Citrus Heights Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Citrus Heights, California.
- Location
- 7807 Uplands Way, Citrus Heights, California 95610
- CMS Provider Number
- 555337
- Inspections on file
- 32
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Citrus Heights Post Acute during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, polyneuropathy, muscle weakness, and documented weight loss was care planned and ordered via diet tickets to receive adaptive equipment, including a divided plate, plate guard, and sippy cup, to support self-feeding. During a lunch meal observation, the resident, who had shaky hands and required supervision/touching assistance with eating per MDS, was given regular drinking cups and a divided plate without a plate guard, contrary to the meal ticket and nutritional risk reviews. The resident reported being unable to hold the regular cups, and staff (a CNA, an LN, the RD, and the Administrator) acknowledged that the adaptive devices should have been provided in accordance with the meal ticket, care plan, and facility policy on self-feeding devices.
A resident with paraplegia and a skin infection was transferred due to a conflict of interest with an NP, but the facility failed to obtain a physician order, complete a discharge summary, or provide a notice of discharge as required. Staff interviews confirmed the absence of these documents in the medical record, despite facility policy mandating their completion for all discharges.
Two residents with chronic wounds and skin conditions did not consistently receive prescribed wound care treatments, including hydrocortisone cream, Aquaphor ointment, and zinc oxide paste, as documented in treatment administration records. Staff interviews confirmed that wound care orders were not followed as directed and that required documentation was lacking when treatments were missed.
A resident with COPD, CHF, and sleep apnea received oxygen therapy multiple times without an active physician's order, as documented in clinical records and confirmed by staff interviews. Facility policy requires a physician's order for oxygen administration, but staff provided oxygen when the resident experienced breathing difficulties, resulting in care that did not follow established procedures.
Two residents with chronic pain conditions did not receive pain medications as ordered by their physicians, with staff administering medications intended for different pain levels than those documented. Medication administration records and staff interviews confirmed that pain management orders were not consistently followed, contrary to facility policy and professional standards.
Surveyors identified failures in emergency medication documentation and controlled substance management, including missing entries in the E-Kit log after medications were removed, retention of expired insulin from a previous pharmacy, and a discrepancy in the narcotic count for a resident's pain medication. The ADON and LNs confirmed that these actions did not follow facility policy for medication tracking and reconciliation.
Surveyors found that food service equipment, including steam table pans, a food processor, and a blender, were stored wet and with food residue, contrary to facility policy and FDA Food Code. Additionally, the dry storage area floor was observed to have food packets and debris, with the Dietary Supervisor confirming the need for cleaning. These failures demonstrate noncompliance with professional standards for food storage and preparation.
Surveyors identified infection control deficiencies involving three residents: an incentive spirometer was left unlabeled and uncovered, enhanced barrier precautions were not followed during personal care for a resident with a chronic wound, and a nasal cannula used for oxygen therapy was left uncovered when not in use. Staff interviews and facility policies confirmed these lapses in required infection prevention practices.
Two residents who were dependent on staff for ADLs did not receive necessary nail care, resulting in one having long, curling toenails and another with long fingernails containing debris. Both residents expressed discomfort and a desire for nail care, but staff either deferred care to the podiatrist or did not initiate referrals, despite facility policy requiring assistance with hygiene and grooming for residents unable to perform these tasks independently.
Surveyors found that drugs and biologicals were not stored properly, with loose pills present in a medication cart and a Drug Buster bottle observed with a brown substance on its exterior and in the drawer. A nurse confirmed these findings, and facility policy requires medication storage areas to be kept clean and safe.
A resident with chronic kidney disease and hypertension, who was prescribed a No Added Salt (NAS) diet, was served a salt packet with her meal despite clear dietary orders and care plan instructions. Staff interviews and policy reviews confirmed that the NAS diet should have excluded extra salt, and the error was acknowledged by both dietary and nursing staff.
Two residents with cognitive and mobility impairments were found without accessible call light buttons, as the devices were placed out of reach in their rooms. Staff and facility leadership confirmed that call lights should be within reach, and facility policy requires this practice.
A licensed nurse did not wear a gown or perform hand hygiene during a G-tube dressing change for a resident on Enhanced Barrier Precautions, contrary to facility policy requiring these infection control measures for high-contact care activities.
The facility failed to follow food safety standards by improperly thawing pork loin without running water and storing expired food items in the refrigerator. The Kitchen Supervisor confirmed these practices, which were against the facility's policy and the FDA Food Code, posing a risk of foodborne illness.
Failure to Provide Prescribed Adaptive Eating and Drinking Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed adaptive eating and drinking equipment to a resident during a lunch meal. The resident had diagnoses including Parkinson’s disease, polyneuropathy, and muscle weakness, and an MDS indicating moderately impaired cognition and a need for supervision or touching assistance with eating. The resident’s care plan and nutritional risk reviews documented a history of weight loss, weakness in hands and arms, and the ongoing need for a divided plate, plate guard, and sippy cup at meals. During an observation of a lunch meal in the resident’s room, the resident was seen with shaky hands and had not touched the lunch meal on the bedside table. The meal tray contained two full cups of reddish beverages in regular 8 fl oz cups and a small can of ginger ale with a straw. The resident had been provided a divided plate but was not provided a plate guard or sippy cups, despite the lunch meal ticket specifying adaptive equipment including a plate guard and sippy cup. In interviews conducted at the time of the observation, the resident stated she could not hold the regular cups because of her shaky hands and expressed a desire for a better cup to hold drinks more steadily without spilling. A CNA confirmed that the resident had not been provided a plate guard or sippy cups and acknowledged that, due to the resident’s shaky hands, these items should have been provided so she could eat and drink safely and properly. An LN stated that the meal ticket should have been followed and that the resident should have received the plate guard and sippy cups, noting that nurses normally check trays for completeness. The RD confirmed the resident’s weight loss and need for assistive utensils, stated there were no refusals or functional changes documented, and indicated the resident should continue to receive the plate guard and sippy cups with each meal. The Administrator stated an expectation that assistive utensils be provided when indicated on meal tickets, and facility policy specified that self-feeding devices such as plate guards are to be stored by Food & Nutrition Services and provided on meal trays for residents needing them. This failure had the potential to result in the resident not being able to properly and safely eat and drink and had the potential for nutrition and hydration problems.
Missing Required Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure that required documentation for discharge was present in the medical record for one resident. The resident, who had paraplegia and a local skin infection, was admitted with intact cognition. During the resident's stay, a conflict of interest arose when the nurse practitioner (NP) recognized the resident as being involved in a lawsuit with the NP. The resident agreed to be transferred to another facility due to this conflict. Upon review, it was found that there was no physician or provider order indicating the basis for the resident's discharge, no discharge summary, and no notice of discharge in the resident's medical record. Multiple staff interviews confirmed that these required documents were missing. The case manager, social services director, assistant director of nursing, medical records director, and administrator all acknowledged the absence of the necessary discharge documentation. Facility policy required that a physician or provider's order be obtained for all discharges, that a discharge summary be completed, and that a notice of proposed discharge be provided to the resident and documented in the medical record. Despite these requirements, none of these steps were completed for the resident in question, resulting in a lack of proper documentation and communication regarding the discharge.
Failure to Consistently Administer Wound Care Treatments as Ordered
Penalty
Summary
Two residents did not receive wound care treatments as ordered by their physicians, in accordance with professional standards of practice and the facility's policies and procedures. One resident, with diagnoses including peripheral vascular disease, venous insufficiency, and major depressive disorder, had physician orders for hydrocortisone cream and Aquaphor ointment to be applied to chronic ulcers on both lower legs. Review of treatment administration records showed that these treatments were frequently missed or not administered at the prescribed frequency over a period of nearly two months. The resident reported not receiving treatments consistently, and staff confirmed that the wound care orders were not followed as directed. Another resident, with diagnoses including vascular parkinsonism, adult failure to thrive, morbid obesity, and overactive bladder, was at risk for skin breakdown and had open sores on the back. This resident had physician orders for zinc oxide paste to be applied to the rear thighs and right buttock twice daily for moisture-associated skin damage (MASD). Treatment administration records indicated that these treatments were also missed or not performed at the required frequency. The resident reported that staff were not properly caring for the sores, and staff interviews confirmed the inconsistency in following wound care orders. Interviews with nursing staff, the Director of Staff Development, and the Director of Nursing confirmed that wound treatments were not consistently performed as ordered and that documentation was lacking when treatments were not administered. Facility policy required that wound care be provided according to physician orders and that the care plan be reviewed for special needs, but these procedures were not followed for the two residents identified.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sleep apnea was provided with oxygen therapy without an active physician's order. The resident's care plan indicated the need for oxygen as ordered, and multiple clinical records, including vital summaries and progress notes, documented the use of oxygen via nasal cannula on several occasions. During interviews, both the licensed nurse and the Director of Staff Development confirmed that oxygen was administered to the resident when she experienced difficulty breathing, despite the absence of a current physician's order for this treatment. Facility policy and procedures for oxygen administration require verification of a physician's order prior to providing oxygen therapy. Both the Director of Staff Development and the Director of Nursing stated that an active physician's order is necessary to safely administer oxygen to residents. The failure to obtain and verify a physician's order before administering oxygen resulted in the delivery of respiratory care that was not consistent with facility policy and standard practice.
Failure to Follow Physician Orders for Pain Management
Penalty
Summary
The facility failed to ensure that two residents received appropriate pain management services in accordance with professional standards of practice, facility policy, and physician orders. For one resident with vascular parkinsonism and osteoarthritis, pain medication orders specified different medications for mild, moderate, and severe pain levels. However, medication administration records showed that this resident was given acetaminophen, intended for mild pain, when experiencing moderate pain, and was also administered hydrocodone-acetaminophen, intended for severe pain, during episodes of moderate pain. These discrepancies were confirmed by the nurse supervisor during record review. Another resident with multiple fractures and osteoarthritis had physician orders for acetaminophen for mild pain and varying doses of Norco for moderate and severe pain. Medication administration records indicated that this resident received 1 tablet of Norco, intended for moderate pain, during episodes of severe pain, and 2 tablets of Norco, intended for severe pain, during episodes of moderate pain on multiple occasions. The nurse supervisor confirmed that the pain medication orders were not consistently followed for this resident as well. Interviews with staff, including the Director of Staff Development, Consultant Pharmacist, and Director of Nursing, all confirmed that pain medications should be administered according to physician orders. The facility's policies and procedures also require that pain medications be administered as ordered and in accordance with the resident's care plan. The failure to follow these orders was observed in the medication administration records and confirmed by staff interviews.
Deficiencies in Emergency Medication Documentation and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with its policies and procedures, as evidenced by several deficiencies related to emergency medication management and controlled substance documentation. During inspections of the medication rooms and carts, it was observed that emergency kits (E-Kits) had been opened and resealed with red color-coded locks, but there was no documentation in the Emergency Kit Log regarding which medications were removed or the dates of removal. Multiple white slips in the narcotic E-Kit indicated repeated access, yet the required log entries were missing. The Assistant Director of Nursing (ADON) confirmed that licensed nurses were expected to record all medication removals in the log and notify the pharmacy for kit replacement, as outlined in the facility's policy. Additionally, an expired insulin E-Kit from a previous pharmacy provider was found in the refrigerator, and the ADON acknowledged it should have been removed or destroyed after the pharmacy change, in accordance with policy requirements for handling discontinued or outdated medications. Further, a discrepancy was identified in the controlled drug record for a resident receiving narcotic pain medication. The on-hand count of Percocet tablets did not match the documented record, with one less tablet present than recorded. The licensed nurse attributed the discrepancy to a missed documentation by the night nurse, who had administered the medication but failed to record it. The ADON stated that both outgoing and incoming staff were expected to reconcile and sign off on narcotic counts at each shift change, as per facility policy. These findings demonstrate lapses in medication documentation, storage, and accountability.
Improper Food Storage and Equipment Cleaning in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food service operations. Three steam table pans were found stored while still wet, with one pan containing food residue, in the ready-to-use area. Additionally, both a food processor and a blender were stored with their lids on, wet, and with food residue inside. The Dietary Supervisor confirmed during interviews that these items were expected to be clean and air-dried before storage, and acknowledged that improper washing and drying could lead to foodborne illness. Review of the facility's dishwashing policy and the FDA Food Code confirmed that all dishes and equipment should be properly sanitized, free of food residue, and air-dried before storage. Further observations revealed that the dry storage area floor contained food packets, a piece of plastic wrap, and paper debris. The Dietary Supervisor confirmed that the floor needed to be swept. According to the FDA Food Code, food must be stored in a clean, dry location, protected from contamination. These findings demonstrate that the facility did not consistently follow professional standards for food storage, preparation, and cleanliness, as required by both facility policy and federal regulations.
Infection Control Lapses in Device Labeling, PPE Use, and Respiratory Equipment Storage
Penalty
Summary
The facility failed to follow infection prevention and control practices for three residents. For one resident with chronic respiratory failure, an incentive spirometer was observed on a shared shelf, unlabeled and not contained in a protective covering. Both the resident and a licensed nurse confirmed that the device was not labeled or bagged, despite facility policy requiring labeling and storage in a bag. The resident had a physician's order for use of the spirometer multiple times per week. Another resident with a history of cellulitis of the lower limb was on enhanced barrier precautions (EBP) due to a chronic wound. During personal care, a certified nursing assistant provided direct care without wearing the required personal protective equipment (PPE), even though signage at the room entrance indicated EBP and the care plan specified the use of gown and gloves for high-contact activities. The CNA acknowledged not wearing PPE, and the infection preventionist confirmed that PPE was required for such care. A third resident, admitted with chronic obstructive pulmonary disease, congestive heart failure, and sleep apnea, was observed with an oxygen concentrator and nasal cannula. The nasal cannula was left uncovered on top of the concentrator when not in use. Both the resident and a CNA confirmed the cannula was not bagged, and the director of staff development stated that respiratory tubing should be placed in an antimicrobial bag when not in use to prevent contamination. Facility policy also required safe storage of oxygen administration equipment.
Failure to Provide Nail Care Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents who were unable to perform this activity of daily living independently. One resident, with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus, dermatophytosis, and varicose veins with ulcer, was dependent on staff for bathing, personal hygiene, and required assistance with dressing and footwear. Observations revealed that this resident had thick, long, and curling toenails. The resident expressed a desire to have her toenails trimmed, but staff indicated that due to her diabetes diagnosis, only the podiatrist could perform this care, and she was not currently on the podiatrist's list. The podiatrist only visited every two months, and the resident was at risk for ingrown toenails and skin injury if her nails were not trimmed. Another resident, with a history of stroke, muscle wasting, diabetes, and major depressive disorder, required substantial to maximal assistance with personal hygiene and was dependent on staff for several ADLs. During observation, this resident was found to have long fingernails with a grayish substance underneath. The resident stated discomfort and a desire for nail care. A CNA confirmed the condition of the nails and stated that they should be trimmed and cleaned to prevent infection. The resident had not been referred for podiatry care, and staff interviews revealed that nail care was considered an implied daily task for nurses, with referrals to the podiatrist as needed for complex cases. Review of facility policy indicated that appropriate care and services should be provided for residents unable to carry out ADLs independently, including hygiene and grooming. Despite this, both residents did not receive necessary nail care, as observed and confirmed by staff and record review. The lack of timely nail care for these dependent residents constituted a failure to meet their basic hygiene needs as outlined in their care plans and facility policy.
Improper Storage and Handling of Medications and Disposal System
Penalty
Summary
Surveyors observed that drugs and biologicals were not properly stored according to facility policy and accepted professional standards. During an inspection of a medication cart, multiple loose pills were found inside the cart, and a bottle of Drug Buster, used for medication disposal, was noted to have a brown substance on its exterior and on the bottom of the drawer where it was stored. The licensed nurse present confirmed the presence of the loose pills and the brown substance. The Assistant Director of Nursing later stated that the expectation was for loose pills to be destroyed and for any Drug Buster bottle with spilled contents to be discarded. The facility's policy requires nursing staff to maintain medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Follow Physician-Ordered No Added Salt Diet
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered No Added Salt (NAS) diet was served a packet of iodized salt with her lunch meal. The resident, who had a history of multiple fractures, chronic kidney disease, and hypertension, was admitted in February 2025 and had a care plan and physician's order specifying the NAS diet. Despite these orders, the resident received a salt packet on her meal tray, which she did not request. Observations and interviews confirmed that the meal ticket indicated the NAS diet, and both the Certified Nurse Assistant and Registered Dietician acknowledged that the resident should not have received extra salt. The Registered Dietician stated that nursing staff are expected to check meal trays before serving them to residents, and the Director of Nursing confirmed that prescribed diets should be followed. Facility policies also required that therapeutic diets be provided as ordered by the physician.
Call Light System Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for two residents. For one resident with dementia, gait abnormalities, and muscle weakness, the call light button was found on the floor, approximately three feet away from the bed, and the resident was unaware of its location. This resident required substantial to maximal assistance with daily activities and had a care plan intervention to reinforce the need to call for assistance. A certified nurse assistant confirmed the call light was not within reach and acknowledged it should have been accessible to the resident. For another resident with Alzheimer's disease, dementia, muscle weakness, and difficulty walking, the call light button was placed inside a bedside drawer about four feet from the bed. This resident was dependent on staff for most activities of daily living and had a care plan intervention to keep the call light within reach. A certified nurse assistant confirmed the call light was not accessible and stated it should have been within the resident's reach. Both the Director of Staff Development and the Director of Nursing confirmed that call light buttons should be accessible to residents, as outlined in the facility's policy.
Failure to Follow Enhanced Barrier Precautions During G-Tube Dressing Change
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow proper infection control practices during a dressing change for a resident with a G-tube. The resident, who had a history of dysphagia and cerebral infarction, was on Enhanced Barrier Precautions (EBP) as indicated in their care plan. The facility's policy required staff to don a gown and gloves for high-contact care activities, such as G-tube care, and to perform hand hygiene after glove removal and after contact with potentially contaminated surfaces. During the observed dressing change, the nurse did not wear a gown and did not perform hand hygiene after removing the old dressing or after removing gloves. The nurse confirmed these lapses during the interview. The infection preventionist also confirmed that these actions were not in accordance with facility policy and increased the risk of spreading infectious organisms.
Improper Food Storage and Thawing Practices
Penalty
Summary
The facility failed to adhere to professional standards of food safety in two significant instances. Firstly, four large cuts of pork loin were observed thawing improperly in a sink without running water. The Kitchen Supervisor confirmed this method of thawing, which did not comply with the facility's policy that requires meat to be thawed under running cold water. The Registered Dietitian emphasized the importance of proper thawing to prevent the growth of bacteria that could lead to foodborne illnesses. Secondly, during the same observation, expired food items, including a container of plain low-fat yogurt and a pre-cooked ham, were found in the walk-in refrigerator. The Kitchen Supervisor acknowledged that these items were past their expiration and use-by dates and should have been discarded. The Registered Dietitian reiterated that expired foods pose a risk of foodborne illness, aligning with the US Food and Drug Administration Food Code, which mandates that time/temperature control for safety refrigerated foods must be consumed, sold, or discarded by their expiration date.
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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