Corona Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Corona, California.
- Location
- 2600 South Main Street, Corona, California 92882
- CMS Provider Number
- 555566
- Inspections on file
- 61
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Corona Post Acute Center during CMS and state inspections, most recent first.
The facility failed to follow physician orders and timely respond to changes in condition for several residents. One resident with a coccyx wound debridement had multiple IV antibiotic doses undocumented as given on the MAR. Another resident with a UTI had an ordered IV Ceftriaxone dose not documented as administered, contrary to facility expectations for medication administration and physician notification. A resident reporting right ear pain had a physician-ordered ENT referral with no documented appointment scheduled for several days, despite ongoing pain. A cognitively intact resident with morbid obesity, CKD, and anemia had persistently poor PO intake documented over weeks after a short-term nutrition intervention, without a documented change of condition, RD reassessment, or care plan updates. Another resident with hemiplegia and dysphagia had a physician order for ST evaluation and treatment, but the evaluation occurred four days later, outside the facility’s stated 24–72 hour best-practice timeframe for therapy evaluations.
Surveyors found that the facility did not maintain linens, shower curtains, and privacy curtains in a clean, stain-free condition as required by its infection prevention and control program. During observations with the Director of Housekeeping and Laundry, shower curtains in two shower rooms were noted with black and brown discoloration, and a stained linen item was found folded on a shelf in the clean linen closet, ready for resident use. In a resident’s room, the IP identified a brown streak on the privacy curtain and confirmed it was an infection control issue. The DON stated that linens and curtains designated as clean are expected to be free of stains to support a clean environment and prevent infection, in line with the facility’s infection control policy.
A resident with BPH, urinary incontinence, and urinary retention had an indwelling Foley catheter ordered and documented in the medical record, but the care plan incorrectly listed neurogenic bladder as a related diagnosis. Review of physician documentation and diagnoses showed no evidence of neurogenic bladder, and both the MDS Supervisor and DON confirmed that this diagnosis was inaccurate and should not have been included in the care plan, resulting in an inaccurate medical record.
A resident with chronic kidney disease was discharged, and a written request for their medical records was submitted by the legal representative. The facility failed to provide access to the records within the required 48-hour timeframe, instead delaying the release for 27 days after forwarding the request to the legal department, which did not comply with regulatory requirements.
A resident with a history of spinal fusion and depression was discharged without the required physician documentation providing clinical rationale for the discharge. Although the resident was noted to benefit from continued care, a discharge notice was issued and the medical record did not include evidence that the resident no longer required facility services or that discharge was appropriate, as required by facility policy.
Two LVNs did not wear required gowns while administering medications via G-tube to two residents on Enhanced Barrier Precautions for MDROs, despite care plans and orders specifying the use of PPE for high-contact activities involving feeding tubes and indwelling devices. Both nurses acknowledged the requirement during interviews, and the facility's infection prevention policy confirmed the need for gowns and gloves in these situations.
A resident with a history of metabolic encephalopathy and right-sided hemiplegia, who required supervision with eating, was served a hot beverage by a CNA who failed to check the temperature as required by facility policy. The resident spilled the hot liquid, resulting in second and third degree burns to her right breast and shoulder, necessitating medical intervention. Staff interviews and documentation confirmed that the CNA was unaware of the temperature-checking requirement, and facility policy mandated hot beverages be served at or below 155°F.
Three residents experienced failures in timely assessment, monitoring, and follow-up of skin injuries and changes. One resident with burns did not receive prompt treatment or a specialist follow-up as recommended. Another resident with dementia and on anticoagulant therapy developed significant bruising that was not properly assessed or reported to a physician. A third resident with diabetic ulcers had worsening wounds that were not identified as a change in condition or communicated to the physician. These lapses were confirmed by staff interviews and documentation review.
A resident with ALS was unable to reach staff after her call light fell, and her family member's repeated phone calls to the facility went unanswered and unreturned. Interviews revealed that after-hours calls were not consistently answered or forwarded to residents, and two other residents also reported not receiving intended calls. The administrator acknowledged that calls should be answered and properly forwarded at all times.
A resident with spinal stenosis did not receive prescribed Hydrocodone because the medication was not reordered in advance, as required by facility policy. Nursing staff confirmed that the medication ran out and there was no documentation of a timely reorder, resulting in the pain medication being unavailable when needed.
A facility failed to provide a resident's medical records within the required 48-hour timeframe, resulting in a 14-business-day delay. The resident's legal representative requested the records with valid authorization, but the Medical Record Director did not follow up promptly with the legal team, causing the delay. This failure potentially denied the resident representative timely access to review records and make critical decisions.
The facility failed to provide pressure ulcer treatment as ordered for three residents. A resident with a Stage 4 ulcer was found without a dressing, and staff failed to ensure it was reapplied. Another resident with a similar condition also lacked a dressing, with poor communication among staff. A third resident at risk for ulcers did not receive consistent treatment, as an LVN signed off on care that was not provided. The DON and Administrator acknowledged the need for adherence to treatment orders.
A resident with hemiplegia was provided a wheelchair in poor condition, with burn holes and a torn armrest, by the facility. Staff interviews revealed that the wheelchair was mistakenly taken from a storage area meant for repairs, and the facility failed to ensure it was in good condition before use. The Director of Maintenance and Administrator acknowledged the error, and the Director of Nursing emphasized the expectation for well-maintained equipment.
A facility failed to refer a resident with bipolar disorder for a Level II PASRR screening. The resident was admitted with a negative Level I screening, which inaccurately indicated no serious mental illness. Despite the resident's medical history showing a bipolar disorder diagnosis, the facility did not identify this as an SMI. Interviews revealed that the MDS Coordinator was unaware of the inaccuracy, and the Director of Nursing was not involved in the PASRR process, leading to the oversight.
A resident with hemiplegia and hemiparesis was observed with long, dirty fingernails due to the facility's failure to provide adequate nail care. Despite the resident's request and the availability of nail trimmers, staff did not trim the resident's nails, citing an inability to locate the trimmers. Interviews revealed a lack of communication and awareness among staff regarding the resident's need for nail care.
A resident with COPD did not receive prescribed DuoNeb treatments due to a transcription error in the electronic health record, leading to infrequent administration. The nebulizer was not easily accessible, and staff failed to verify and double-check the order, resulting in inadequate respiratory care.
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. Staff did not follow the facility's policy or CDC guidelines, leading to the application of wound treatment with potentially contaminated gloves. Interviews revealed a lack of adherence to hand hygiene protocols, highlighting a significant lapse in infection prevention and control practices.
A resident with sepsis and enterocolitis experienced low blood pressure, recorded at 65/49, but was not reassessed or monitored while awaiting hospital transfer. Interviews revealed that the nursing staff failed to recheck the blood pressure, contrary to facility policy requiring documentation of condition changes.
A resident with Clostridium Difficile (C. diff) was placed on contact precautions, but the facility failed to provide disposable equipment, such as a stethoscope and sphygmomanometer, for the resident in isolation. This deficiency was confirmed by staff, including a CNA, RN, IP, and DON, who acknowledged the need for such equipment to prevent infection spread. The facility's policies emphasize the importance of dedicated equipment for residents on transmission-based precautions, but these were not followed, increasing the risk of infection transmission.
A legally blind resident with multiple medical conditions did not receive necessary assistance with meals, as observed during an unannounced visit. Despite care plan instructions for feeding assistance, staff left the resident's lunch tray without providing help. Interviews with staff confirmed a lack of adherence to the facility's policy on meal assistance.
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as per their policy. The process involved sending requests to the corporate office for approval, which took one to two weeks due to short staffing. This delay was identified during an unannounced visit, with requests pending approval and not fulfilled within the required timeframe.
A resident with Alzheimer's Disease was found with their call light out of reach during an unannounced visit. An LVN admitted the oversight occurred after repositioning the resident. The DON confirmed that staff are expected to ensure call lights are always accessible, as per facility policy.
A resident was exposed to pesticide vapor when the Maintenance Supervisor sprayed pesticide in the room while the resident was present, without notifying nursing staff or moving the resident. The facility's protocol requires residents to be relocated before such treatments, which was not followed, compromising the resident's safety and comfort.
A resident with a stage 4 pressure ulcer was not repositioned every two hours as required by their care plan. Observations showed the resident remained in the same position for over three hours. A CNA admitted to not repositioning the resident due to being busy, which was against the facility's policy and care plan directives.
The facility failed to maintain a clean and sanitary environment in two resident rooms. Observations revealed a brown splatter, dirty gloves, and dried blood in one room, and trash, food crumbs, and dust behind headboards in another. A resident confirmed the blood was from their toe, and the housekeeper admitted to not cleaning behind the headboards. A Registered Nurse verified the unclean conditions, which contradicted the facility's policy for a homelike environment.
A resident with depression and schizoaffective disorder was discharged to a hospital without receiving a written notice of transfer. The DON confirmed that the required Notice of Proposed Transfer/Discharge form was incomplete and not acknowledged by the resident, contrary to facility policy.
A resident reported feeling uncomfortable when a CNA touched her shoulder and breast without consent. The CNA admitted to the action, and the DON confirmed it violated the resident's rights to respect and dignity, as per the facility's policy.
A resident with paraplegia and a newly developed Stage 4 pressure ulcer was discharged to an assisted living facility without proper re-evaluation and communication of their condition. The receiving facility, unaware of the pressure ulcer, admitted the resident, who then required acute hospitalization due to the worsening condition.
The facility failed to properly manage and account for a resident's personal belongings, leading to missing items such as groceries, dentures, contact lenses, underwear, and a speaker. The Inventory of Personal Effects form was not properly filled out or signed by staff upon both admission and discharge, resulting in a deficiency in honoring the resident's right to a dignified existence and self-determination.
A resident with diabetes and dementia experienced significant weight loss due to the facility's failure to provide RNA feeding assistance as ordered. Staff often provided only set-up or clean-up assistance, and the resident's family had to step in to help with meals. The facility's policy required physical prompts and verbal cues, but these were not consistently provided.
Failure to Follow Physician Orders and Timely Respond to Changes in Condition
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders and to recognize and respond to changes in residents’ conditions. For one resident with a coccyx wound debridement, physician orders dated in late February directed administration of IV Meropenem every 12 hours until early March and IV Linezolid every 12 hours until a similar date. Review of the MAR showed no documentation that Linezolid was administered on several specified dates and times, and no documentation that a scheduled Meropenem dose was given on one evening. The Infection Preventionist confirmed that if a medication was not documented as administered in the MAR, it was considered not given. Another resident admitted with a UTI had a physician order for IV Ceftriaxone once daily for five days. Review of the eMAR showed that the 6 a.m. dose on one of the ordered days was not documented as administered. A RN confirmed the eMAR reflected that the dose was not given and stated the medication should have been administered as ordered and the physician notified of the missed dose. The DON stated that licensed nurses were expected to administer medications as ordered, document administration in the eMAR, and notify the physician when medications were not administered, and acknowledged that the facility’s process for following physician orders for medication administration was not followed. A separate deficiency involved a resident who reported right ear pain during a care conference and for whom a physician order and IDT note documented a referral to ENT for right ear issues. From the days following the order through a specified review period, there was no documentation that an ENT appointment was scheduled. The resident reported that several days had passed without any update on the appointment and that she continued to experience increased right ear pain. The Social Service Director, who was responsible for scheduling the ENT consultation, stated that the resident had been placed on the next six‑month ENT visit and acknowledged she should have asked the resident about seeing an outside physician and that not scheduling the resident for acute ear pain as soon as applicable had the potential to result in a delay in medical care and worsening pain. The Administrator confirmed there was no documentation that the ENT consultation was scheduled during the review period and stated the consultation should have been arranged in a timely manner. Another resident with morbid obesity, chronic kidney disease, and anemia had an MDS showing intact cognition and a nutritional assessment indicating the resident consumed mostly 25% of meals. An intervention was initiated for health shakes three times daily for 14 days, with instructions to monitor intake, skin, weight trends, and labs. Nutrition reports and meal intake documentation over several weeks showed ongoing poor intake, including multiple instances of 25–50% intake, 0–25% intake, and refusals. Despite this continued poor intake after the intervention was started and completed, there was no evidence of a documented change of condition, no reassessment by the RD, no ongoing nutritional monitoring, no progress notes reflecting deteriorating intake, and no care plan updates. Staff interviews confirmed that such intake patterns should have triggered a change of condition process and physician notification, and the DON stated the facility did not recognize and address the resident’s ongoing poor intake. For another resident admitted with hemiplegia and dysphagia, a physician order was placed for speech therapy evaluation and treatment on the date of admission. The resident’s history and physical indicated the resident did not have capacity to make medical decisions. The record showed that the speech therapy evaluation did not occur until four days after the order. The Speech Therapist stated residents are usually evaluated the day after an order, or on Monday if the order is placed on a weekend, and that this resident should have been evaluated earlier. The Director of Rehab stated that speech therapy evaluations are expected within one to two days of the order and acknowledged the evaluation was not timely. The ADON also stated that if a speech therapy order is placed on a Saturday, the resident should be evaluated by Monday and that this resident should have been evaluated sooner to ensure correct diet texture and prevent aspiration. Facility policy on therapy evaluations indicated evaluations should be completed as soon as possible, with a best practice of 24–72 hours, which was not met in this case.
Soiled Linens and Curtains Not Maintained Clean Under Infection Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program to ensure linens and environmental surfaces, including shower and privacy curtains, were maintained clean and free of visible soil. During an observation in the North shower room at 10:24 a.m., a shower curtain was noted with black stains and discoloration on the bottom; the Director of Housekeeping and Laundry (DHL) acknowledged it needed to be removed and washed. At 10:28 a.m., in the Medically Complex Unit shower room, another shower curtain was observed with brown stain discoloration, and the DHL again stated the curtain needed to be removed and washed. At 10:20 a.m., in the North clean linen closet, a linen item folded on the shelf and ready for resident use was observed with a visible stain mark, which the DHL stated should not be present and that the item needed to be discarded. At 10:52 a.m., in a resident’s room, the Infection Preventionist Nurse (IP) observed and acknowledged a brown streak stain on the resident’s privacy curtain, stating it should not have a stain, needed to be replaced, and that it was an infection control issue. Later, the Director of Nursing (DON) stated that clean linens in the clean linen closet, resident privacy curtains, and shower curtains should be clean and free from stain marks, and that the expectation is to maintain a clean and homelike environment and prevent the spread of infection, consistent with the facility’s Infection Prevention and Control Policy requiring a safe, sanitary environment with cleaning, disinfection, and linen handling procedures.
Inaccurate Diagnosis Documented in Catheter Care Plan
Penalty
Summary
The facility failed to ensure the accuracy of the medical record and care plan for one sampled resident when an incorrect diagnosis was documented. The resident was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, unspecified urinary incontinence, and urinary retention, and had an indwelling Foley catheter in place per physician orders and history and physical documentation. Review of the physician documentation and diagnoses showed no evidence that the resident had a diagnosis of neurogenic bladder. Despite the absence of this diagnosis in the medical record, the resident’s care plan documented that the resident had an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. During interview and concurrent record review, the MDS Supervisor stated that an MDS nurse had completed the care plan, confirmed that the resident did not have neurogenic bladder, and acknowledged that this diagnosis should not have been included. In a separate interview, the DON also confirmed that the resident did not have a diagnosis of neurogenic bladder and that its inclusion in the care plan was incorrect, stating the facility was responsible for ensuring the accuracy of residents’ medical records.
Delayed Release of Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide timely access to medical records for a resident who had been discharged with chronic kidney disease. The resident's legal representative submitted a written request for the resident's medical records, which was received by the Medical Records Director (MRD) on August 12, 2025. According to facility policy, records should have been released within 48 hours (two working days) of the request. However, the MRD forwarded the request to the facility's legal department, and the facility did not respond until September 8, 2025, resulting in a 27-day delay. The MRD confirmed that this delay did not comply with the regulatory requirement or facility policy for timely release of records.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that the physician documented the clinical rationale for the discharge of a resident who had been admitted with diagnoses including spinal fusion and depression. Record review showed that, as of June 1, the resident was recommended for follow-up imaging and was noted to benefit from continued care. Despite this, a Notice of Proposed Transfer/Discharge was issued, and subsequent documentation did not provide clinical justification that the resident no longer required facility services or that discharge was in the best interest of the resident's health and safety. Progress notes later stated the resident was independent and cleared for discharge, but lacked supporting clinical rationale from the physician. Interviews with facility staff, including the Social Service Director, Nurse Practitioner, and Director of Nursing, confirmed that discharge planning began with a physician order, but the medical record did not reflect the necessary assessment or documentation supporting discharge readiness. The facility's policy required that the basis for transfer or discharge be documented in the resident's clinical record by the attending physician, which was not done in this case.
Failure to Use PPE During G-Tube Medication Administration for Residents on Enhanced Barrier Precautions
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to implement required infection control practices for two residents who were on Enhanced Barrier Precautions (EBP) due to the presence of indwelling catheters, feeding tubes, and wounds. Both residents had care plans and physician orders specifying that staff must use gowns and gloves during high-contact care activities, including medication administration via G-tube. During observations, LVNs were seen entering the residents' rooms and administering medications through G-tubes without wearing the required isolation gowns, despite the established protocols and documented requirements in the residents' records. Interviews with the involved LVNs confirmed that they were aware of the need to wear isolation gowns but failed to do so, with one stating she forgot and the other acknowledging the requirement to protect residents and prevent infection spread. The Infection Preventionist also confirmed that staff are expected to follow the designated precaution protocols and use appropriate PPE as indicated. Facility policy reviewed further supported the necessity of gowns and gloves for high-contact activities involving device care, such as feeding tubes.
Failure to Ensure Safe Serving Temperature of Hot Beverages Resulting in Resident Burns
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) served a hot beverage to a resident without checking the temperature to ensure it was within a safe serving range. The resident, who had a history of metabolic encephalopathy and multiple strokes resulting in right-sided hemiplegia, required supervision and set-up assistance with eating. Despite these needs, the CNA heated water in a microwave, prepared tea, and served it to the resident without verifying the temperature, contrary to facility policy. The incident resulted in the resident spilling the hot beverage on herself, causing significant burn injuries to her right breast and shoulder. Documentation and interviews confirmed that the resident experienced severe pain and required medical intervention, including an emergency room visit and follow-up wound care for second and third degree burns. The resident's care plan indicated a need for assistance with eating, and staff interviews revealed that the CNA was unaware of the requirement to check beverage temperatures before serving, while another CNA confirmed that such checks were part of their training and policy. Facility policies reviewed specified that hot beverages must be served at or below 155°F and that temperatures should be measured with a calibrated thermometer prior to service. The Director of Nursing confirmed that the CNA did not follow this policy, leading to the resident's injury. The resident recalled not being warned about the hot beverage and did not remember if the spill was caused by staff or occurred after she awoke from a brief sleep.
Failure to Assess, Monitor, and Follow Up on Skin Injuries and Changes
Penalty
Summary
Three residents experienced failures in assessment, monitoring, and follow-up of skin conditions and injuries. One resident, with a history of metabolic encephalopathy and diabetes, sustained burn injuries from a hot beverage spill. Upon return from the hospital, there was no evidence that treatment for the burns was initiated or monitored for several days, and a follow-up appointment with a burn specialist, as recommended by the hospital, was not arranged in a timely manner. Documentation gaps were noted, and staff interviews confirmed that the treatment nurse was not informed of the incident until four days later, delaying necessary wound care and evaluation. Another resident, with dementia, diabetes, and on long-term aspirin therapy, developed significant bruising on both hands. The skin changes were identified by a CNA and reported to nursing staff, but there was no documented assessment, monitoring, or referral to a physician for further evaluation and treatment. The care plan and physician orders required monitoring for signs of bleeding and prompt reporting, but these steps were not followed. Staff interviews confirmed that the bruising was not properly assessed or documented, and the DON acknowledged that the required protocols were not adhered to. A third resident, with diabetes and peripheral vascular disease, had known diabetic ulcers on both feet. Over a two-week period, the size of the wounds increased, but this change in condition was not identified or communicated to the physician. Weekly wound documentation failed to note the progression, and staff interviews revealed that the increase in wound size should have been recognized as a change in condition and reported. The DON confirmed that the lack of timely communication and documentation could have led to a delay in appropriate care.
Failure to Ensure Timely Response to Resident Telephone Calls
Penalty
Summary
The facility failed to ensure that telephone calls for a resident were answered by staff, resulting in a lack of immediate access to the resident. During an unannounced visit, it was found that a resident with ALS, a progressive neurodegenerative disease, was unable to use her call light after it fell to the floor. She called out for assistance but received no response from staff. The resident then contacted a family member for help. The family member reported making multiple unsuccessful attempts to reach facility staff by phone over an 11-minute period, eventually being transferred to the nurses' station without the call being answered or receiving a callback. Interviews with facility staff revealed that after the receptionist left at 9 p.m., incoming calls were transferred to the Registered Nurse Supervisor, who stated that calls might not be answered immediately if she was attending to resident care. Additional interviews with two other residents indicated that calls intended for them were also not forwarded. The administrator confirmed that the expectation was for calls to be answered and forwarded appropriately during and after office hours.
Failure to Timely Reorder Pain Medication Resulting in Unavailability
Penalty
Summary
The facility failed to ensure that Hydrocodone, a strong pain medication, was reordered in a timely manner for a resident with spinal stenosis of the lumbosacral region. The resident was admitted with diagnoses that included this condition, which can cause significant pain, numbness, and weakness. On review of the resident's progress notes, it was found that Hydrocodone 5-325 was not administered as prescribed because the medication was not available on a documented date. Interviews with a Licensed Vocational Nurse (LVN) and the Registered Nurse Supervisor (RNS) confirmed that the medication was not reordered when only seven pills remained, as required by facility policy. Both staff members acknowledged that there was no documentation of a timely reorder, and the facility's policy indicated that medications should be ordered in advance. This lapse resulted in the resident not receiving the physician-ordered pain management regimen due to the unavailability of the medication.
Delayed Provision of Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records within the required 48-hour time frame, as mandated by their policy. The legal representative of a resident, who had been admitted with diagnoses including a pressure ulcer and diabetes mellitus, requested the resident's medical records on January 16, 2025, with a valid authorization dated January 8, 2025. Despite the facility's policy requiring records to be provided within 48 hours, the records were not delivered until February 5, 2025, which was 14 business days after the request was made. The Medical Record Director (MRD) acknowledged receiving the request on January 16, 2025, and instructed the Medical Record Assistant to forward it to the facility's corporate legal team. However, the MRD did not follow up with the legal team until January 22, 2025, resulting in a delay. The Administrator confirmed that the facility's protocol required records to be provided within approximately 48 hours, but the legal representative did not receive the records until February 5, 2025. This delay had the potential to deny the resident representative access to review records and delay critical legal or medical decision-making for the resident.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer treatment as ordered by the physician for three residents, leading to deficiencies in care. Resident #57, who was admitted with a Stage 4 pressure ulcer, did not have a dressing in place during an observation, despite orders to replace it as needed. The treatment nurse and CNAs were aware of the issue but failed to ensure the dressing was reapplied, and documentation was inconsistent with the actual care provided. Resident #63, also with a Stage 4 pressure ulcer, was found without a dressing during an observation. The CNA who provided care did not report the missing dressing to a nurse, and the treatment nurse expressed frustration over the lack of communication and follow-through. The facility's policy required that any nurse could replace the dressing if notified, but this protocol was not followed. Resident #160, at risk for pressure ulcers, had treatment orders for redness on the heels that were not consistently followed. The LVN responsible for the treatment admitted to signing the treatment administration record without actually providing the care, leading to missed treatments. The DON and Administrator acknowledged the expectation for staff to follow treatment orders and document care accurately, but these standards were not met in practice.
Facility Fails to Provide Safe Wheelchair for Resident
Penalty
Summary
The facility failed to provide a wheelchair in good condition for a resident, leading to a deficiency in maintaining a safe and homelike environment. The resident, who was admitted with conditions including hemiplegia and muscle wasting, was dependent on staff for transfers and used a wheelchair provided by the facility. Observations revealed that the wheelchair had multiple burn holes in the seat and a torn armrest with exposed foam, which posed a potential safety hazard. The resident's family confirmed that the wheelchair was provided by the facility, and the resident denied being a smoker, suggesting the damage was not self-inflicted. Interviews with facility staff, including a physical therapist, the Director of Maintenance, and the Administrator, revealed a breakdown in the process of ensuring wheelchairs were in good condition before being assigned to residents. The physical therapist acknowledged the wheelchair's poor condition but stated that cosmetic repairs were not their responsibility. The Director of Maintenance admitted that the wheelchair was not part of the facility's standard equipment and should not have been used. The Administrator confirmed that the wheelchair was mistakenly taken from a storage area meant for repairs and was not suitable for resident use. The Director of Nursing emphasized the expectation for equipment to be clean, well-maintained, and functional, highlighting the facility's failure to adhere to its own policies regarding wheelchair maintenance and safety.
Failure to Refer Resident for Level II PASRR Screening
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of bipolar disorder was referred for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted with a negative Level I screening, which incorrectly indicated that the resident did not have a serious mental illness (SMI). Despite the resident's medical history and hospital records indicating a diagnosis of bipolar disorder, the facility did not identify this as an SMI and did not refer the resident for the necessary Level II PASRR screening. Interviews with facility staff revealed a lack of awareness and oversight in the PASRR screening process. The MDS Coordinator, responsible for checking the accuracy of PASRR screenings, was unaware that the resident's Level I PASRR was inaccurate. The Director of Nursing stated he was not involved in the PASRR process, and the Administrator indicated that the Admission Director and MDS Coordinator were responsible for ensuring the accuracy of PASRR screenings. This oversight led to the failure to identify and refer the resident for appropriate mental health services.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who required assistance with activities of daily living. The resident, who had a medical history of hemiplegia and hemiparesis following a stroke, was observed with long and dirty fingernails. Despite the resident's request for nail trimming, the staff did not fulfill this need, citing a lack of available nail trimmers. The resident had previously purchased nail trimmers, but they were taken by the staff and not used to trim the resident's nails. Interviews with facility staff revealed a lack of communication and awareness regarding the availability of nail trimmers. Certified Nurse Aides and a Licensed Vocational Nurse were unaware of the resident's need for nail care, and the Director of Nursing and Administrator stated that nail trimmers were available in the utility room. However, the staff failed to locate and use them, resulting in the resident's unmet need for personal hygiene care.
Failure to Administer Respiratory Treatments as Ordered
Penalty
Summary
The facility failed to provide respiratory breathing treatments as ordered by the physician for Resident #15, who was diagnosed with chronic obstructive pulmonary disease (COPD). The resident was supposed to receive DuoNeb treatments every six hours for seven days, but the order was incorrectly transcribed into the electronic health record as every six hours every seven days. This transcription error led to the resident receiving the treatment only once since the order was initiated in December 2024. Observations and interviews revealed that the nebulizer machine was not readily accessible, being covered by personal items, and the medication cannister and tubing were dated 12/30/2024, indicating infrequent use. Despite the resident's complaints of shortness of breath, cough, and congestion, the treatments were not administered as frequently as ordered. The respiratory therapist renewed the order on 01/02/2025 but did not correct the scheduling error, resulting in continued inadequate treatment. Interviews with staff, including LVNs and the Director of Nursing, highlighted a lack of verification and double-checking of the orders entered into the electronic health record. The Director of Nursing and the Administrator acknowledged that the orders should have been verified and checked by another nurse to ensure accuracy. The failure to provide the prescribed respiratory care was due to a combination of transcription errors, oversight in order verification, and inadequate monitoring of the resident's treatment schedule.
Failure in Hand Hygiene and Glove Changes During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during wound and peri-care for two residents with Stage 4 pressure ulcers. The facility's policy on wound care and the CDC's recommendations for hand hygiene were not followed by the staff. Specifically, during the care of Resident #57, the Treatment Nurse and Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before proceeding with wound care. This resulted in the application of wound treatment with potentially contaminated gloves. Similarly, for Resident #63, the staff did not adhere to proper hand hygiene protocols. The Certified Nurse Aide did not change gloves or perform hand hygiene after providing incontinence care and before assisting with wound care. The Treatment Nurse also failed to perform hand hygiene between glove changes while treating the resident's sacral wound and an additional open area on the resident's back. These actions were contrary to the facility's policy and CDC guidelines, which emphasize the importance of hand hygiene before and after glove use and between different care tasks. Interviews with the staff, including the Treatment Nurse, Certified Nurse Aides, Licensed Vocational Nurses, the Director of Nursing, and the Administrator, revealed a lack of adherence to hand hygiene protocols. The staff acknowledged the need for hand hygiene before and after care and between glove changes, but their actions during the observed care did not reflect this understanding. The deficiency highlights a significant lapse in infection prevention and control practices within the facility.
Failure to Reassess and Monitor Low Blood Pressure
Penalty
Summary
The facility failed to reassess and monitor the vital signs of a resident who was experiencing low blood pressure, which was initially recorded at 65/49. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who had been admitted with diagnoses including sepsis and enterocolitis, showed a change in condition on November 5, 2024, when abnormal vital signs were noted. Despite receiving an order to transfer the resident to a hospital for further evaluation, there was no documentation of any reassessment or monitoring of the resident's blood pressure while waiting for the transfer. Interviews with the Director of Nursing and nursing staff revealed that the licensed nurse did not recheck the resident's blood pressure after the initial low reading, despite acknowledging that it should have been done. The facility's policy required documentation of changes in a resident's condition, but there was no record of reassessment or interventions provided to the resident. This lack of action and documentation could have delayed prompt response to the resident's condition.
Inadequate Infection Control for Resident with C. diff
Penalty
Summary
The facility failed to implement proper infection control practices for a resident diagnosed with Clostridium Difficile (C. diff), a highly contagious bacteria. The resident was readmitted to the facility with enterocolitis due to C. diff and was placed on contact precautions. However, during an observation and interview, it was noted that disposable equipment, such as a stethoscope and sphygmomanometer, was not readily available for the resident in isolation. This lack of designated disposable equipment was confirmed by a Certified Nursing Assistant (CNA), a Registered Nurse (RN), the Infection Preventionist (IP), and the Director of Nursing (DON), all of whom acknowledged that such equipment should be available to prevent the spread of infection. The facility's policy and procedure documents, including those titled 'Clostridium Difficile' and 'Isolation-Categories of Transmission Based Precautions,' emphasize the importance of using dedicated equipment for residents on transmission-based precautions to prevent the transmission of infections. Despite these guidelines, the facility did not ensure that the necessary disposable equipment was available for the resident, increasing the risk of spreading the infection to other residents and staff. This oversight highlights a deficiency in the facility's infection prevention and control program.
Failure to Assist Legally Blind Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with meals to a resident, who was legally blind and had multiple medical conditions including type 2 diabetes mellitus, anxiety disorder, coronary artery dissection, and hypertensive heart disease. The resident's care plan indicated a need for assistance with feeding due to her inability to read the menu and her risk for aspiration related to difficulty swallowing. Despite these documented needs, during an unannounced visit, it was observed that a staff member placed the resident's lunch tray in front of her and left the room without providing the required assistance. Interviews conducted with the resident, a CNA, an RN, and the DON revealed a lack of adherence to the facility's policy on meal assistance. The resident expressed her inability to read the menu and her reliance on others to inform her about the meals. The CNA admitted to not knowing if the resident was aware of what was being served, while the RN acknowledged that assistance should be provided to someone who is blind. The DON confirmed that assistance should have been given to the resident, as per her care plan and the facility's policy, which mandates that residents receive meal assistance tailored to their individual needs.
Delayed Medical Records Requests
Penalty
Summary
The facility failed to provide requested medical records for four residents within the 48-hour timeframe as stipulated by their policy and procedure. The process for obtaining medical records involved the requestor filling out a form, which was then sent to the corporate office for approval. This process was confirmed by both the Medical Records Assistant and the Medical Records Director, who stated that it typically took one to two weeks to fulfill a request. This delay was attributed to the medical records department being short-staffed, which resulted in the department falling behind in processing requests. The deficiency was identified during an unannounced visit to the facility, where it was found that requests for medical records for four residents were pending approval at the corporate office. These requests had been received between August 12 and August 20, 2024, but had not been fulfilled within the required timeframe. The Interim Administrator acknowledged that the medical records department was expected to complete requests within 48 hours, as per the facility's policy. The facility's policy, revised in November 2009, stated that residents could access their records within 48 hours of a request, excluding weekends and holidays.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was within reach for one of the sampled residents, identified as Resident 3. During an unannounced visit, it was observed that Resident 3, who has Alzheimer's Disease, was in bed with the call light clipped to her pillowcase and hanging off the left side of her bed, making it inaccessible. A Licensed Vocational Nurse (LVN) confirmed the call light was out of reach and admitted it was due to not repositioning the call light after the resident was repositioned. The Director of Nursing stated that the expectation is for nursing staff to ensure call lights are always within reach of residents. The facility's policy, revised in September 2022, also indicates that call lights should be accessible to residents when in bed.
Pesticide Application Conducted with Resident Present in Room
Penalty
Summary
The facility failed to provide a safe and comfortable environment for a resident when pest treatment was conducted while the resident was inside the room. On August 20, 2024, an observation was made of the resident lying in bed, unresponsive to interview questions. The Maintenance Supervisor admitted to spraying pesticide inside the resident's room while the resident was present, stating that the spray was not toxic to humans and only a small amount was used. The Maintenance Supervisor did not move the resident or consult with the visitor present at the time before proceeding with the pesticide application. The facility's Administrator stated that the protocol for spraying pesticides in resident rooms includes moving the resident out and deep cleaning the room afterward. The Administrator expected the Maintenance Supervisor to notify nursing staff before spraying so that residents could be relocated. However, Registered Nurse 1 was unaware of the pesticide application in the resident's room and would have expected to be informed to move the resident out to prevent direct exposure. The facility's policy on maintaining a homelike environment emphasizes providing a safe, clean, and comfortable setting, which was not adhered to in this instance.
Failure to Reposition Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident with an existing stage 4 pressure ulcer was repositioned at least every two hours, as outlined in the resident's care plan. Observations on a specific day revealed that the resident remained in the same position on her back with the head of the bed elevated at 30 degrees for over three hours, from 9:50 a.m. to 12:59 p.m. This was contrary to the care plan's directive to turn and reposition the resident at least every two hours to minimize skin impairment. During an interview, a CNA assigned to the resident admitted to not repositioning the resident during the observed period, citing being busy as the reason. The facility's policy on repositioning, revised in May 2013, emphasizes the importance of repositioning immobile residents every two hours to prevent skin breakdown and promote circulation. The Director of Nursing confirmed that the expectation is for nursing staff to adhere to the care plan's repositioning schedule.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in two of four resident rooms, as observed during an unannounced visit. In one room, a brown-colored splatter of an unknown substance was found on the window wall, dirty gloves were on the floor outside of the trash can, and three dried drops of blood were on the floor near Bed B. A resident in this room confirmed that the blood was from their toe but could not specify how long it had been there. The housekeeper admitted that she had not yet cleaned this room on the day of the observation. In another room, trash, food crumbs, and dust were found behind the headboards of Beds A and B, despite the housekeeper stating that she had already cleaned the room. The housekeeper acknowledged that she had not cleaned behind the headboards, which she should have done. A Registered Nurse verified the unclean conditions and expressed that the room should have been cleaned better. The facility's policy, titled 'Homelike Environment,' emphasizes providing a clean, sanitary, and orderly environment, which was not adhered to in these instances.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to a resident and their representative, as required by regulations. This deficiency was identified during a review of the records for a resident who was admitted with diagnoses including depression and schizoaffective disorder. The resident was discharged to an acute hospital for psychiatric evaluation and medication management, but there was no documentation indicating that a written notice of transfer was provided to the resident or their representative. The Notice of Proposed Transfer/Discharge form was incomplete, with no entries for the name or relationship of the person notified, and no indication that it was mailed to a representative. During interviews, the Director of Nursing (DON) confirmed that the licensed nurses are responsible for providing the Notice of Proposed Transfer/Discharge form to the resident upon transfer. However, the form was neither signed nor dated by the resident, indicating that the notice was not acknowledged. The DON acknowledged that the licensed nurse who facilitated the transfer should have ensured the resident received a written notice. The facility's policy, revised in December 2016, mandates that residents and their representatives be notified in writing of the reasons for transfer or discharge and the facility's bed-hold policy.
Violation of Resident's Personal Space and Dignity
Penalty
Summary
The facility failed to protect a resident's personal space and dignity when a Certified Nursing Assistant (CNA) touched the resident on the shoulder near her breast without her consent, making her uncomfortable. The incident was reported by the resident, who stated that the CNA entered her room, started rubbing her shoulder, and moved down to her breast. The resident did not ask for this contact and felt uncomfortable, leading her to remove the CNA's hand and tell him to stop. The resident's medical records indicated she had no cognitive impairments and was alert and oriented at the time of the incident. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) confirmed the resident's account. The CNA admitted to touching the resident without asking for permission, and the DON acknowledged that this action violated the resident's rights to respect and dignity. The facility's policy on Resident's Rights, which mandates treating all residents with kindness, respect, and dignity, was not followed in this instance.
Failure to Re-evaluate Discharge Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to re-evaluate and modify Resident A's discharge plan when the resident developed a Stage 4 pressure injury. Resident A, who had paraplegia, was admitted to the facility with a history of skin conditions. On May 19, 2023, Resident A's fragile scar tissue on the coccyx reopened, resulting in a Stage 4 pressure ulcer. Despite this significant change in condition, the facility did not update the discharge plan or communicate the presence of the pressure ulcer to the accepting assisted living facility, which does not provide extensive medical care. The Assisted Living Assistant Administrator (AA) stated that she was not informed about Resident A's pressure ulcer and would not have admitted the resident if she had known about it. The AA confirmed that the facility staff had assured her that Resident A had no wounds. Consequently, Resident A was discharged to the assisted living facility on May 28, 2023, and had to be transferred to an acute hospital two days later due to the worsening of the pressure ulcer. Interviews with the facility's staff, including the Registered Nurse (RN), Director of Nursing (DON), and Social Service Assistant (SSA), revealed that there was a lack of communication and documentation regarding Resident A's pressure ulcer. The SSA, responsible for discharge planning, was unaware of the pressure ulcer and did not inform the assisted living facility. The DON acknowledged that the discharge plan should have been re-evaluated and updated, and the RN confirmed that the Interdisciplinary Team (IDT) should have coordinated the discharge plan modification. The facility's policy on transfer and discharge was not followed, leading to an unsafe discharge for Resident A.
Failure to Properly Manage and Account for Resident's Personal Belongings
Penalty
Summary
The facility failed to properly manage and account for the personal belongings of Resident A, leading to a deficiency in honoring the resident's right to a dignified existence and self-determination. Resident A, who was discharged from the facility, reported missing several personal items including groceries worth $193, dentures, contact lenses, underwear, and a speaker. The facility's documentation process for personal belongings was found to be inadequate, as the Inventory of Personal Effects form was not properly filled out or signed by staff upon both admission and discharge. This lack of documentation and accountability was confirmed through interviews with various staff members, including the Medical Records Director, Licensed Vocational Nurse, Registered Nurse, and Social Service Director, all of whom acknowledged the failure to follow the facility's policies and procedures for managing personal belongings. The report highlights that the facility's policy required the inventory of personal belongings upon admission and discharge, but this was not adhered to in Resident A's case. The staff failed to document and verify the items returned to Resident A or her representative, leading to the loss of personal property. Interviews with staff members revealed that the process for managing personal belongings was not consistently followed, and there was no proper documentation or signature to confirm the items returned. This failure in procedure resulted in Resident A feeling disrespected and undignified due to the mishandling of her personal property.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide care and services for activities of daily living (ADLs) for a resident when feeding assistance was not provided according to the physician's orders and plan of care. The resident, who had diagnoses including diabetes mellitus and dementia, was admitted to the facility with fluctuating capacity to understand and make decisions. The resident had a physician's order for RNA feeding assistance for breakfast, lunch, and dinner, but this assistance was not consistently provided, leading to a significant weight loss of five pounds in one month. Observations and interviews revealed that the resident often consumed only 0-25% of her meals and was mostly provided with set-up or clean-up assistance rather than the required feeding assistance. Staff members, including CNAs and LVNs, acknowledged that the resident would benefit from RNA feeding assistance to increase meal intake but admitted that such assistance was not consistently provided. The resident's family member also reported that meal trays were often left uncovered without staff present to assist, and the family member had to step in to help when available. The facility's policy indicated that residents on the Restorative Dining Program should receive physical prompts and verbal cues to facilitate maximum potential in feeding. However, the documentation and staff interviews confirmed that the resident did not receive the necessary feeding assistance as ordered, contributing to her poor oral intake and weight loss. The interim Director of Nursing and other staff members acknowledged the deficiency and the importance of providing the ordered feeding assistance to prevent further weight loss.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
