolactone from an old card containing 25 mg whole tablets even though the order had been changed to 12.5 mg, and he confirmed the old card should have been removed from the cart to avoid a medication error. For another resident with GERD, hypothyroidism, and osteoporosis, the MAR scheduled alendronate 70 mg at the same time as Prilosec, levothyroxine, and acetaminophen. The physician's order directed alendronate to be given first thing in the morning at least 30 minutes before any other beverage, food, or medication, and the manufacturer's labeling stated it should be taken at least one-half hour before the first food, beverage, or medication of the day. The DON later reviewed the MAR and confirmed the resident received all four medications together on the days alendronate was due.
Unnecessary Long-Term Omeprazole Use Without Documented R/B Review
Penalty
Summary
The facility failed to ensure that Resident 19’s drug regimen was free from an unnecessary medication. Resident 19 was an over-[AGE] year-old resident with diagnoses including age-related osteoporosis and gastro-esophageal reflux disease without esophagitis. Her record showed that GERD was diagnosed on [DATE], and the clinical record indicated she had no active GERD or other bowel disorders. Her MDS dated 2/4/26 showed a BIMS score of 6, indicating severe cognitive impairment. The resident’s physician orders showed she had been receiving alendronate 70 mg weekly for osteoporosis and Prilosec (omeprazole) 20 mg daily for GERD, with the omeprazole order dated 12/28/22. The manufacturer’s prescribing information for omeprazole stated that for GERD it is used for up to 8 weeks to heal acid-related damage to the esophagus, with an additional 4 weeks if needed to maintain healing, and that it is not known to be safe and effective when used longer than 12 months for this purpose. The prescribing information also stated that PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist, or spine, and that patients should use the lowest dose and shortest duration appropriate to the condition being treated. Resident 19 was also receiving three psychotropic medications—quetiapine, escitalopram, and mirtazapine—each of which has the ability to cause falls. During record review and interviews, the DON, ADON, and consultant pharmacist could not find documentation supporting the long-term use of omeprazole or a documented risk-versus-benefit assessment. The consultant pharmacist stated she understood the fracture risk and checked monthly for opportunities, but said she was nervous about reducing the PPI because of the resident’s psych issues and could not find documentation of a clinical rationale. The DON later stated that no recommendation to discontinue omeprazole was made for this resident, reflecting individualized clinical judgment based on her condition and risk profile.
Food Served Below Appetizing Temperature
Penalty
Summary
Food was not served at an appetizing temperature for multiple residents. During room rounds and interviews, Resident 34 stated hot foods were always served cold for all three meals, Resident 68 stated hot foods were always served cold and that coffee was not hot, Resident 9 stated hot foods were always served cold, and Resident 54 stated hot foods were always served cold and not appetizing to eat cold. Additional residents, including Residents 123, 36, 59, 16, 85, 46, and 74, also reported that the food was lukewarm, not warm, cold, or served last so nothing was warm. Several of these residents had intact cognition based on MDS assessments with BIMS scores of 15/15. During lunch tray observation, two test trays were requested after multiple resident complaints. The trayline began at 12:17 p.m., the last food cart left the kitchen at 1:15 p.m., and trays were distributed to rooms by 1:33 p.m. At 1:36 p.m., surveyors measured the food temperatures on a regular diet tray and a puree regular diet tray. The regular diet tray items ranged from 109.8 F to 127.8 F, and the puree regular diet tray items ranged from 114 F to 126 F. The Head [NAME] stated food served to residents should not be below 140 F and said the plates were warmed before food was placed on them, but the plate base and cover were not warmed. The facility policy and procedure titled HACCP (Hazard Analysis and Critical Control Points) and Food Safety stated the Food Code uses 135 F for hot foods and that the food service manager and RDN should determine appropriate temperature ranges.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering lorazepam, a psychotropic antianxiety medication, to a resident with diagnoses including dementia and an anxiety disorder. The physician order dated 3/17/26 directed lorazepam 0.5 mg by mouth every 1 hour as needed for agitation, and the resident’s clinical record contained no documented evidence that informed consent was obtained for its use. The resident’s April 2026 MAR showed five as-needed doses of lorazepam 0.5 mg were administered for agitation. During a concurrent interview and record review, the DON and ADON reviewed the record and verified that no informed consent was present for lorazepam. In a follow-up interview, the ADON stated the nurse who received the order did not obtain informed consent and thought the hospice nurse was to get it, and acknowledged that informed consent was required before starting lorazepam.
Uneven hallway flooring created tripping hazards
Penalty
Summary
The facility failed to ensure an even floor surface in hallway areas used by residents. During observation on 4/13/2026 at 12:55 p.m., an uneven floor surface was identified where carpeted flooring transitioned to wooden flooring in a hallway near one resident’s room. Residents were observed passing through the area frequently, including individuals using walkers, wheelchairs, and walking without a mobility device. During observation on 4/14/2026 at 1:30 p.m., an uneven floor surface with missing and broken tile pieces was identified in a hallway near another resident’s room. This area was also frequently used by residents with walkers, wheelchairs, and residents who walked independently. During a concurrent observation and interview on 4/16/2026 at 11:49 a.m., the Director of Environmental Services observed and confirmed both uneven floor surfaces. The Director stated the carpeting-to-wood transition near one resident’s room was part of an ongoing flooring replacement project and that no threshold strip had been placed to fill the gap, and acknowledged the broken tile pieces in the other hallway area.
Fluid Restriction Not Followed and Care Plan Missing for Restricted Fluids
Penalty
Summary
The facility failed to ensure fluid restrictions were followed for Resident 3. During observation, Resident 3 had a plastic reusable cup with a built-in straw full of water on a tray table next to the bed and within reach, while a posted fluid restriction for a total of 1800 ml was displayed in the room. Resident 3 stated nursing staff replaced water in the cup for him to drink throughout the day. Resident 3’s record showed diagnoses of end stage renal disease and dependence on renal dialysis, an order for a 1800 ml per day fluid restriction dated 4/10/2026, and a care plan for renal failure/hemodialysis that included daily fluid restrictions. CNA F confirmed the cup of water was within reach and stated restricted fluids were divided between meals and medications, that the water in the cup was not included in the restricted fluids, and that nursing staff should not have provided extra water. RN K also stated Resident 3 should not have been provided extra water in a cup to maintain the fluid restriction and prevent complications from fluid overload. The facility also failed to initiate a care plan for restricted fluids for Resident 54. Resident 54’s record showed diagnoses of chronic kidney disease and congestive heart failure, and an order for fluid restriction of 1800 ml per day dated 4/7/2026. Review of the care plans showed no mention of fluid restriction. During review with LVN L, the order for fluid restriction was verified and the absence of any care plan addressing restricted fluids was confirmed. The MDS coordinator stated nursing staff should have initiated and implemented a care plan for restricted fluid management for Resident 54. The facility policy stated the interdisciplinary team develops and implements a comprehensive, person-centered care plan for each resident.
Missing CNA Annual Performance Evaluation
Penalty
Summary
The facility failed to conduct the CNA annual performance evaluation for one of three sampled employees, CNA M. Review of the employee file showed CNA M was hired on 7/9/2013, but there was no current annual performance evaluation in the file. The report stated this evaluation was a formal, documented review of the employee's work over the past year, assessing performance against established goals and expectations. During interviews, the DSD stated the business office records showed CNA M's last annual performance evaluation was on 8/27/2023, but the hard copy could not be found and the date was known only because CNA M received a raise that day. The DON stated the evaluation should have been done annually and was not sure why it was missed. In a follow-up interview, the DSD stated CNA M went on leave in 6/2025 and returned on light duty on 1/18/2026, and confirmed the performance evaluation should have been completed when she came back to work. The employee handbook stated staff members generally receive a performance evaluation at the same time, generally in December, and that work during the year will be evaluated by the supervisor.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors occurred during observation of two residents, resulting in a medication error rate of 6.06% based on 2 errors out of 33 opportunities. For Resident 61, who had an order for metformin 500 mg twice daily for diabetes, LVN C prepared metformin and brought it to the resident with applesauce. The medication was administered without a meal, and LVN C acknowledged that the resident did not receive metformin with a meal. The DON also acknowledged that metformin should be given with a meal, and the surveyor observed that dinner had not yet arrived in the resident’s hallway by the time the surveyor left the facility. For Resident 18, who had an order for Zyprexa Zydis (olanzapine) ODT 2.5 mg twice daily for agitation related to neurocognitive disorder, LVN D prepared half a tablet of olanzapine ODT and half a tablet of metoprolol, placed both in a plastic bag, and crushed them into fine powder before mixing them with applesauce and administering them to the resident. LVN D stated she crushed the medications because the resident could not take anything non-crushable, but after checking an online resource she stated olanzapine ODT should not be crushed. The DON and the consultant pharmacist also stated olanzapine ODT should not be crushed, and the prescribing information indicated the tablet is intended to disintegrate quickly on the tongue.
Medication Cart Items Labeled Beyond Manufacturer Expiration Dates
Penalty
Summary
The facility failed to ensure that 3 inhalers and 3 insulin pens were labeled with expiration dates that matched the manufacturers’ instructions, and an expired, discontinued insulin pen was left in a medication cart. During observation of the Station 2 Pebble Beach Medication Cart with two LVNs, the Incruse Ellipta inhaler for one resident was labeled to expire 2 months after opening even though the manufacturer instructed it be discarded 6 weeks after opening or when the counter reached 0. The Breo Ellipta inhaler for the same resident was also labeled with a 2-month expiration date after opening, despite the manufacturer’s 6-week instruction. The Trelegy Ellipta inhaler for another resident was labeled with a 3-month expiration date after opening, although the manufacturer instructed it be discarded 6 weeks after opening. The Lantus insulin pen for one resident was labeled to expire 30 days after opening, while the pharmacy label stated it should be used for up to 28 days after first use. Another Lantus pen for a different resident was labeled with a 30-day expiration date after opening, despite the pharmacy label stating it should be thrown away 28 days after first use. A Lispro insulin pen for a resident was labeled with a 30-day expiration date after opening, but the pharmacy label stated any remaining medicine should be thrown away 28 days after first use. The LVNs stated staff used the pharmacy’s expiration date reference guide, which listed the inhalers as having a 6-week expiration after opening and insulin pens as good for 28 days after opening. One LVN also confirmed the resident’s Lispro pen had expired and that the resident no longer had an order for it, and the resident’s medication order review showed the Lispro order had been discontinued more than a month before the survey date.
Improper Storage of Respiratory Equipment and Resident Care Items
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when multiple resident care items were observed left uncovered, unlabeled, or improperly stored. During room observations, nasal cannulas for Residents 31, 1, 44, 3, and 84 were found either attached to oxygen equipment with the tubing coiled on the concentrator or floor, or in use without being labeled. The assistant director of nursing and the director of staff development/interim infection preventionist stated nasal cannulas should be changed weekly, labeled when changed, and stored in a black bag when not in use. Resident 25, who was admitted with COPD and acute respiratory failure and had a BIMS score of 15/15, was observed with an uncovered nebulizer face mask left on top of the nebulizer machine on the nightstand after treatment. The resident stated staff left the mask there after the morning treatment and that this occurred every day. The assistant director of nursing and the director of staff development/interim infection preventionist stated the nebulizer mask should be cleaned, air dried, and stored in an assigned black bag when not in use. C-PAP face masks for Residents 118 and 34 were also observed uncovered or exposed in a drawer or on the bed when not in use. In addition, a wet wash cloth and bath towel were observed on the floor next to Resident 107's bed, and two unlabeled wash basins were observed in shared bathrooms between resident rooms. Staff confirmed the basins were in use without resident names and stated they should be labeled and stored when not in use. The facility policy for reusable resident care items stated basins and personal care items are for individual resident use, are not shared, and are not stored on the floor or in contaminated areas.
Kitchen Walk-In Freezer Floor Was Buckled and Cracked
Penalty
Summary
The facility failed to ensure a safe and functional environment for kitchen staff in the walk-in freezer of the kitchen. During observation, the concrete floor was seen to be buckled and broken with multiple lines, and condensed ice was observed on both the floor and the ceiling. The Head [NAME] stated the floor had been in this condition for about three years and that it was slippery and not safe for staff. The administrator acknowledged the damaged floor and stated it had been identified during the prior recertification survey in December 2024. The Director of Environmental Services and a Maintenance Assistant also observed the buckled and cracked concrete floor with condensed ice and stated the floor was supposed to be even and smooth. The facility policy identified irregular floor surfaces as a hazard, and the 2022 Federal Food Code requires indoor floor, wall, and ceiling surfaces in food areas to be smooth, durable, and easily cleanable.
Deficiencies in Food Handling and Kitchen Maintenance
Penalty
Summary
The facility failed to adhere to its own policies regarding food handling and kitchen maintenance, which could potentially affect all residents receiving food from the kitchen. Observations revealed that utensils were not stored inverted as required, which could lead to cross-contamination. Additionally, meats were improperly thawed in room temperature water instead of using safe thawing practices outlined in the facility's policy. A significant crack was noted in the kitchen floor, which the Certified Dietary Manager (CDM) acknowledged as an ongoing issue. Further deficiencies were observed with the cleanliness and maintenance of kitchen equipment. The ice machine had a whitish build-up around the dispenser, and the drain underneath the dish machine was filled with food debris, contrary to the facility's policy that required daily cleaning. Expired food items were found in the nourishment refrigerator, indicating a lapse in monitoring expiration dates. Interviews with the CDM, Director of Nursing (DON), and Administrator confirmed these practices were not in line with the facility's policies, and there was a lack of awareness regarding the cleaning process for food drains.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to develop a comprehensive water management program, which is essential for identifying and mitigating the risk of Legionella bacteria growth and the potential spread of Legionnaires' disease. The facility's policy, titled 'Legionella Water Management Program,' revised in July 2017, outlined the need for a detailed description and diagram of the water system, including various components such as receiving, cold and hot water distribution, and waste. However, the facility's Legionella Environmental Assessment Form lacked evidence of such a detailed description and diagram. Interviews with facility staff, including the Maintenance Supervisor, Administrator, and Director of Nursing, revealed that while the need for a water management program was briefly discussed, the facility did not have a water flow diagram in place. The Administrator acknowledged the absence of a flow diagram, which is crucial for understanding and preventing the growth of Legionella. This deficiency had the potential to affect all 91 residents residing in the facility.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medication carts were locked when not within the sight of the nurse during medication administration. This deficiency was observed during a medication administration observation where a medication cart was found unlocked while the Licensed Vocational Nurse (LVN) was in a resident's room, behind a privacy curtain, and the cart was out of her line of sight. The LVN left the medication cart unlocked multiple times while administering medications to several residents. Interviews with the LVN, the Director of Nursing (DON), and the Administrator confirmed the expectation that medication carts should be locked when unattended. The LVN acknowledged that she did not lock the cart during the medication pass, and the DON and Administrator reiterated the facility's policy that medication carts must be locked when not in the nurse's line of sight to prevent unauthorized access.
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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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