Corona Regional Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Corona, California.
- Location
- 730 Magnolia Avenue, Corona, California 92879
- CMS Provider Number
- 555390
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Corona Regional Medical Center D/p Snf during CMS and state inspections, most recent first.
Two residents with respiratory failure and documented ROM limitations did not receive ordered ROM devices and splinting. One resident, who had orders for towel rolls in both hands each day shift, was observed in bed without the hand rolls; the RNA stated she had provided a shower and forgot to replace them, despite being responsible for their application. Another resident, with an order for a left elbow extension splint to be applied daily, was observed without the splint; the RNA reported being unaware of the order and noted no elbow splint was present in the resident’s splint storage bag. Facility policy states that RNAs must carry out restorative programs, including splinting and orthotic application, according to the written plan of care.
A nurse failed to administer a resident’s scheduled 10:00 a.m. medications within the facility’s required one‑hour before/after window, instead giving multiple routine drugs (including vitamin supplements, benztropine, esomeprazole, and quetiapine) via gastric tube at 12:08 p.m. The nurse reported being behind on the med pass due to attending to other residents’ dressing changes and PRN needs, and stated that all other licensed nurses were busy and unable to assist. The DON confirmed that facility policy requires medications to be administered within one hour before and one hour after the scheduled time.
A resident with multiple complex conditions and no decision-making capacity had a physician order for Tylenol #3 for pain while the resident’s responsible party was present and involved in requesting pain management. After the pharmacy reported that Tylenol #3 was not recommended due to a documented hydrocodone allergy, the RN contacted the physician, who changed the order to tramadol 50 mg via G-tube as needed. The RN and nurse manager confirmed that the resident’s representative was not informed of this medication change, contrary to facility policy requiring notification of representatives about changes in care and services.
A resident with multiple complex conditions, including chronic respiratory failure, tracheostomy with ventilator dependence, hemiplegia, and vascular dementia, had a documented sacral pressure area that had reopened and was being treated per physician orders with cleansing, Triad cream, and dry dressings. However, the Quarterly MDS assessment for the same time frame recorded that the resident had no unhealed pressure ulcers and was not receiving pressure ulcer care. During an interview and record review, the NM confirmed the discrepancy between the wound care documentation and the MDS, acknowledging that the assessment did not accurately reflect the resident’s pressure ulcer status as required by the RAI Manual.
A resident with complex medical conditions and impaired decision‑making capacity was given a shower and skin check by a CNA/RNA, who documented routine care and application of triad barrier cream to abdominal folds but reported no abnormal findings. Later that day, an ER photograph showed a skin tear on an abdominal fold covered with cream, and a subsequent hospital admission assessment documented a left abdominal fold skin tear present on arrival. The CNA/RNA and nurse manager acknowledged that this skin tear met the facility’s criteria for an abnormal finding that should have been identified and reported under the CNA job description and the facility’s skin care policy, but it was not reported at the time of care.
A resident with chronic respiratory failure, tracheostomy, and ventilator dependence had multiple months of IDT Monthly Meeting Notes documenting use of two locked bedrails for "seizure activity" and whole body jerking while coughing or during suctioning, despite no seizure diagnosis in the medical record. During interviews, the Director of Subacute and the Nurse Manager confirmed there was no documented seizure diagnosis and that the notes inaccurately described restraint use. The Director reported that the MDS nurse did not adequately customize the IDT notes to reflect the resident’s actual clinical status, resulting in medical record documentation that did not accurately represent the resident’s condition, contrary to facility policy requiring accurate records.
Surveyors found that the facility did not provide documentation of annual fuel quality testing for its emergency generators, with the last available record being nearly two years old. This deficiency affected all residents and multiple smoke compartments, and had been previously cited during a prior survey.
Surveyors found that the facility did not provide documentation of required emergency preparedness exercises, including an annual full-scale community-based exercise and an additional annual exercise, as required by federal regulations. This deficiency affected all residents in the facility and was identified during a Life Safety Code recertification survey.
The facility did not conduct required monthly inspections of its automatic sprinkler system components, with 8 out of 12 inspection records missing and only quarterly inspections being performed. Additionally, a corroded sprinkler head was found in a dining area, and facility leadership was unaware of its condition. These deficiencies affected all residents and smoke compartments in the facility.
The facility did not conduct or document quarterly fire drills for all required shifts, with missing records for certain AM and PM shifts. Staff confirmed that while drills were performed in various departments, some were not properly recorded, affecting all residents.
The facility did not correct or document resolution of deficiencies found during the annual inspection of its medical gas and vacuum system, including leakage, loose outlets/inlets, a zone valve box needing cleaning, and missing caution labels, affecting all residents and smoke compartments.
The facility did not review or update its Emergency Operations Plan within the required annual timeframe, as the last update was over a year prior. The Director of Plant Operations believed the review was required every two years, following hospital guidelines, rather than annually as required for LTC facilities. This deficiency affected all patients in the facility.
A smoke detector in a hallway near Nurse Station 1 and resident rooms failed to activate the fire alarm system during a functional test using smoke detector test spray. The Director of Subacute was unable to provide an explanation for the failure, which affected 24 of 59 residents in one smoke compartment.
Surveyors found that corridor doors, including those to the SNF Nurse Manager office and a storage room, did not latch upon self-closing as required. This deficiency affected multiple residents and a smoke compartment, and facility leadership was unaware of the issue at the time of the survey.
A LVN did not verify nasogastric tube (NGT) placement before administering medication to a resident with a history of postpartum cardiac arrest. The LVN attempted to aspirate for gastric residual but, finding none, proceeded to give medications without further placement verification, contrary to facility policy and care plan instructions.
A vial of Ativan 2 mg was found stored in the medication refrigerator past its expiration date. The NM confirmed expired medications should be removed to prevent administration, and the DON acknowledged staff failed to identify and remove the expired vial as required by facility policy.
Surveyors observed two expired fruit cups and one unlabeled fruit cup stored in the kitchen refrigerator, all readily available for use. The DNS confirmed that these items should have been labeled and discarded according to facility policy. At the time, two residents were on an oral diet.
An LVN did not follow the required two-minute contact time when disinfecting a shared glucometer with Sani cloth wipes before and after use on a resident. The LVN acknowledged not adhering to the manufacturer's instructions, and both the DSD and DON confirmed that staff are expected to follow these guidelines for proper infection control.
The facility failed to implement necessary interventions for turning and repositioning a dependent resident, leading to an increased risk of pressure injuries. Documentation showed significant gaps in repositioning, and interviews confirmed that if it was not documented, it was not done. The resident had a pressure injury that required consistent care, highlighting a deficiency in the facility's practices.
Failure to Follow Physician Orders for ROM Devices and Splinting
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for range of motion (ROM) and positioning devices for two residents with significant functional limitations. One resident, initially admitted with respiratory failure and documented functional limitations in ROM of both upper and lower extremities, had physician orders for a left and right towel roll in each hand every day shift. On observation, this resident was in bed with upper extremities flexed on the chest and no hand rolls in either hand. During interview, the Restorative Nursing Assistant (RNA) confirmed the resident was supposed to have towel rolls in each hand and stated she had given the resident a shower that morning and forgot to replace the towel rolls, acknowledging she was responsible for placing them. The second resident, also admitted with respiratory failure and documented functional limitations in ROM of all extremities, had a physician order for nursing/RNA to manage a left elbow extension splint up to four hours as tolerated each day shift. On observation, this resident was in bed with the left upper extremity extended at the side and no elbow splint in place. During interview, the RNA stated she was not aware the resident had a left elbow splint and reported that all splints were kept in a mesh bag, but there was no elbow splint present. Review of the facility’s Restorative Nursing Assistant Program policy indicated the facility is responsible for providing maintenance and restorative programs and that the RNA carries out programs according to the written plan of care, including splinting and application of orthotics and braces.
Late Administration of Scheduled Medications Outside Required Time Window
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the facility’s required 60‑minute window around the scheduled time for one resident. During a medication pass observation on March 11, 2026, at 11:18 a.m., LVN 1 prepared multiple 10:00 a.m. medications for Resident 3, including ascorbic acid 500 mg, benztropine mesylate 0.5 mg, cranberry 250 mg, esomeprazole 40 mg, lactobacillus, a multivitamin and mineral 15 ml, and quetiapine 100 mg. These medications, ordered for administration at 10:00 a.m. per the resident’s Order Summary Report and March 2026 MAR, were not actually administered via gastric tube until 12:08 p.m., more than two hours after the scheduled time and outside the facility’s one‑hour before/after administration window. Resident 3’s face sheet showed an admission with diagnoses including respiratory failure, and the medications observed were part of her routine 10:00 a.m. regimen. During interview, LVN 1 stated that nurses are expected to administer medications within one hour before and one hour after the scheduled time and acknowledged being behind on the 10:00 a.m. med pass due to attending to other residents who required a dressing change and PRN medication. LVN 1 reported that if falling behind, he would ask other licensed nurses for help but that they were all busy. In a separate interview, the DON confirmed that licensed nurses are expected to administer medications within one hour before and one hour after the scheduled time, consistent with the facility’s written Medication Administration – General Guidance policy dated July 2025.
Failure to Notify Resident Representative of Pain Medication Change
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to have their designated representative informed of significant changes in care, specifically a change in prescribed pain medication. Resident 1, who lacked decision-making capacity and had her daughter designated as responsible party, was admitted with multiple serious medical conditions including chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, ventilator dependence, hemiplegia, hemiparesis, and vascular dementia. On one date, a physician made rounds while the responsible party was at the bedside and, at the responsible party’s request for pain management, ordered Tylenol #3 (acetaminophen-codeine) for pain. This order was faxed to the pharmacy. The pharmacy notified the RN that Tylenol #3 was not recommended due to the resident’s documented allergy to hydrocodone. The RN then contacted the physician, who changed the order from Tylenol #3 to tramadol 50 mg via G-tube every 12 hours as needed for moderate to severe pain. The RN acknowledged that the responsible party was not notified of this change in medication from Tylenol #3 to tramadol, despite the facility’s process and policy requiring that resident representatives be informed of changes in condition, care, and services, and the policy on patient rights stating that patients and their designated representatives have the right to participate in decisions regarding care and to receive information necessary for informed consent or refusal.
Inaccurate MDS Documentation of Pressure Ulcer Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Comprehensive MDS assessment accurately reflected the resident’s current pressure ulcer status. The resident had been admitted with multiple serious medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia/hemiparesis, and vascular dementia, and lacked capacity to make decisions, with a daughter designated as responsible party. A wound care note dated May 19, 2025 documented a sacral fragile skin scar tissue reopening, measuring 3 cm in length, 1 cm in width, and 0.1 cm in depth, and included a physician’s order to cleanse with normal saline, apply Triad cream, and cover with a dry dressing for 30 days. Despite this documented wound and active treatment orders, the Quarterly MDS assessment for the same period indicated that the resident had no unhealed pressure ulcer injuries and was not receiving pressure ulcer care. During a concurrent interview and record review on February 18, 2026, the Nurse Manager confirmed that the wound care note showed a reopened pressure ulcer with specific treatment orders, and acknowledged that the MDS assessment did not reflect the resident’s actual pressure ulcer status. The Nurse Manager also stated that the facility follows the federal mandate for MDS assessments, and the cited RAI Manual language emphasized that MDS information must cover the specified observation period and be validated for accuracy by the IDT, which did not occur in this case.
Failure to Identify and Report Abdominal Skin Tear During CNA Skin Check
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a non‑pressure related skin impairment received appropriate treatment and services in accordance with professional standards of practice. The resident had multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia, hemiparesis, and vascular dementia, and lacked decision‑making capacity, with her daughter designated as responsible party. On the day of transfer to an acute care hospital, CNA documentation in the electronic medical record indicated that the resident received a complete linen change, face care, peri care, and a shower. During a concurrent interview and record review, the CNA/RNA who assisted with the shower stated that facility process requires CNAs to perform skin checks during incontinent care, bed baths, and showers, and to report abnormal findings to the wound care nurse or charge nurse. The CNA/RNA reported that she performed a skin check during the shower and noted no abnormal findings to report, and that she applied triad barrier cream to the resident’s abdominal folds. However, a photograph taken later that day in a general acute care hospital emergency room showed a skin tear covered with white cream on an abdominal fold, which the CNA/RNA acknowledged would have been an abnormal finding that should have been reported to the wound care nurse and that she had not identified during the shower. Subsequent review with the SNF nurse manager and the wound/ostomy nurse from a second acute care hospital confirmed that the resident arrived at the hospital with a left abdominal fold skin tear. The second hospital’s admission process included a skin assessment and photograph of the left abdominal fold skin tear, and the wound/ostomy nurse identified it as such. The SNF nurse manager, after reviewing the hospital photographs, stated that the photos indicated a left abdominal skin tear and that CNAs are expected to identify and report such abnormalities during routine skin checks. The facility’s CNA job description and the skin care and pressure injury prevention policy both require CNAs to monitor and report noticeable changes in residents’ skin condition and to routinely assess for signs of irritation or breakdown, which did not occur in this instance.
Inaccurate IDT Documentation of Restraint Use and Clinical Status
Penalty
Summary
The facility failed to ensure that Interdisciplinary Team (IDT) notes accurately reflected a resident’s current status, resulting in discrepancies in the medical record. The resident was initially admitted with chronic respiratory failure with hypoxia, a tracheostomy, and ventilator dependence, and was later discharged to a general acute care hospital. Review of the IDT Monthly Meeting Notes for multiple months showed documentation of restraints described as two bedrails raised and locked while in bed for seizure activity and whole body jerking while coughing or while being suctioned. However, there was no documented evidence in the medical record that the resident had a diagnosis of seizures from admission through discharge. During an interview and concurrent record review with the Director of Subacute and the Nurse Manager, it was confirmed that the medical record did not contain a seizure diagnosis for the resident, despite the repeated references to seizure activity in the IDT Monthly Meeting Notes. The Director of Subacute stated that the IDT notes inaccurately reflected the resident’s restraint usage by citing a seizure diagnosis instead of documenting the use of two locked bedrails for ventilator-dependent whole body jerking while coughing or during suctioning. The Director further stated that the MDS nurse failed to adequately customize the IDT Monthly Meeting Notes to reflect the resident’s correct clinical status, resulting in documentation that did not accurately represent the resident’s specific condition, contrary to the facility’s policy requiring accurate completion of medical records for patient safety.
Failure to Perform and Document Annual Fuel Quality Testing for Emergency Generators
Penalty
Summary
The facility failed to maintain the Emergency Power Supply System (EPSS) as required by NFPA 101 and NFPA 110 standards. During a facility tour, record review, and interviews with facility leadership, it was found that documentation was not provided to show that a fuel quality test had been performed at least annually on the 200-kilowatt diesel generator for the subacute area and the 125-kilowatt diesel generator for the annex building. The last available documentation for the subacute generator was from nearly two years prior, and no current or previous year's report was provided by the deadline set by surveyors. The Plant Operations Manager stated that a recent fuel quality test had been performed, but the report was not available for review at the time of the survey. This deficiency affected all 59 residents and four smoke compartments within the facility. The lack of current fuel quality testing documentation could impact the operational reliability of the emergency power system. This issue had also been previously cited during a prior Life Safety Code Recertification Survey, indicating a repeated failure to comply with required maintenance and testing protocols for the facility's emergency generators.
Plan Of Correction
The contracted company to take samples for fuel quality testing on 5/15/25. The Director of Plant Operations contacted the company for the results. Both generators will be tested for fuel quality on an annual basis. Action plans are generated with findings and deadlines for completion. The Plant Operations Manager or qualified designee will be maintaining the record of preventive maintenance of the electrical system, including the generator fuel quality test. The Director of Plant Operations will do a random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Maintain Emergency Preparedness Testing Requirements
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness testing requirements as outlined in federal regulations. During a record review and interviews with the Director of Subacute and the Director of Plant Operations, surveyors requested documentation of the facility's Emergency Operations Plan and evidence of participation in required emergency preparedness exercises. The facility was unable to provide documentation showing participation in an annual full-scale community-based exercise or an additional annual full-scale exercise to test the emergency plan. The Director of Plant Operations indicated that they needed to locate the after-action report for an actual emergency event that had occurred in the past year, but this documentation was not provided by the deadline given by surveyors. The lack of documentation meant that the facility could not demonstrate compliance with the requirement to conduct at least two emergency preparedness exercises per year, including unannounced staff drills using emergency procedures. This deficiency affected all 59 residents in the facility at the time of the survey. The survey findings were based on the absence of required records and the inability of facility leadership to produce evidence of compliance with emergency preparedness testing standards during the annual Life Safety Code recertification survey.
Plan Of Correction
E 039 Facility was compliant with frequency of drills/actual events as evidenced by the following documents: On 5/30/2024, incident command was set up internally for a water pipe ruptured in the ceiling of a non-patient care hallway. This is contiguous to a supply room and near the kitchen. Code Triage Internal was called and facility engineers were already on-site mitigating the issue. Water was shut off to the building at the street. County and state were notified. (Please see the attachment) On 2/19/2025, incident command was set up due to phone outage and inability to receive incoming calls or make outgoing calls. Internal unit to unit and employee mobile phones being utilized to support communication. First information from IT is that is not a switch issue, but more widespread and involves AT&T. In addition, Pyxis is on critical override. Intermittent computer down. (Please see the attachment). PLAN: Facility will continue to perform mock disaster drills as scheduled per our Environment of Care (EOC)/Emergency Management (EM)/Life Safety (LS) in accordance with state and county guidelines and participate in tabletop exercises with the county and other agencies. All documents will be maintained by the disaster coordinator. A scheduled tabletop exercise is planned for October 16th, 2025 in collaboration with local and State agencies, "The great California shakeout".
Failure to Perform Required Sprinkler System Inspections and Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 requirements. Specifically, the facility did not perform monthly inspections of the sprinkler system components, such as gauges and valves. During the survey, it was found that 8 out of 12 required records documenting these monthly inspections were not provided. The Plant Operations Manager confirmed during an interview that only quarterly visual inspections were being conducted, rather than the required monthly inspections. This deficiency had been previously cited during a prior Life Safety Code Recertification Survey. Additionally, a corroded sprinkler head was observed in Dining Room C of the main building. The Director of Subacute stated during the interview that they were unaware of the corroded sprinkler head. The presence of corrosion on the sprinkler head is a direct violation of NFPA 25, which requires that sprinkler heads be free from corrosion, leakage, and other physical damage. These failures affected all 59 residents in the facility, as well as all four smoke compartments. The lack of proper inspection and maintenance of the sprinkler system and its components, as well as the presence of a corroded sprinkler head, were identified through observation, record review, and staff interviews during the survey.
Plan Of Correction
The sprinkler located by dining room C was replaced by contracted company. (Please see the attachment.) Scheduled recurring preventative maintenance was implemented to occur monthly to visually inspect the sprinklers PM schedule. MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the sprinklers on a semi-annual basis. 2. Added monitoring is a visual inspection to be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations. K 353
Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct required quarterly fire drills for each shift, as evidenced by missing documentation for specific shifts and quarters. During a record review and interview with the Director of Subacute and Plant Operations Manager, it was found that there were no records of a fire drill for the AM shift in the first quarter and third quarter, nor for the PM shift in the fourth quarter. The Plant Operations Manager stated that fire drills were performed quarterly per shift in various departments, but some fire drill reports did not record subacute staff responses. This deficiency affected all 59 residents in the facility.
Plan Of Correction
The director of plant operations updated the current fire drill matrix to reflect a separate Subacute fire drills that will occur monthly for each shift (Main Building and Annex). The director of plant operations provided in-service to the plant operation staff for the new process with the updated fire matrix. (Please see the attachments). MONITORING: 1. The Plant Operations Manager or qualified designee will be inspecting the fire drill record and fire drill process on a quarterly basis. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Correct Deficiencies in Medical Gas and Vacuum System Maintenance
Penalty
Summary
The facility failed to maintain its Piped Medical Gas and Vacuum System as required by NFPA 99 standards. During a review of records and interviews with the Plant Operations Manager, it was found that the annual inspection and testing report for the medical gas and vacuum system identified several deficiencies, including leakage when an adapter was inserted, loose outlet/inlet, a zone valve box that required cleaning, and a missing caution label. The report did not include documentation of any corrective actions taken to address these issues. These deficiencies affected all 59 residents and all four smoke compartments in the facility. The lack of timely correction and documentation of the identified discrepancies in the medical gas and vacuum system constituted a failure to comply with required inspection, testing, and maintenance protocols. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Plan Of Correction
The contracted company repaired medical gas equipment according to the inspection report on 6/13/25. MONITORING: 1. The Plant Operations Manager or qualified designee will be maintaining the preventive maintenance of the piped gas and vacuum system. 2. The Director of Plant Operations will do random record review and inspection of the process at least annually or as needed to check compliance. Findings and data collected are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Annually Review and Update Emergency Operations Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring the annual review and update of its Emergency Operations Plan (EOP). During a record review and interview with the Director of Subacute and the Director of Plant Operations, it was found that the EOP had last been reviewed and updated on 11/29/22. This was confirmed when the Director of Plant Operations stated that they believed the plan only needed to be reviewed every two years, following the hospital's review schedule, rather than annually as required for long-term care facilities. This deficiency affected all 59 patients in the facility, as the EOP had not been reviewed or updated within the required annual timeframe. The lack of timely review and update of the emergency preparedness plan could result in the facility being unprepared in the event of an emergency or disaster, as the plan may not reflect current procedures, resources, or risks.
Plan Of Correction
E 004 The director of plant operations revised the emergency operations plan. The emergency management committee approved the revised emergency operations plan and will be presented to the Subacute Quality Assurance and Performance Improvement committee for final approval. The Director of plant operations will be revising the emergency operations plan on an annual basis (within the first quarter of the year).
Smoke Detector Failed to Activate During Functional Test
Penalty
Summary
During a facility tour and interview, surveyors observed that a smoke detector located in the hallway near Nurse Station 1 and resident rooms 730 and 743 failed to activate the fire alarm system when tested. The test involved spraying the smoke detector three times with smoke detector test spray, but the device did not trigger an alarm. The Director of Subacute, present during the test, was unable to explain why the smoke detector did not respond. This deficiency affected 24 out of 59 residents in one of four smoke compartments. Records of system acceptance, maintenance, and testing were expected to be readily available and the fire alarm system was required to be maintained in reliable operating condition in accordance with NFPA 70 and NFPA 72 standards.
Plan Of Correction
Smoke detector located in the hallway by nurse station 1 and resident rooms 730 and 743 was repaired by contracted company (Please see the attachment). MONITORING: 1. The plant operations team, headed by the plant operations director or qualified designee, will be inspecting all smoke detectors on a semi-annual basis. Monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Corridor Doors Failed to Latch Upon Closing
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with regulatory requirements. During a facility tour, it was found that the corridor door to the SNF Nurse Manager office and the corridor door to the storage room by resident room 732 did not latch upon self-closing. These doors are required to resist the passage of smoke and have positive latching hardware to ensure proper containment in the event of a fire. The deficiency affected 14 of 59 residents and one of four smoke compartments. During the interview, the Director of Subacute stated they were unaware that the doors did not latch. The report does not mention any specific medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
The contracted company repaired the corridor door to the SNF nurse manager office and storage room by resident room 732. (Please see the attachment). MONITORING: 1. The plant operations team, headed by the Plant Operations Director or qualified designee, will be inspecting the doors on an annual basis. Additional monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.
Failure to Verify NGT Placement Prior to Medication Administration
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to verify the placement of a nasogastric tube (NGT) prior to administering medication to a resident. During a medication administration observation, the LVN prepared the resident's medications, verified the resident's identity, and attempted to aspirate for gastric residual from the NGT, but no residual was obtained. Despite this, the LVN proceeded to administer the medications through the NGT without further verification of tube placement. When questioned, the LVN stated that checking tube placement was unnecessary for an NGT, as opposed to a G-tube. The resident involved had a history of postpartum cardiac arrest and was care planned to have an NGT, with instructions to check tube placement and gastric contents per facility protocol. The facility's policy required verification of NGT placement by aspirating for gastric contents and, if none were obtained, by injecting air and listening for a swooshing sound with a stethoscope. The Director of Nursing confirmed that all licensed nurses were expected to follow this protocol for both NGT and G-tube placements prior to administering feedings or medications.
Expired Ativan Vial Not Removed from Medication Storage
Penalty
Summary
During an inspection of the medication storage room, one vial of Ativan 2 mg was found stored in the medication refrigerator beyond its manufacturer's recommended discard date. The Nurse Manager confirmed that expired medications should be removed from use to prevent administration to residents. The Director of Nursing acknowledged that staff are responsible for checking medication expiration dates and that the expired Ativan vial was overlooked and not removed or returned to the pharmacy as required. Facility policy states that discontinued, outdated, or deteriorated drugs must not be used and should be returned to the dispensing pharmacy or destroyed.
Expired and Unlabeled Food Items Stored in Kitchen Refrigerator
Penalty
Summary
During an initial kitchen tour with the Director of Nutritional Services (DNS), two fruit cups labeled with a use-by date that had already passed and one fruit cup with no label or date were found stored in the refrigerator and readily available for use. The DNS confirmed that all items stored in the refrigerator should be labeled with a use-by date and that expired or unlabeled items should not be stored or available for use. A review of the facility's policy indicated that all prepared salads must be covered, labeled, and dated with a use-by date before being placed in the refrigerator. At the time of the observation, two residents in the facility were on an oral diet.
Improper Disinfection of Shared Glucometer by LVN
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to properly disinfect a shared glucometer during medication administration. The LVN was observed wiping the glucometer with a Sani cloth disposable wipe but did not adhere to the manufacturer's specified contact time of two minutes. Instead, the LVN allowed the glucometer to air dry while still wet, but not for the required duration. This process was performed before and after checking a resident's blood sugar, and the LVN acknowledged not following the manufacturer's instructions regarding contact time during an interview. Interviews with the Director for Staff Development (DSD) and the Director of Nursing (DON) confirmed that staff are expected to sanitize the glucometer before and after each use, following the manufacturer's instructions for a two-minute contact time. A review of the facility's policy and the manufacturer's instructions both indicated that all patient care equipment should be disinfected between uses and that surfaces must remain wet for two minutes to ensure proper disinfection. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Implement Turning and Repositioning Interventions
Penalty
Summary
The facility failed to implement the necessary interventions for turning and repositioning a dependent resident, leading to an increased risk of pressure injuries. Resident 1, who was nonverbal and noncommunicative, had a care plan that required turning and repositioning every two hours and at specific times requested by the family. However, documentation from January 17-21, 2024, showed that Resident 1 was not turned or repositioned as required, with significant gaps in the records indicating a lack of adherence to the care plan. Interviews with CNAs and the DON confirmed that if repositioning was not documented, it was not done, highlighting a failure in the facility's care practices. Further interviews with treatment nurses revealed that Resident 1 had a pressure injury on the buttocks, which was improving but still required consistent turning and repositioning to promote healing and prevent further injuries. The facility's policy on skin care and prevention of pressure injuries emphasized the importance of changing positions regularly to maintain skin integrity. The lack of documentation and adherence to the care plan for Resident 1 indicates a significant deficiency in the facility's care practices, putting the resident at risk for developing and worsening pressure injuries.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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