College Oak Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 4635 College Oak Drive, Sacramento, California 95841
- CMS Provider Number
- 056158
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at College Oak Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food was found improperly stored in the freezer, including unsealed bags of biscuits, enchiladas, and sausage patties that were exposed to the air and available for use. A heavy black residue was also observed around the inside door frame and piping area of the walk-in refrigerator, and staff including the DS, DA, MS, and RD stated they had not noticed the discoloration; facility policy required frozen foods to be stored in airtight moisture-resistant wrappers and refrigeration equipment to be routinely cleaned.
A resident with intact cognition was moved into another resident's room without a clear explanation, consent, or documentation of the reason for the transfer. Staff and leadership confirmed there was no record that either resident or the responsible party was notified, and the room change assessment and transfer form were not completed.
Failure to provide timely ordered pain medication affected two residents who reported significant pain. One resident with epididymitis waited hours after requesting oxyCODONE and described severe testicular pain that limited mobility, while another resident with breast cancer missed a PRN hydrocodone-acetaminophen dose overnight because staff said it was not available even though it was in the e-kit. The DON stated residents should be assessed and given ordered pain meds without waiting hours.
Improper Storage of OTC Medication: Surveyors found seven cough drops on a med cart stored in a clear plastic cup instead of the original package. An LPN confirmed the finding and stated there were no expiration dates on the cough drops. Another LPN and the DON stated OTC meds must be kept in their original packaging, and the facility policy required medications to remain in the packaging in which they were received.
A resident with anxiety disorder and bipolar disorder had a physician order for PRN Valium 5 mg. Nursing staff signed the medication out on the CDR but did not document the administration on the MAR, and the DON confirmed the MAR was inaccurate. The NS stated controlled drugs were expected to be documented in both the CDR and MAR when administered.
The facility failed to accurately account for controlled medications, leading to discrepancies between the Controlled Drug Record and medication blister cards for several residents. A resident's morphine sulfate solution was also improperly reconciled, with more liquid observed than recorded. The facility's policy on reporting discrepancies was not followed.
A facility failed to maintain a medication error rate below 5%, with errors observed in three residents. A resident received an incorrect mixture of ArgiMent AT, another did not have their pulse checked before medication administration and did not consume the full Glycolax dose, and a third received the wrong form of aspirin. These actions were contrary to the facility's policies on medication administration.
The facility failed to properly store and label medications, including an insulin pen without an open date, methadone tablets outside their original packaging, and a morphine sulfate solution in a mismatched box. These actions could lead to medication errors and resident exposure to expired medications.
The facility failed to maintain food safety and sanitation standards, as evidenced by debris on stove burners and improper food handling by a dietary staff member. The staff member used bare hands to handle parsley and continued plating food after scratching her back without washing her hands, increasing the risk of infection spread.
The facility failed to properly dispose of garbage and refuse, with a large amount of cardboard and miscellaneous items found around dumpsters. Despite regular pest control and garbage collection, maintenance did not keep the area clean, as observed over two days. The maintenance log showed several dates where the trash area was not marked as cleaned, contrary to facility policy.
The facility failed to maintain an effective infection prevention and control program, with deficiencies including inadequate TB screening, lack of Enhanced Barrier Precautions for residents with wounds, improper storage of medical equipment, and insufficient hand hygiene. These lapses increased the risk of infection spread among residents.
The facility failed to ensure call lights were within reach for two residents, compromising their ability to call for assistance. One resident, with multiple diagnoses including muscle weakness, had her call light on the floor, while another resident with severely impaired cognition had the call light wrapped under the bedrail. Both residents expressed difficulty in calling for help, and their care plans indicated the need for accessible call lights. The DON confirmed the importance of call light accessibility to prevent distress.
A facility failed to submit a discharge MDS for a resident within the required timeframe, as mandated by federal regulations. The MDS Coordinator confirmed the delay, acknowledging the need to adhere to submission deadlines. The facility's policy requires compliance with federal and state timeframes, as outlined in the RAI Manual, which specifies a seven-day submission period.
A resident with dementia, dependent on staff for care, was not assisted to participate in daily activities as outlined in their care plan. Observations showed the resident remained in bed, and staff confirmed the lack of documented activities or refusals, posing a risk to the resident's well-being.
A resident with obstructive and reflux uropathy had a Foley catheter without an active physician's order, as required by facility policy. Despite the presence of the catheter, no order was documented in the resident's records, confirmed by a licensed nurse. The Director of Nursing stated that an order should include care instructions and a diagnosis, but this was not present, placing the resident at risk for inadequate care.
A resident with Type 2 Diabetes and dysphagia was served a disliked food item, fish, despite documented preferences. This was confirmed by a CNA and the Dietary Supervisor, who acknowledged the oversight. The facility's policy emphasizes considering resident wishes, but it was not followed, potentially impacting the resident's nutritional status.
A resident in a long-term care facility, admitted for rehabilitation after hip and knee surgery, experienced severe pain rated at 8 out of 10. Despite a physician's order to administer two tablets of oxycodone 5 mg for severe pain, the LN on duty only provided one tablet. The DON confirmed the failure to follow the physician's order, as corroborated by the resident's MAR and care plan interventions.
Food Storage and Refrigerator Cleanliness Deficiencies
Penalty
Summary
Food was not stored and the kitchen environment was not maintained in a sanitary manner for a census of 112. During a concurrent observation and interview in the facility kitchen, three food items were found in the freezer in unsealed plastic bags: a plastic bag of 216 biscuits that was about one-third full, a large bag of 144 enchiladas in an open box, and a partial bag of 107 sausage patties. The Dietary Supervisor verified that the bags were unsealed and available for use. During observation of the walk-in refrigerator, a heavy black residue was seen around the inside door frame, with heavier residue toward the bottom and blackish residue on the putty around a pipe containing electrical wiring in the left corner of the refrigerator window. Dietary staff and the Dietary Supervisor stated they had not noticed the residue, and the Maintenance Supervisor verified the black colored residue around the door jam and pipes. The Registered Dietician stated she inspects the walk-in refrigerator monthly and had never seen the black discoloration, and facility policy stated frozen foods should be stored in airtight moisture resistant wrappers and refrigeration equipment should be routinely cleaned.
Failure to Notify Residents and Complete Room Transfer Assessment
Penalty
Summary
The facility failed to notify two residents of a room change and failed to complete a room transfer assessment after moving Resident 127 into Resident 32's room. Resident 127 was admitted with diagnoses including Type II diabetes with neuropathy and asthma, and her record showed she had capacity to understand choices and make health care decisions, with a BIMS score of 14 out of 15 indicating intact cognition. During interview, Resident 127 stated she was moved from her previous room without a clear explanation, was told only that the room needed cleaning and she would return afterward, and said she did not want to move. She also stated nursing staff and CNAs did not provide additional information, and she was later told the room had been reassigned for short-term residents. The ADON stated residents must consent before being moved and must be informed of the reason for any transfer, but she was unaware of the reason for Resident 127's room change. The SSD confirmed Resident 127 was relocated and that the room change assessment section was not completed, with no documentation of the reason for the transfer or evidence of consent, and she could not identify who initiated the move. Resident 32, who had diagnoses including epilepsy and Type II diabetes, stated she remembered Resident 127 moving into her room and was not informed by staff. The SSD verified there was no documentation that Resident 32's RP was notified, no record that Resident 32 was informed of the transfer, and the transfer form had not been initiated. The ADM confirmed the transfer occurred but could not provide who authorized it or why it happened.
Failure to Provide Timely Ordered Pain Medication
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not met for two residents who reported significant pain and did not receive their ordered pain medication when requested. Resident 3 was admitted with epididymitis and had a BIMS score of 15, indicating no cognitive deficits. His order was for oxyCODONE 10 mg by mouth every 6 hours as needed for pain. The MAR showed his last dose was given at 5:22 a.m. on 4/6/26, making the next dose due by 11:22 a.m. During interview, Resident 3 stated he requested his oxycodone before lunch but did not receive it until 1:59 p.m., two to three hours later. He described severe pain, saying it felt like someone was hitting him with a hammer on his testicle, and said the pain made it very difficult to move around and limited his mobility and independence. Resident 136 was admitted with breast cancer and had an order for hydrocodone-acetaminophen 5-325 mg by mouth every 4 hours as needed for pain management, with a hold parameter if respirations were less than 12. The MAR showed her last dose was given at 1:44 a.m. on 4/5/26. During interview, Resident 136 stated she requested pain medication during the night but was told it was not available, and she reported she did not sleep well and was in pain because the dose was missed. LN 2 confirmed that the resident did not receive the medication even though it was due and available in the e-kit, and stated nursing staff should have ensured pain medications did not run out and should have called pharmacy before running out to maintain adequate pain management. The DON stated that residents reporting pain should be assessed and given ordered pain medication without waiting hours, and if medication was not in the cart, staff should have obtained it from the e-kit and requested a refill from pharmacy.
Improper Storage of OTC Medication
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted professional principles and current standard of practice. During a concurrent observation and interview on the south medication cart, seven cough drops were found in a clear plastic cup and not in their original packaging. The Licensed Nurse present confirmed the cough drops were not in their original packaging and stated there were no expiration dates on them and that they should have been stored in the original package. During interviews, another Licensed Nurse stated over the counter cough drops needed to be stored in their original package and that if they were not, they could potentially be expired and not safe for residents. The Director of Nursing stated the expectation was for nursing staff to store all medications, including over the counter medications, in their original packaging, and that medications not stored in their original packaging and without expiration dates could potentially be expired and have reduced potency. The facility policy titled Medication Labeling and Storage stated medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received, and that only the issuing pharmacy is authorized to transfer medications between containers.
Inaccurate Documentation of Controlled Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one of 13 sampled residents when Resident 12’s Medication Administration Record (MAR) was inconsistent with the Controlled Drug Record (CDR). Resident 12 was admitted in March 2026 with multiple diagnoses including anxiety disorder and bipolar disorder. A physician’s order dated 4/7/26 directed Valium (Diazepam) 5 mg by mouth every 6 hours as needed for anxiety. A review of Resident 12’s MAR and CDR for March and April 2026 showed that nursing staff did not document Valium administration on the MAR when the medication was signed out from the CDR on 4/1/26 at 5:30 p.m. During a concurrent interview and record review, the DON confirmed the Valium use was not accurately documented on the MAR. The NS stated the expectation was for nursing staff to document in both the CDR and MAR when a controlled drug was administered, and that inaccurate documenting could potentially result in residents not getting accurate dosage of medication per physician’s order.
Controlled Medication Accountability Discrepancies
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for several residents, leading to discrepancies between the Controlled Drug Record (CDR) and the medication blister card (medcard). During a medication cart check, it was found that Resident 76's CDR for clonazepam and hydrocodone-apap showed more doses than were present in the medcard. Similarly, Resident 151's CDR for methadone hydrochloride and Resident 17's CDR for lacosamide also showed discrepancies. Licensed Nurse 5 confirmed that controlled medications should be signed out in the CDR when taken from the medcard, and the Director of Nursing stated that reconciliation should occur before administering medication. Additionally, a bottle of morphine sulfate solution for Resident 63 was not reconciled properly. The liquid in the bottle was observed to be at 24 ml, while the CDR indicated only 17 ml remained. The Pharmacist/Pharmacy Manager confirmed that manufacturers do not overfill containers, suggesting an error in reconciliation. The facility's policy requires any discrepancy in controlled substance medication counts to be reported immediately to the Director of Nursing, but this was not adhered to, resulting in inaccurate accountability of controlled medications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 17.86% during a medication pass observation. This involved five medication errors out of 28 opportunities for three residents. For Resident 7, a Licensed Nurse (LN) prepared an ArgiMent AT packet without measuring the liquid, resulting in a mixture exceeding the recommended amount. The facility's policy required the correct dose preparation, which was not followed. For Resident 204, LN 4 did not check the pulse rate before administering medications, which was necessary according to the resident's orders. Additionally, the resident did not consume the entire Glycolax mixture, leading to an incomplete dose. The facility's policy required verification of vital signs and ensuring the resident consumed all medications. For Resident 351, LN 8 administered the wrong form of aspirin, providing a chewable tablet instead of the prescribed enteric-coated form. The facility's policy required medications to be administered according to prescriber orders, which was not adhered to in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a medication cart check. An insulin pen was found without an open date, which is crucial for tracking its expiration, as confirmed by the Director of Nursing (DON). The facility's policy requires that nursing staff label insulin pens with the date they are opened. Additionally, methadone tablets were improperly stored outside their original packaging, which is necessary to maintain essential information such as the resident's name and expiration date. Furthermore, a bottle of morphine sulfate solution was found in a mismatched box, lacking the correct administration instructions. The medication administration instructions on the label did not match the medical doctor's order, as confirmed by the DON. The facility's policy mandates that medications be stored in their originally received containers to meet legal requirements. These deficiencies in medication storage and labeling could lead to medication diversion, errors, and resident exposure to expired medications.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. Thick, black, charcoal-like debris was found between all spokes of the two front gas burners on the facility's industrial stove, which was verified by the Dietary Manager (DM) during an initial tour of the kitchen. This indicates a lack of proper maintenance and cleaning of kitchen equipment, which is essential for ensuring sanitary food preparation. Additionally, a dietary staff member, referred to as [NAME] 2, was observed handling parsley with bare hands and placing it directly on resident plates, contrary to the facility's policy that requires the use of utensils or gloves when handling ready-to-eat food. Furthermore, the same staff member scratched her back and continued plating food without washing her hands, which was confirmed by the DM. The Registered Dietician (RD) also emphasized the importance of wearing gloves and washing hands after contact with clothing. These actions increased the risk of infection spread and compromised the sanitary preparation of food for the residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. A large amount of cardboard and miscellaneous items, including milk cartons, straws, sugar packets, plastic gloves, a coffee pot top, soft drink cans, a Christmas tree decoration, Styrofoam pieces, a metal tube, and zip lock bags, were found strewn around and under the garbage dumpsters at the back of the facility. This situation was observed during an interview with the Dietary Assistant Supervisor, who was unsure how long the trash had been there, suggesting it might have been a day or so. The Maintenance Supervisor indicated that pest control services the area once a month and that the dumpsters are emptied daily, with cardboard being collected three times a week. However, the maintenance team is responsible for keeping the area clean. Further observations revealed that the cardboard was still protruding from under the dumpster the following day. The Maintenance Assistant mentioned that they clean the area around 8:45 a.m. daily, provided there are no urgent tasks, and noted that the cardboard should be disposed of in the dumpster with the lid closed. A review of the facility's maintenance log showed several dates where the trash area was not marked as cleaned, and a note indicated that new trash cans were delivered late. The facility's policy and procedure document stated that maintenance is responsible for keeping the grounds free of litter and maintaining a safe and orderly environment around the buildings.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Three residents were not properly screened or tested for tuberculosis (TB) upon admission or annually, as required. Resident 3 had not received a TB test since the initial test in 2021, and there was no documentation of further testing or physician notification. Resident 8's records lacked evidence of a TB test or refusal documentation, and no chest X-ray was ordered to rule out TB. Resident 79 was not annually screened for TB, contrary to the facility's policy. Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds, increasing the risk of infection spread. Resident 9 and Resident 151, both with chronic wounds, did not have EBP signage outside their rooms, and staff did not wear gowns during wound care. The facility's policy required EBP for residents with wounds, but this was not followed, as observed during wound care procedures. Infection control practices were further compromised by improper storage of medical equipment and inadequate hand hygiene. Resident 201's nebulizer mask and the oxygen tubing for Residents 84 and 202 were found on the floor, posing a risk of contamination. Additionally, a Restorative Nursing Assistant (RNA) failed to perform hand hygiene between assisting multiple residents during lunch, and a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) for a resident on droplet precautions. These lapses in infection control practices increased the risk of spreading infections within the facility.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights were within reach for two residents, which is a deficiency in accommodating the needs and preferences of each resident. Resident 6, who was admitted with multiple diagnoses including aftercare following joint replacement surgery and muscle weakness, was observed with her call light on the floor and out of reach. Despite being cognitively intact and requiring partial assistance for activities of daily living, Resident 6 expressed difficulty in calling for help when the call light was not accessible. The care plan for Resident 6, dated prior to the observation, indicated that the call light should be within reach to mitigate fall risks related to impaired mobility. Similarly, Resident 307, who had severely impaired cognition and required substantial assistance for activities of daily living, was found with the call light wrapped under the bedrail and out of reach. During an interview, Resident 307 expressed discomfort due to the inability to call for help when needed. The care plan for Resident 307, which included a bladder re-training program, also specified that the call light should be within reach and answered promptly. The Director of Nursing confirmed that the call light should be accessible to prevent resident distress. The facility's policy on the call light system mandates that each resident should have a means to call a staff member directly.
Failure to Timely Submit Discharge MDS
Penalty
Summary
The facility failed to submit a Minimum Data Set (MDS) for a resident in a timely manner, as required by federal regulations. Specifically, the discharge MDS for a resident who was admitted in September and discharged on an unspecified date was not submitted to the Centers for Medicare and Medicaid Services (CMS) within the mandated seven-day timeframe. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged the delay and the need to adhere to submission deadlines. The facility's policy, revised in July, mandates compliance with federal and state submission timeframes as outlined in the Resident Assessment Instrument (RAI) Manual. The RAI Manual, dated October, specifies that discharge MDS must be submitted within seven days of completion.
Failure to Implement Resident's Care Plan for Activities
Penalty
Summary
The facility failed to implement a comprehensive and person-centered care plan for a resident diagnosed with dementia, who was totally dependent on staff for all care needs, including bed mobility, dressing, hygiene, and activities. The resident's care plan indicated that they should be up in a chair daily and out of the room for activities. However, multiple observations over several days revealed that the resident remained in bed and did not participate in any activities as outlined in their care plan. Interviews with staff, including a CNA and the Activities Director, confirmed that the resident was not assisted to get out of bed and participate in activities. The Activities Director also confirmed the absence of documented evidence of activities offered to the resident or any refusal by the resident to participate. This lack of adherence to the care plan posed a risk to the resident's ability to attain their highest practicable physical, mental, and psychosocial well-being.
Lack of Physician's Order for Foley Catheter
Penalty
Summary
The facility failed to meet professional standards of nursing practice for a resident who had a Foley catheter without an active physician's order. The resident was admitted with diagnoses including obstructive and reflux uropathy and an infection due to an indwelling catheter. Despite the presence of a catheter, there was no active order documented in the resident's records, including the Order Summary Report and the Medication Administration Record (MAR). This oversight was confirmed during an observation and interview with a licensed nurse, who acknowledged the absence of an active order for the Foley catheter. The Director of Nursing stated that an order for a Foley catheter should include catheter care instructions, the need for changing the catheter, and a diagnosis justifying its use. The facility's policy also required verification of a physician's order for catheter insertion. However, the resident's care plan, which mentioned the indwelling catheter, did not have an accompanying active order. This lack of documentation and adherence to policy placed the resident at risk for not receiving proper nursing care related to the catheter.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, leading to a deficiency in care. The resident, who was admitted in August 2024 with diagnoses including Type 2 Diabetes Mellitus, dysphagia, and long-term use of insulin, was served a food item they disliked. Specifically, during a meal observation, the resident was served a filet of breaded fish despite having a documented dislike for fish. This oversight was confirmed by both a Certified Nursing Assistant and the Dietary Supervisor, who acknowledged that the resident's food preferences were not respected. The Dietary Supervisor and the Director of Nursing both confirmed that not honoring food preferences could negatively impact the resident's nutritional status. The facility's policy on nutrition and unplanned weight loss emphasizes the importance of considering resident wishes and food intake in treatment decisions. However, in this instance, the facility did not adhere to its policy, resulting in the resident receiving a meal that did not align with their documented preferences.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to provide services according to professional standards of quality for a resident when the resident's pain medication was not administered per physician order. The resident, who was admitted for rehabilitation therapy after hip and knee surgery, reported severe pain rated at 8 out of 10. Despite the physician's order to administer two tablets of oxycodone 5 mg for severe pain, the Licensed Nurse (LN) on duty only provided one tablet. The Director of Nursing (DON) confirmed that the LN did not follow the physician's order, which was also corroborated by a review of the resident's Medication Administration Record (MAR) and care plan interventions. The facility's policy and procedure for administering medications, which requires medications to be administered as prescribed, was not adhered to in this instance.
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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