Delano District Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 1509 Tokay Street, Delano, California 93215
- CMS Provider Number
- 555479
- Inspections on file
- 61
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Delano District Skilled Nursing Facility during CMS and state inspections, most recent first.
A resident with major depressive disorder was receiving Paxil 20 mg daily for depression, but nursing staff did not monitor for adverse reactions as required by facility policy. The DON confirmed that the resident had been on Paxil for an extended period with no orders for adverse reaction monitoring and no shift-to-shift assessments documented. The facility’s psychotropic medication policy requires licensed nurses to observe for adverse reactions, notify the physician if they occur, and document both the reactions and the communication, but this was not done for this resident.
A resident with schizoaffective disorder, bipolar type, anxiety, major depressive disorder, and urinary retention requiring a Foley catheter twice attempted suicide in her room, first by wrapping a call light cord around her neck and shortly afterward by removing her Foley catheter and wrapping the tubing around her neck, during a period when staff had removed cords but had not clearly assigned continuous supervision. Nursing staff acknowledged knowing the resident was a danger to herself but left the room after the first attempt, each assuming another staff member would monitor her, and the DON later reported not knowing there had been two separate attempts. The resident was placed on q30‑minute visual checks rather than 1:1 monitoring until days later, and review of suicide‑observation documentation showed missed q30‑minute checks at multiple times despite an order for such monitoring, in contrast to the facility’s Suicide Prevention Guidelines policy requiring close monitoring and documented 30‑minute checks after suicidal ideation or attempts.
The facility failed to ensure a CNA received required annual abuse prevention training, as confirmed by training records, staff interviews, and facility policy. A resident’s responsible party reported that the resident complained a night-shift CNA was rude and mean. Review of the CNA’s file showed her last abuse training was completed more than three years earlier, despite the Administrator, DSD, and written policy all stating that abuse and resident rights training must be provided annually and as needed.
The facility did not complete the required 5-day abuse investigation report after a CNA reported overhearing an argument and alleged verbal abuse by a resident’s daughter during a meal pass. The incident was documented on an SBAR form, and facility policy required that a final investigation report be faxed to the appropriate agency within five working days. The Administrator stated the DON was responsible for this report, and the DON acknowledged that the 5-day report was not completed, despite more than a week having passed since the allegation.
A resident experienced a verbal altercation with her daughter that was reported by a CNA via an SBAR form after staff overheard an argument in the resident’s room during meal pass. The resident’s care plan was updated to address an alteration in well-being related to this incident and included an intervention for the Social Service Designee to conduct wellness checks for 72 hours. During later review, the SSD could not provide documentation that these wellness checks were completed, and both the Administrator and DON acknowledged that Social Services should have monitored the resident as care-planned, resulting in a failure to implement the care plan intervention.
The facility failed to ensure staff who operated the resident transport van were assessed and documented as competent, despite using the vehicle to take residents to medical appointments and activity outings. A staff member and the AD reported routinely transporting residents, including wheelchair-bound individuals, using a van equipped with a hydraulic lift and wheelchair restraints, without ever being required to demonstrate driving competency or safety. The DSD confirmed there was no process to verify driver competency, and the DON acknowledged that no competencies had been completed for staff who drive the van, contrary to the facility’s own competency evaluation policy requiring staff providing care, treatment, or services to be competent.
The facility did not follow its Abuse Prevention Program policy for an agency CNA. The DON and DSD could not provide a clear hire date for the CNA, who had been working intermittently at the facility for about a year. The DSD reported that the staffing agency, not the facility, handled all background and reference checks and ensured required training, and confirmed the facility did not perform its own reference checks or provide resident-rights and abuse-prevention training to agency staff. Policy required reference checks for potential employees and mandated that all new employees receive resident-rights and abuse-prevention in-service training during orientation within 60 days of employment and annually, but these steps were not completed for this CNA.
A resident lying in bed with the head of the bed elevated reported that CNAs did not provide their call light and was later heard repeatedly calling out for a CNA, stating they did not have a call button. When a CNA entered the room, the call light was found looped to the bed rail but hanging behind the top side of the mattress, out of the resident’s reach; the CNA confirmed it was not reachable and that call lights should be easily accessible. Facility policy required that all residents have a call light in place at all times as the primary means to alert nursing staff to their needs, but this was not followed for this resident.
A cognitively intact resident sustained a skin tear to the hand during ADL care provided by two CNAs and immediately stated, "you hit me," while one CNA reportedly gripped the resident and commented on the resident screaming. Both CNAs documented and later confirmed that the resident alleged they hit her but asserted she struck the siderail, and neither reported the abuse allegation at the time it occurred. An SOC 341 abuse report was not completed until two days later, and the DON confirmed the allegation was not promptly reported, contrary to facility policy requiring immediate reporting and protective measures during abuse investigations.
A resident sustained a skin tear during care, after which a CNA obtained triple antibiotic ointment and a bandage from the treatment nurse, then cleaned the wound and applied the ointment and bandage herself. The DON stated that CNAs are not permitted to perform wound treatments. Facility documentation reflected that the CNA recorded applying antibiotic ointment and a bandage after the resident was accidentally hit against a side rail. Review of the facility’s medication administration policy showed that medications are to be prepared and administered only by licensed nurses, pharmacy, or other personnel authorized by state regulations, which was not followed in this case.
Surveyors determined that the facility did not follow its abuse prevention screening policy when hiring two CNAs. Review of personnel files with the DON and Human Resource Assistant showed that one CNA was hired without any reference checks or required exclusion/OIG background check, and another CNA was hired without any reference checks. The facility’s Abuse Prevention Program required pre-employment screening for abuse, neglect, or mistreatment history, including reference checks and multiple background checks (e.g., CA courts, Megan’s Law, exclusion lists, and L&C verification), but these procedures were not completed before these CNAs began employment.
Two CNAs were hired without documented evidence of completed criminal background checks prior to their start dates. Although HR stated that checks were performed, no proof with dates was available, resulting in noncompliance with the facility's hiring policy.
The facility did not provide a written discharge notice to a resident and their responsible party prior to discharge, instead giving the notice on the day of discharge. Additionally, discharge notices were not sent to the State LTC Ombudsman for twelve discharged residents, despite facility policy and prior written notification from the Ombudsman requiring this action.
A resident with significant physical limitations was discharged home without the physician-ordered home health PT/OT/ST services due to lack of available providers and insurance network issues. The discharge summary lacked a documented post-discharge care plan, and the resident's family member reported being unable to provide the necessary care.
A resident with multiple health conditions, including anxiety disorder and legal blindness, alleged that staff were hitting and kicking him. The administrator, who was also the abuse coordinator, was informed of the allegation but did not report it to CDPH as required by facility policy and state law.
The facility failed to promptly answer call lights for several residents, leading to unmet needs and frustration. A resident's call light was ignored by staff, including a new CNA unsure of her assignment, resulting in a delay in changing a dirty brief. Other residents reported feeling desperate and frustrated due to routine delays exceeding 15 minutes. The facility's policy requires prompt response to call lights, but this was not followed, as acknowledged by the administrator.
The facility failed to meet pharmaceutical service needs for three residents. A resident's Lidocaine patch was not removed as prescribed, another received a crushed Nifedipine ER tablet instead of whole, and discrepancies were found in the accounting of controlled drugs for a third resident. Additionally, a nurse signed the narcotic count sheet prematurely, violating policy.
The facility failed to maintain food safety and sanitation standards, as dented tomato soup cans were found in storage and a container of lentil beans was left open. The Dietary Manager acknowledged these issues, which violated the facility's policies on canned and dry goods storage, posing a potential risk of foodborne illness to residents.
The facility failed to maintain infection control standards, with soiled laundry cart covers and a dirty linen closet floor potentially contaminating clean linen. Additionally, two RNs did not properly disinfect glucometers after use, risking exposure to bloodborne pathogens. The Infection Preventionist confirmed the need for proper disinfection procedures.
The facility failed to document the COVID-19 vaccination status of nine employees, including a PM worker, a housekeeper, CNAs, an RN, an LVN, and NAs, hired between July 2024 and January 2025. The Infection Preventionist Nurse did not record their vaccination status, as it was not mandatory at the time of hiring, despite the facility's policy requiring such documentation. This oversight had the potential to spread COVID-19 within the facility.
A facility failed to ensure the accuracy of the MDS for a resident, leading to an incorrect record of the resident's discharge location. The MDS indicated a discharge to a hospital, while Nurse's Notes showed the resident was discharged home. The MDSC acknowledged the error, noting the lack of a specific policy for MDS accuracy and admitted to not verifying the information against the medical record.
A resident at risk for dehydration due to diarrhea did not have fluids accessible at the bedside. The water pitcher and cup were placed out of reach, and no straw was available, hindering the resident's ability to drink independently. A nurse confirmed the need for the bedside table to be within reach, aligning with the facility's hydration policy.
The facility failed to monitor the oxygen saturations of two residents as per physician orders. One resident was observed without oxygen despite an order for oxygen inhalation when saturation was below 93%, and their oxygen levels were not documented. Another resident's oxygen saturations were missing from records for several shifts, despite an order for continuous oxygen inhalation for low saturation. Staff confirmed the lack of documentation and monitoring, which was against the facility's process to follow physician orders.
A registered nurse at the facility was found to lack current CPR certification, a requirement stated in the job description. The nurse's certification had expired the previous year, and both the nurse and the Human Resource Manager acknowledged the deficiency. This lapse in certification could impact the nurse's ability to respond to medical emergencies.
A resident who required adaptive eating equipment due to coordination issues was not provided with the necessary utensils during meals, as observed during a survey. Despite a physician's order and care plan indicating the need for build-up foam utensils, the resident was seen using regular utensils. RN 2 confirmed the oversight and noted that the kitchen was responsible for providing the adaptive equipment, as per the facility's policy.
The facility failed to maintain clean and sanitary conditions in resident shower rooms, affecting multiple residents. Observations revealed discolored grout, dirty shower chairs, and a bowel movement on the wall. The Facility Director and Administrator acknowledged the issues, which were contrary to the facility's housekeeping policy.
A resident with moderately impaired cognition was subjected to undignified treatment when an RNA placed her hand over the resident's mouth to quiet her. This incident, observed by a CNA and confirmed by security footage, violated the facility's policy on dignity and respect. The DON verified the incident, leading to the termination of the involved RNAs.
A facility failed to follow its Abuse Prevention Program when a CNA observed an RNA placing her hand over a resident's mouth to stop her from screaming. Despite the immediate report of the incident, the RNA continued working for several hours before being sent home, contrary to the policy requiring accused employees to be placed on administrative leave during investigations.
The facility failed to follow its safety policy when tools were left unattended on the floor, posing a potential injury risk. Nine screws were found in a hallway, and a screwdriver with repair parts was left in an open office. The Maintenance Assistant admitted to leaving the tools, and both the Administrator and DON expressed safety concerns. The Director of Maintenance emphasized the need to clear hazards and block off work areas.
The facility failed to position two high-risk residents near the nurse's station as required by their care plans, leading to multiple falls. One resident, with a history of falls and conditions like dementia and osteoporosis, was placed far from the nurse's station, resulting in a hip fracture after an unwitnessed fall. Another resident, also at high risk, fell while trying to get up from a wheelchair, despite having an alarm. Staff confirmed the residents' rooms were not close enough for effective monitoring.
The facility failed to report multiple allegations of abuse involving residents, including physical altercations and sexual misconduct. Despite being informed of these incidents, the facility did not report them to the state agency as required. The incidents involved residents with varying cognitive abilities, and staff were aware of the situations but did not take appropriate action to ensure resident safety.
The facility failed to provide timely dental services for two residents, resulting in potential oral health issues. One resident experienced severe pain due to delayed referrals for recommended extractions, while another faced delays in receiving oral surgery. The facility's policy emphasized prompt dental care, but the lack of follow-up and delayed referrals highlighted a failure to adhere to these guidelines.
The facility failed to process complaints from four cognitively intact residents regarding medication administration issues by registry nurses (RNNs) according to their policy. Residents reported issues such as medications not being passed on time or not at all during night shifts. The Facility Scheduler acknowledged complaints but did not verify RNN competency, and the Director of Staff Development confirmed medication errors without identifying affected residents. The facility's grievance policy was not followed, as complaints were not documented or resolved.
A new LVN at an LTC facility administered medications without completing the required competency evaluation, leading to a medication error. The LVN placed medications into a resident's tube feeding bag, which was against protocol. The resident, who was cognitively intact, noted forgetfulness in night shift medication administration. The DON confirmed this as a medication error, highlighting a lapse in ensuring staff competency.
A resident with hemiplegia, hemiparesis, and a history of falls experienced an unwitnessed fall resulting in a laceration and fracture of the right pinky finger. The facility failed to document required two-hour checks and interactions, as per their fall prevention protocol, contributing to the incident.
The facility failed to label tube feeding bags with dates and times for two residents, as required by its policy. Both residents, who had diagnoses related to gastrostomy and were on Jevity 1.5, had unlabeled feeding bags. This oversight was confirmed by nursing staff and had the potential to result in the residents consuming contaminated feeding formula.
A resident's room was found to be 84.4°F, exceeding the facility's policy of 71-81°F, verified by the Facility Director. The resident had multiple medical conditions and was unable to participate in cognitive assessments. The facility's policy emphasized maintaining safe temperatures to minimize health risks, but this was not adhered to.
A resident reported an altercation with a CNA, alleging abuse, but the CNA did not report the incident to management and continued working. The facility's policy requires immediate reporting and removal of the accused staff, which was not followed, potentially delaying the investigation.
A resident with a history of walking difficulties and high fall risk fell and sustained a shoulder injury due to inadequate assistance during ambulation. The Director of Rehabilitation was holding a cellphone and a wheelchair, failing to provide necessary hand support or use a gait belt, contrary to facility policy. This resulted in the resident losing balance and falling, leading to severe pain and hospitalization.
The facility failed to maintain an effective pest control program, as observed in the resident patio area where two residents reported seeing black widow spiders and cockroaches. Despite daily cleaning by maintenance staff, thick webs and egg sacs were present, indicating inadequate pest control measures. The facility had recently changed pest control services, but lacked proper tracking of the new company's activities.
A resident was moved to the dining room to sleep for one night after a late admission tested positive for COVID-19 and no other rooms were available. The resident felt scared and rushed, and the resident's representative stated there was no consent given for the move, describing it as humiliating. The facility's policy on Resident Rights was not upheld in this situation.
A resident with a history of seizures experienced multiple, prolonged seizures that were not promptly addressed by the RN, leading to a significant decline in the resident's condition. Despite staff urging, the RN did not send the resident to the hospital and left unqualified CNA students to monitor the resident.
The facility failed to treat four residents with dignity and respect, as evidenced by multiple incidents involving a registered nurse (RN). The RN dismissed a resident's concerns about another resident's seizures, displayed a bad attitude, and was intimidating. The RN had a history of similar complaints and disciplinary actions.
Failure to Monitor Antidepressant Adverse Reactions
Penalty
Summary
The facility failed to ensure licensed nurses monitored for adverse reactions to an antidepressant medication for one of three sampled residents. The resident had a diagnosis of major depressive disorder and had been receiving Paxil 20 mg orally once daily for depression manifested by verbalization of sadness since 8/6/25. Review of the resident’s order summary showed there was no physician order in place to monitor Paxil’s adverse reactions, and the DON confirmed that no monitoring for adverse reactions had been conducted since the medication was started. This occurred despite the facility’s psychotropic medication policy, which requires licensed nurses to observe for adverse drug reactions, notify the physician if such reactions are noted, and document both the reactions and the communication with the physician. The DON stated that monitoring for Paxil’s adverse reactions should have been done every shift to ensure the resident was not experiencing adverse effects and to notify the physician if any were observed. However, this monitoring did not occur, and there was no documentation of adverse reaction assessments or related physician communication for this resident while on Paxil.
Failure to Adequately Supervise and Monitor Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and monitor a resident after suicide attempts, and failure to follow its Suicide Prevention Guidelines policy. The resident was admitted with schizoaffective disorder, bipolar type, cognitive communication deficit, anxiety disorder, and major depressive disorder, and had a BIMS score of 14, indicating cognitively intact status. The resident required a Foley catheter for urinary retention. On one day in March, the resident attempted to commit suicide in her room by wrapping her call light cord around her neck. Staff removed the call light and other cords from the room, but there was no clear assignment or confirmation of continuous supervision at that time. Later that same day, the resident made a second suicide attempt by removing her Foley catheter and wrapping the tubing around her neck. CNA 1 reported first finding the resident with the call light around her neck and then, about 10 minutes after leaving the room at the request of nursing staff, finding the resident again with the Foley catheter around her neck while no staff were present. LVN 1 confirmed she knew the resident was a danger to herself and needed monitoring, but she left the room after the first attempt assuming that either RN 1 or CNA 1 would stay with the resident, and did not obtain confirmation of who would supervise. The DON later stated she was not aware that the resident had made two separate suicide attempts that day and believed the call light and Foley catheter were used at the same time. Following these events, the resident was placed on every 30‑minute visual checks rather than one‑to‑one monitoring. LVN 2, who worked the night shift after the attempts, stated the resident was on 30‑minute checks and questioned why one‑to‑one monitoring was not implemented given the suicide attempts. The DON stated the resident was not placed on one‑to‑one monitoring until two days after the attempts. Review of the facility’s Observation of Resident: Suicidal Ideation/Suicidal Attempts documentation showed that on a later date, the resident, who was ordered to be monitored every 30 minutes, was not monitored at 11:00 a.m., 3:00 p.m., and 3:30 p.m. The DON acknowledged the resident should have been monitored at those times. The facility’s Suicide Prevention Guidelines policy required immediate attention, close monitoring, and 30‑minute checks with documentation and room inspection when residents threaten or attempt self‑harm, but the monitoring ordered and the documentation of checks were not consistently carried out as required.
Failure to Ensure Annual Abuse Prevention Training for CNA
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA 1) completed required annual abuse training, as identified through interviews and record review. Resident 1’s interdisciplinary team (IDT) note documented that the responsible party reported the resident complained that a night-shift CNA was rude and mean. During review of CNA 1’s training records with the Human Resource Assistant, it was confirmed that CNA 1’s last abuse training occurred on 2/7/23, more than three years prior to the survey, and no more recent abuse training could be produced. In separate interviews, the Administrator and the Director of Staff Development both stated that abuse training was required to be completed annually, and CNA 1 also confirmed that her last abuse training before the allegation was on 2/7/23. The facility’s Abuse Prevention Program policy dated 7/22/2021 stated that all new employees must attend resident rights and abuse prevention training during orientation and that such training shall be provided on an annual basis and as needed, which was not followed in the case of CNA 1. This deficiency centers on the facility’s failure to adhere to its own policy and procedure requiring annual in-service training on resident rights and abuse prevention, resulting in CNA 1 not receiving the mandated annual abuse training for more than three years prior to the reported complaint about her behavior toward Resident 1.
Failure to Complete 5-Day Abuse Investigation Report for Verbal Abuse Allegation
Penalty
Summary
The facility failed to complete and submit a final abuse investigation report within five working days for an allegation of verbal abuse involving one of three sampled residents (Resident 1). On 2/21/26 at 5:30 p.m., a CNA overheard an argument coming from the resident’s room during the meal pass and reported verbal abuse by the resident’s daughter, which was documented on an SBAR communication form and progress note at 6:54 p.m. the same day. The facility’s policy, “Abuse Prevention Program” dated 7/29/2020, requires that the final investigation report be faxed and confirmed to the appropriate agency within five working days from the time the incident occurred. During interviews on 3/5/26, the Administrator stated that the DON was responsible for completing the five-day report, and the DON acknowledged that the five-day report for this allegation was not completed, nine working days after the incident, contrary to facility policy. No additional medical history or clinical condition details for the resident at the time of the incident are provided in the report.
Failure to Implement Care Plan Wellness Checks After Verbal Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident following a reported verbal altercation with her daughter. On 2/21/26 at 6:54 p.m., an SBAR (Situation, Background, Appearance, Review and report) communication form and progress note documented that a CNA reported verbal abuse from the resident’s daughter after overhearing an argument from the resident’s room during meal pass. In response, the resident’s care plan, dated 2/23/26, identified an alteration in well-being related to the verbal altercation between the resident and her daughter and included an intervention for the Social Service Designee to conduct wellness checks for 72 hours. During a concurrent interview and record review on 3/5/26 at 11:35 a.m., the Social Service Director was unable to provide documentation that the wellness checks had been completed for the resident. In separate interviews on 3/5/26, both the Administrator and the DON stated that Social Services should have monitored the resident and completed the 72-hour wellness checks after the incident. Review of the facility’s Comprehensive Care Plans policy dated 11/2017 indicated that the comprehensive care plan should be updated to reflect changes in condition and that interventions are instructions to disciplines to perform direct care or provide assistance so residents may strive to achieve their established goals. Despite the care plan intervention specifying wellness checks, there was no documented evidence that these checks were carried out.
Failure to Ensure Driver Competency for Resident Transport Vehicle
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff members who drive the facility’s transport vehicle were assessed and documented as competent to do so. During interviews, one facility staff member stated he had transported residents in the facility vehicle when asked by leadership, and employee file review showed another staff member also used the transport vehicle to transport residents. The DON confirmed that the facility provides transportation for residents to and from appointments and for activity outings. The DSD reported that facility staff, including two identified staff and activities staff, use the facility van for these purposes but stated there was no process in place to verify that these staff were competent and safe to operate the transport vehicle. The AD, who had worked at the facility for 15 years, stated that transporting residents on outings is part of her job and described the facility van as accommodating nine residents, including wheelchair-bound residents, with a hydraulic lift and wheelchair securement straps. She reported she had not been required to demonstrate competency or safety in driving the van. A concurrent observation with the DON confirmed the presence of a hydraulic lift and capacity for nine residents, including those who must remain in wheelchairs. The DON acknowledged that the facility had not completed competencies for staff who drive the transport vehicle. This practice was inconsistent with the facility’s written Competency Evaluation policy, which requires that all staff who provide care, treatment, or services be competent to perform their duties, with competency defined as the demonstrated knowledge and skill necessary to perform a task or job safely, successfully, and efficiently.
Failure to Screen and Train Agency CNA per Abuse Prevention Policy
Penalty
Summary
The facility failed to follow its Abuse Prevention Program policy regarding screening and training of staff, specifically for one CNA obtained through an agency (CNA 1). During interviews and record reviews with the DON and DSD, it was determined that the facility could not provide a hire date for CNA 1, who had been working at the facility approximately once or twice a week for about a year. The DSD stated that the staffing agency was responsible for ensuring CNA 1 had all required training and for performing background and reference checks, and confirmed that the facility did not conduct its own reference checks or provide abuse-prevention or resident-rights training for agency staff. Review of the facility’s Abuse Prevention Program policy, revised 7/22/21, showed that potential employees were to be screened for a history of abuse, neglect, or mistreatment through reference checks with previous or current employers, and that all new employees were required to attend resident rights and abuse prevention in-service training during orientation within 60 days of employment and annually thereafter. These policy requirements were not followed for CNA 1.
Failure to Keep Call Light Within Resident’s Reach
Penalty
Summary
The facility failed to ensure a resident’s call light was placed within reach, as required by its policy that all residents have a call light in place at all times to alert nursing personnel to their needs. During an observation and interview in the resident’s room, the resident was lying in bed with the head of the bed elevated and stated that CNAs did not give them their call light. Later, while outside the room, the resident was heard repeatedly yelling for a CNA and stating they did not have a call button, continuing to call out for several minutes. A subsequent observation with a CNA in the room showed the resident still in bed with the head of bed elevated, and the call button looped to the bed rail but hanging behind the top right-hand side of the mattress, out of the resident’s reach. The CNA confirmed the resident could not reach the call light and acknowledged that the call light should be within easy reach for residents. A review of the facility’s “Call Light – Answering” policy, last reviewed on 4/25/14, indicated that the call light system is the only mechanism at the bedside for residents to alert nursing personnel to their needs, that each resident receives directions on its use and positioning upon admission, and that all residents will have a call light in place at all times. The observations and interviews showed that this policy was not followed for this resident, resulting in the resident not having ready access to the call light while in bed.
Failure to Timely Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of abuse involving one cognitively intact resident. The resident’s MDS dated 10/28/25 showed a BIMS score of 15, indicating intact cognition. On 12/21/25, documentation on an SBAR form indicated the resident sustained a skin tear while being changed and performing ADLs, with a note that the resident was accidentally bumped on the side rail. A Special Problems entry the same day, signed by CNA 3, documented that the resident screamed an expletive and said, "you hit me," and that CNA 3 responded that she did not hit the resident and that the resident hit herself on the siderail. A nurse’s note dated 12/23/25 indicated that an SOC 341 was completed because the resident claimed she was hit on the right hand and sustained a skin tear during ADLs, showing a delay between the allegation and formal reporting. During interviews, the resident stated that on 12/21/25 two CNAs provided care, that one CNA was gripping her and told her she screamed too much and should say please and thank you, and that her hand was injured during care, prompting her to tell the CNAs, "you hit me." On observation, a scab the size of a dime was noted over the pinky finger knuckle of the resident’s right hand. CNA 2 and CNA 3 both confirmed that during care on 12/21/25 the resident was injured, that they believed she hit herself on the bedrail, and that the resident told them, "you hit me." Both CNAs acknowledged they did not report the resident’s allegation of being hit. The DON confirmed that the resident made allegations to CNA 2 and CNA 3 that they hit her and that these allegations were not reported, despite the CNAs having been trained on reporting abuse. The facility’s Abuse Prevention Program policy required that alleged or suspected abuse be reported to specified parties and agencies within 24 hours and that residents be protected from harm by ensuring the accused perpetrator was not near the resident, measures that were not followed in this case.
Unlicensed Staff Performed Wound Treatment Using Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s wound was treated by a licensed nurse, as required by facility policy. During care, Resident 1 sustained a skin tear, described as an acute, traumatic wound where the top layers of skin separate from the underlying tissue. Certified Nursing Assistant (CNA) 2 reported that after the skin tear occurred, CNA 3 went to the treatment nurse and obtained triple antibiotic ointment, a pad to clean the wound, and a bandage. CNA 2 stated that CNA 3 cleaned Resident 1’s skin tear, applied the triple antibiotic ointment, and then placed the bandage on the wound. The Director of Nursing (DON) stated that CNAs are not allowed to perform wound treatments. Review of Resident 1’s Special Problems documentation dated 12/21/25 showed an entry indicating that after accidentally hitting the resident against the side rail, CNA 3 went to get a bandage and some antibiotic ointment and applied it to the resident, with the note signed by CNA 3. In a separate interview, CNA 3 confirmed that Resident 1 received a skin tear during care, that she informed the treatment nurse, and that the treatment nurse gave her ointment and a bandage, which she then applied to the resident’s skin tear. Review of the facility’s Medication Administration Schedule policy, revised 10/19/22, indicated that medications are to be administered only by persons legally authorized to do so and prepared only by licensed nurses, pharmacy, or other personnel authorized by state regulations, which was not followed in this instance.
Failure to Complete Required Abuse-Prevention Screening for CNAs Prior to Hire
Penalty
Summary
Surveyors found that the facility failed to follow its abuse prevention screening policies by not completing required reference and background checks for two certified nursing assistants (CNAs) prior to their employment. During an interview and concurrent record review with the DON and Human Resource Assistant, CNA 1’s personnel file showed a hire date of 3/25/25 with no reference checks and no exclusion (Office of Inspector General) background check completed before employment, despite facility policy requiring these screenings. In the same review, CNA 2’s file, with a hire date of 1/9/23, showed no reference checks completed prior to employment, again contrary to facility policy. The facility’s written Abuse Prevention Program policy dated 7/22/21 stated that potential employees would be screened for a history of abuse, neglect, or mistreatment using reference checks with previous and/or current employers and additional hiring procedures, and that all applicants must have checks completed through CA courts (including supreme and 5th appellate district), Megan’s Law website, exclusion lists, and L&C verification searches. DON and HRA both acknowledged during the interviews that, per facility policy, reference checks and background checks were required to be completed prior to employment for these CNAs, but this was not done in these two cases.
Failure to Document Criminal Background Checks Prior to Hire
Penalty
Summary
The facility failed to ensure that two certified nursing assistants (CNAs) had completed and documented criminal background checks prior to their dates of hire. During a review of employee files, it was found that there were no documented dates on the criminal background checks for both CNAs. The Director of Nursing confirmed the hire dates and the absence of documentation, while Human Resources stated that background checks were performed before hiring but could not provide evidence, as the screen grabs taken did not include dates. The facility's policy requires that all applicants be screened for criminal background, fraud, and sex offender status before employment, and that any applicant with documented actions against them would not be considered for hire. However, the lack of documented dates on the background checks meant there was no verifiable proof that these checks were completed prior to employment, resulting in noncompliance with the facility's own hiring procedures.
Failure to Provide Timely Discharge Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written discharge notice to a resident and their responsible party prior to discharge, as required. The discharge order for the resident was written by the physician, and the resident was discharged two days later. However, the Notice of Proposed Transfer/Discharge was only provided to the responsible party on the day of discharge, rather than in advance. The responsible party was verbally informed of the discharge, but the written notice, which included the reason for discharge, was not given until the day the resident left the facility. Additionally, the facility did not send copies of discharge notices to the State Long-Term Care Ombudsman for twelve residents who were discharged during the review period. The Ombudsman confirmed that they did not receive the required notices, only a list of discharged residents with basic information. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, but this was not done. The Ombudsman had previously notified the facility in writing of this requirement.
Failure to Arrange Ordered Home Health Services and Document Discharge Plan
Penalty
Summary
The facility failed to implement an effective discharge plan for a resident who was discharged home without the home health services ordered by the physician. The resident, who had diagnoses including generalized muscle weakness, difficulty walking, and unsteadiness on feet, required assistance with ambulation, transfers, toileting, dressing, bathing, and grooming. The discharge summary indicated the need for physical, occupational, and speech therapy at home, but did not provide information on how these services would be obtained. Additionally, the section of the discharge summary designated for the discharge planning or post-discharge care plan was left blank. Facility staff documented that no home health agency was available to provide services in the resident's area, and the resident's insurance did not have in-network agencies nearby. The social services assistant informed the responsible party that out-of-network services would be needed, but there was uncertainty about whether this was understood. As a result, the resident was discharged to the care of a family member without any home health services in place, despite being physically weak and unable to independently perform activities of daily living.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a male resident with a history of anxiety disorder, muscle weakness, legal blindness, history of falling, and need for assistance with personal care. The resident was admitted to the facility and, during an emergency department visit, reported that facility staff were abusing him. The resident specifically told the facility's administrator, who also served as the abuse coordinator, that staff were hitting and kicking him. This allegation was made directly to the administrator after staff called him to the resident's room due to the resident's behavior, which included kneeling on the floor, refusing food and medication, and requesting to be sent to the hospital. Despite the resident's clear allegation of abuse, the administrator did not submit a report to the California Department of Public Health (CDPH) as required by the facility's policy and state law. The facility's policy states that all alleged or suspected violations and substantiated incidents of abuse must be promptly reported to the Ombudsman, law enforcement, and CDPH within 24 hours if no serious bodily injury occurred. As of the date of the survey, no report had been made to CDPH regarding this incident.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for five of the 72 sampled residents, leading to unmet needs. Observations and interviews revealed that Resident 47's call light was on for an extended period without being addressed, despite multiple staff members passing by. CNA 4, who was new to the facility, was unsure of her assignment and did not assist Resident 47, who needed a brief change. Resident 47 expressed that CNAs had told her she was too needy, which discouraged her from using the call light. Other residents, such as Resident 105 and Resident 92, reported feeling desperate and frustrated due to delays in call light responses, with waits often exceeding 15 minutes. The facility's policy on call light answering, dated 4/25/14, emphasizes the importance of meeting residents' needs promptly, yet this was not adhered to. The administrator acknowledged that a 15-minute delay is not prompt and that staff should answer call lights regardless of whose resident it is. Resident 96 experienced a 15-minute wait after pressing the call light for assistance, and Resident 86 confirmed that such delays were routine. These findings indicate a systemic issue with the facility's response to call lights, impacting residents' ability to have their needs met in a timely manner.
Pharmaceutical Service Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents. For Resident 93, staff did not adhere to the physician's order to remove a Lidocaine patch after 12 hours of application. This oversight resulted in the patch being left on longer than prescribed, as observed when a nurse removed the previous day's patch before applying a new one. The facility's policy requires medications to be administered according to physician orders, which was not followed in this instance. Resident 128 was administered a Nifedipine Extended Release tablet in a crushed form, contrary to the physician's order and FDA guidelines, which specify that such tablets should be swallowed whole to ensure the medication is released slowly over time. The Licensed Vocational Nurse crushed the tablet and mixed it with food, leading to the resident receiving a higher dose than intended. The facility's policy states that only medications that can be crushed should be crushed, which was not adhered to in this case. For Resident 96, there were discrepancies in the documentation and accounting of controlled drugs, specifically Morphine and Methadone. The Narcotic Logs did not match the actual amounts of medication left in the vials, indicating a failure to properly account for these controlled substances. Additionally, the outgoing nurse signed the end-of-shift narcotic count sheet before the end of her shift and without the incoming nurse present, which is against the facility's policy requiring both nurses to verify and sign the controlled drug count together at shift change.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and sanitary kitchen conditions, as observed during a survey. In the dry food storage room, multiple dented 50-ounce tomato soup cans were found, which the Dietary Manager (DM) acknowledged should not have been there and needed to be removed. The facility's policy and procedure (P&P) on canned and dry goods storage, dated 2018, required that dented cans be set aside for return to the vendor or proper disposal. The DM admitted that the policy was not followed, and the designated area for dented cans was in their office. Additionally, a 22-quart container of dry lentil beans was found with its lid open, which the DM confirmed should have been closed to prevent food contamination or insect intrusion. The facility's P&P specified that metal or plastic containers with tight-fitting lids should be used for storage. The DM stated that kitchen staff were expected to follow this policy, but it was not adhered to in this instance. These lapses in following established procedures had the potential to cause foodborne illness among the vulnerable residents.
Infection Control Deficiencies in Laundry and Glucometer Disinfection
Penalty
Summary
The facility failed to implement proper infection control practices in several areas. Three personal laundry cart covers were observed to be soiled and discolored, which could potentially contaminate clean linen. The Housekeeping and Laundry Aide acknowledged the discoloration, and the Housekeeping and Laundry Supervisor confirmed that the covers needed replacement to protect clean laundry from dust during transport. Additionally, a clean linen closet was found with a dark discolored floor and debris, which had not been cleaned in a while, contrary to the facility's policy requiring daily cleaning with a detergent germicide. Furthermore, two Registered Nurses failed to properly disinfect glucometers after use, as per the facility's policy and manufacturer's guidelines. RN 1 used a Super Sani-Cloth wipe but did not allow the glucometer to remain wet for the required two minutes. RN 3 used an alcohol prep pad, which is not in line with the facility's policy or the manufacturer's instructions. The Infection Preventionist Nurse confirmed that the glucometers should be disinfected for at least three minutes with Sani-Wipes to prevent the risk of transmission-based infections.
Failure to Document Employee COVID-19 Vaccination Status
Penalty
Summary
The facility failed to track and record the COVID-19 vaccination status of nine employees, including a Plant and Maintenance worker, a Housekeeper, two Certified Nursing Assistants, a Registered Nurse, a Licensed Vocational Nurse, and three Nursing Assistants. These employees were hired between July 2024 and January 2025, and their vaccination statuses were not documented in the facility's Employee COVID-19 Vaccination Log. This oversight was identified during a review of the log, which was undated, and confirmed through interviews with the Infection Preventionist Nurse and Scheduler Personnel. The Infection Preventionist Nurse stated that the vaccination status of recently hired staff was not recorded because COVID-19 vaccination was not mandatory at the time of their hiring, and the nurse no longer inquired about it. The facility's policy, dated January 1, 2022, required all employees to report their vaccination status and provide proof to the infection prevention team or human resources. The policy also mandated that employees provide truthful and accurate information about their COVID-19 vaccination status. Despite this policy, the failure to document the vaccination status of these employees had the potential to spread COVID-19 to residents, staff, and visitors.
Inaccurate MDS Documentation of Resident Discharge Location
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, resulting in an inaccurate medical record regarding the resident's discharge location. During an interview and record review, it was found that the MDS indicated the resident was discharged to a short-term general hospital for acute care. However, the Nurse's Notes documented that the resident was actually discharged to home in stable condition. The MDS Coordinator (MDSC) acknowledged the discrepancy and stated that the MDS should have been accurate. The MDS was completed by the Social Services Director, and the MDSC had attested to its accuracy without reviewing the relevant section for correctness. The facility did not have a specific policy and procedure for ensuring MDS accuracy but followed the CMS RAI Manual. The MDSC admitted to not verifying the information in the MDS Section A2105 against the medical record, leading to the inaccurate documentation of the resident's discharge location.
Inaccessible Fluids for Resident at Risk of Dehydration
Penalty
Summary
The facility failed to ensure that fluids were accessible at the bedside for one of the sampled residents, identified as Resident 47. During an observation and interview, it was noted that the bedside table with a water pitcher and cup was placed next to the window, away from the resident's reach, and no straw was available. Resident 47 expressed that she could drink water independently if a straw was provided and mentioned experiencing diarrhea. A registered nurse confirmed that the bedside table should be within the resident's reach and acknowledged the resident's risk for dehydration due to diarrhea. The resident's care plan indicated a potential fluid deficit, and the facility's policy on hydration required that fresh water and a clean cup be available near the bedside at all times.
Failure to Monitor Oxygen Saturations
Penalty
Summary
The facility failed to monitor the oxygen saturations of two residents, Resident 18 and Resident 41, as per their physician orders. Resident 18 was observed on multiple occasions without wearing oxygen, despite having an order for oxygen inhalation at 2 liters per minute via nasal cannula as needed for oxygen saturation less than 93%. The Registered Nurse (RN) confirmed that Resident 18's oxygen saturations were not documented in the Electronic Medication Administration Record (EMAR), which should have been done according to the order. The Director of Nursing (DON) acknowledged that Resident 18 should have had oxygen saturation monitoring to determine when oxygen needed to be applied. Similarly, Resident 41's oxygen saturations were missing from the electronic medical record (eMR) for several shifts, despite having a physician order for continuous oxygen inhalation at 2-3 liters per minute via nasal cannula for shortness of breath or if oxygen saturation was less than 92%. The Licensed Vocational Nurse (LVN) confirmed the absence of documentation, and the DON stated that the facility's process was to follow physician orders, which included monitoring oxygen saturations. The Respiratory Therapist (RT) indicated that in a nursing home, oxygen saturations are typically monitored once a shift, and other assessments should be performed for residents with oxygen orders.
RN Lacks Current CPR Certification
Penalty
Summary
The facility failed to ensure that a registered nurse (RN 1) maintained current cardiopulmonary resuscitation (CPR) certification, as required by the facility's job description for registered nurses. During a review of RN 1's employee file, it was found that RN 1's CPR certification had expired the previous year, and the Human Resource Manager confirmed that RN 1 did not meet the employment requirement for CPR certification. RN 1, who was observed working in the facility's East wing, acknowledged the lapse in certification and recognized its importance in responding to medical emergencies involving residents. The job description for registered nurses at the facility explicitly stated the necessity of having a CPR license, which RN 1 did not possess at the time of the review.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to a resident, identified as Resident 18, who required such equipment during meals. According to the resident's Order Summary Report dated February 5, 2025, and a physician's order from November 3, 2023, Resident 18 was to use build-up foam utensils with all meals due to a lack of coordination. The resident's care plan also indicated a risk for nutritional decline related to the need for adaptive equipment. However, during an observation on February 5, 2025, Resident 18 was seen eating lunch with regular utensils, contrary to the prescribed adaptive equipment. During an interview with RN 2, it was confirmed that the resident was using regular utensils and that the adaptive equipment was not provided as required. RN 2 acknowledged the oversight and stated that it was the kitchen's responsibility to ensure the provision of the necessary adaptive utensils. The facility's policy on Nutrition Care, dated 2018, mandates that adaptive eating devices should be readily available during meal times for residents assessed to need them, with the Department of Food and Nutrition Services responsible for their provision. This failure to provide the necessary adaptive equipment had the potential to result in nutritional decline for Resident 18.
Facility Fails to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the resident shower rooms, affecting five sampled residents. During an observation and interview with the Facility Director, it was noted that the East Wing Shower Room had blackish discoloration on the grout in the shower stalls, and the grout around the toilet was discolored and damaged. The storage area for shower chairs and gurneys had black spots on the ceiling and floor tiles, and the shower chairs had a thick, slimy black substance under the seat. Similar issues were observed in the [NAME] Wing Shower Room, where the grout and shower chairs were also discolored and dirty. In the North Wing Shower Room, a brown discoloration on the wall was identified as a bowel movement. The Facility Director acknowledged that the housekeeping staff were responsible for cleaning these areas during the day, while janitors were responsible in the evening. The Administrator stated that high-touch surfaces should be cleaned daily and acknowledged the need for cleaning and maintenance in the shower rooms. The facility's housekeeping policy, dated 5/1/12, outlined the responsibility of maintaining a clean and safe environment, but the observations indicated a failure to adhere to these standards, potentially leading to the spread of infection or negative health outcomes.
Violation of Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a Restorative Nurse Assistant (RNA) who placed her hand over the resident's mouth to quiet her down. This incident was observed by a Certified Nursing Assistant (CNA) and was later confirmed through security camera footage. The resident, who has moderately impaired cognition as indicated by a BIMS score of 9, was seen wheeling herself out of her room and screaming for help. The RNA was observed on camera placing her hand over the resident's mouth, which the resident then slapped away. The RNA subsequently touched the resident's head and shoulder. The Director of Nursing (DON) verified the observations from the security footage and confirmed that the facility's investigation had been completed. The facility's policy on dignity and respect, which emphasizes a zero-tolerance stance on harassment and requires employees to maintain professional conduct, was not adhered to in this instance. The actions of the RNA were in direct violation of this policy, leading to the decision to terminate both RNA 1 and RNA 2 involved in the incident.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its Abuse Prevention Program policy and procedure for a resident, leading to a potential risk of further abuse. On a specific date, a Certified Nursing Assistant (CNA) observed a Restorative Nurse Assistant (RNA) placing her hand over a resident's mouth to stop her from screaming. The resident was in her wheelchair, coming out of her room, and was heard screaming for help. The CNA reported this incident immediately to her supervisor. Security camera footage confirmed the incident, showing the RNA placing her hand over the resident's mouth and the resident slapping the hand away. Despite the immediate report of the abuse, the RNA continued to work with residents for several hours before being sent home. The facility's policy required that accused employees be placed on administrative leave during investigations to ensure resident safety, which was not followed in this case.
Unattended Tools Pose Safety Risk
Penalty
Summary
The facility failed to adhere to its policy and procedure on safety for residents when tools were found unattended on the floor, posing a potential risk of injury. During an observation and interview, nine one-inch screws were discovered on the floor in the hallway near the Director of Nursing's office, which the Administrator confirmed. Additionally, a screwdriver and repair parts were found on the floor of an office with the door left open. The Maintenance Assistant admitted to leaving the tools and parts unattended and acknowledged that it was unsafe to do so. The Administrator and Director of Nursing both expressed concerns about the safety implications of leaving tools unattended, especially with the office door open, allowing residents access. The Director of Maintenance and Housekeeping emphasized that all potential hazards should be cleared and work areas should be blocked off. The facility's policy, dated January 28, 2018, clearly states that tools and equipment should not be left unattended in resident areas.
Failure to Position High-Risk Residents Near Nurse's Station
Penalty
Summary
The facility failed to ensure that two residents, who were at high risk for falls, were positioned near the nurse's station as specified in their care plans. Resident 1, who had a history of repeated falls and was diagnosed with conditions such as dementia, muscle weakness, osteoporosis, and difficulty walking, was observed to have their bed placed by the window, far from the nurse's station. Despite interventions in the care plan to keep Resident 1 close to the nurse's station for closer monitoring, the resident experienced multiple falls, including an unwitnessed fall that resulted in a hip fracture. Interviews with the Director of Nursing and staff confirmed that Resident 1's room was not close enough to the nurse's station, which hindered timely response to the resident's bed alarm. Similarly, Resident 3, who also had a history of falls and was diagnosed with muscle weakness and unsteadiness on feet, was found to have their bed positioned by the entrance door, away from the nurse's station. The care plan for Resident 3 also included an intervention to keep the resident close to the nurse's station for monitoring. However, Resident 3 experienced an unwitnessed fall while attempting to get up from their wheelchair, which was equipped with an alarm. The facility's policy on resident falls emphasized the need for prompt intervention and monitoring to prevent further falls, but the failure to position these high-risk residents near the nurse's station as planned contributed to the deficiency.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to the state agency for five of eight sampled residents. Resident 1 reported multiple incidents of physical altercation with another resident, Resident 2. Despite Resident 1 being cognitively intact and reporting these incidents to the Social Services Department, the facility did not report the allegations to the California Department of Public Health (CDPH) because they found no evidence of the altercations on security cameras. Staff interviews revealed that Resident 2 had a fixation on Resident 1, and there were multiple instances where staff had to intervene to prevent altercations. Resident 3 reported multiple incidents of sexual allegations against Resident 4, who had severe cognitive impairment and a diagnosis of Alzheimer's Disease and dementia. Despite Resident 3 being cognitively intact and reporting these incidents to the Social Services Department, there was no documentation of these incidents in Resident 3's medical records. Staff interviews indicated that Resident 4 had a history of wandering into female residents' rooms and making sexual remarks, yet these allegations were not reported to the state agency. Additionally, staff witnessed Resident 4 being sexually inappropriate with Resident 5, who had severe cognitive impairment and multiple disabilities. The incident was reported to a supervisor, but there was no further action taken or report made to the state agency. The facility's policy required all allegations of abuse to be reported to the appropriate authorities, but this was not followed, leading to a failure in ensuring the safety of the residents.
Failure to Obtain Timely Dental Services for Residents
Penalty
Summary
The facility failed to obtain necessary dental services for two residents, leading to potential oral health issues. Resident 6, who was cognitively intact, was observed with multiple discolored and broken teeth, swollen gums, and reported severe pain. Despite expressing his need for dental services to social services, no action was taken to address his dental issues. The resident had been recommended for extractions in April 2024, but the necessary referrals and follow-ups were delayed, leaving him in pain without any pain management. Resident 7 also required dental care, specifically oral surgery on four teeth, as recommended in June 2024. However, the referral for this procedure was not sent until late August 2024, indicating a significant delay in addressing his dental needs. The Business Clerk, who began assisting with referrals in July, was unsure of the process prior to her involvement and acknowledged the delay in sending the referral. The Director of Nursing confirmed that referrals for medical clearance should be made promptly, ideally the same day or the next business day, to prevent complications such as infection, pain, and eating issues. The facility's policy on dental services emphasized the importance of providing necessary routine and emergency dental care, yet the delays in referrals and lack of follow-up demonstrated a failure to adhere to these guidelines.
Failure to Process Resident Complaints on Medication Administration
Penalty
Summary
The facility failed to process complaints from four cognitively intact residents regarding medication administration issues by registry nurses (RNNs) according to their policy and procedure. Resident 2 reported that medications were not passed on time during night shifts, while Resident 3 stated that not all medications were given, with the last incident occurring approximately a week prior. Resident 1 mentioned forgetfulness in medication administration by nurses but could not specify which medications or when the incidents occurred. Resident 4, who is familiar with the shape and color of her medications, reported that an RNN forgot to give her heart medication the previous week. The Facility Scheduler (FS) acknowledged receiving complaints about RNNs not administering medications and stated that she contacted the registry to prevent the return of certain RNNs. However, FS did not verify the competency of new RNNs for medication pass and was unsure of the identities of the RNNs involved or the residents affected. LVN 3 confirmed that Resident 3 had complained about missing medications and noticed a similar issue with Resident 4, where medications were signed off as given but were not administered. The Director of Staff Development (DSD) and the Director of Nursing (DON) both confirmed that RNN 1 was asked not to return due to medication errors, but they were unable to identify the affected residents or the specific medications involved. The facility's policy requires grievances to be logged and resolved within five business days, but this process was not followed, as evidenced by the lack of documentation and resolution of the residents' complaints.
Medication Administration Competency Failure
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) was competent in administering medications, which led to a medication error involving a resident. LVN 1 observed that a resident's tube feeding bag contained medication, which was not the correct procedure. The resident, who was cognitively intact, mentioned that nurses at night could be forgetful with medications. The Director of Nursing (DON) confirmed that medications should not be placed in a tube feeding bag and acknowledged this as a medication error. Further investigation revealed that LVN 2, a new nurse, had been administering medications without having completed the required competency evaluation by the pharmacy or being observed by other staff nurses. LVN 2 admitted to placing medications into the resident's tube feeding bag. The facility's policy requires all staff to demonstrate competency in their duties, but LVN 2 had not been properly evaluated, leading to this oversight.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident, leading to a potential risk of serious injury or harm. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, cerebral infarction, aphasia, muscle weakness, and a history of falls, was identified as high risk for falls. Despite this, the facility did not adhere to its own protocols for fall prevention. On a specific date, the resident experienced an unwitnessed fall in her room, resulting in a laceration and fracture of the right pinky finger, requiring hospital treatment. The facility's policy required staff to document interactions with the resident every two hours, anticipate her needs, and check alarms to prevent falls. However, the Director of Nursing confirmed that there was no documentation of these required interactions and checks in the resident's electronic medical record. This lack of documentation and adherence to the fall prevention protocol contributed to the resident's fall and subsequent injuries. The facility's policies on fall prevention and documentation were not followed, as evidenced by the absence of records indicating compliance with the required interventions.
Failure to Label Tube Feeding Bags
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Enteral Therapy/Tube Feeding' by not labeling tube feeding bags with dates and times for two residents. During an observation, it was noted that Resident 1 had two tube feeding bags hanging in their room that were not labeled with the required information. Resident 1 had a diagnosis related to gastrostomy and was receiving Jevity 1.5, a tube feeding formula. A Licensed Vocational Nurse confirmed that the bags were not labeled as per the facility's policy. Similarly, Resident 5, who also had a diagnosis related to gastrostomy and was on Jevity 1.5, was observed at the nurse's station with an unlabeled tube feeding bag. A Registered Nurse acknowledged that the bag was not labeled with the time, as required by the facility's policy. The facility's policy, dated June 5, 2014, clearly states that each bag should be labeled with the resident's name, date, room number, and the time the formula was started. This oversight had the potential to result in the residents consuming contaminated feeding formula from old tube feeding bags.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe temperature in a resident's room, which was observed to be 84.4 degrees Fahrenheit. This temperature exceeded the facility's policy range of 71 to 81 degrees Fahrenheit, as verified by the Facility Director during an observation and interview. The Administrator confirmed that room temperatures should be maintained within this specified range. The resident involved had multiple medical diagnoses, including epilepsy, aphasia, hemiplegia, encephalopathy, and dysphagia, and was unable to participate in cognitive assessments due to cognition issues. The facility's policy and procedure for resident environment, dated 5/6/11, emphasized the importance of maintaining ambient temperatures to minimize residents' susceptibility to health risks. However, the facility did not adhere to this policy, resulting in a potential risk for the resident's comfort and safety.
Failure to Report and Act on Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure on abuse prevention for a resident who was allegedly abused by a Certified Nursing Assistant (CNA). The incident involved a cognitively intact resident who reported an altercation with the CNA, during which the CNA allegedly punched him. The resident's family member was informed of the alleged abuse but did not report it to the facility staff, believing the resident might be fabricating the incident. The CNA, who was accused of the abuse, did not report the allegation to facility management and continued working his shift, contrary to the facility's policy that mandates immediate reporting of such incidents. The facility's policy requires that any suspected abuse be promptly reported to management and that the accused employee be placed on administrative leave during the investigation. However, the CNA was not removed from duty immediately after the allegation was made, which could have delayed the investigation and potentially allowed the abuse to continue. The facility's Director of Nursing and Administrator acknowledged the need for additional training for the CNA on the abuse reporting process. The facility's policy also mandates that all reports of abuse be thoroughly investigated, but the initial failure to report the incident promptly could have compromised this process.
Inadequate Assistance During Ambulation Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate physical assistance and use of a transfer device during ambulation for a resident, resulting in a fall and injury. The Director of Rehabilitation (DOR) was assisting the resident while walking but did not provide hand support because she was holding a cellphone in her left hand and a wheelchair in her right hand. This lack of support led to the resident losing balance and falling, causing a right shoulder tendon tear and severe pain, necessitating a hospital visit. The resident had a history of difficulty walking, unsteadiness on feet, and muscle weakness, as indicated in her admission record. Her care plan identified her as high risk for falls, requiring one-person assistance with transfers. During the incident, the DOR did not apply a gait belt, which is a standard safety measure for residents with mobility issues. The resident expressed feeling dizzy and attempted to sit back in her wheelchair, which was not within reach, leading to her fall. Interviews and record reviews confirmed that the DOR did not follow the facility's policy and procedure for ambulation, which requires the use of a gait belt and correct guarding or spotting. The physical therapy progress report indicated that the resident required contact guard assistance, meaning a caregiver should have one hand on the resident for stability. The failure to adhere to these protocols directly contributed to the resident's fall and subsequent injuries.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by observations and interviews with two residents. Resident 1, who was cognitively intact, reported seeing a possible black widow spider on a patio chair and noticed other black spiders in the area. The patio area where Resident 1 sat had large, thick, irregularly shaped webs covering the bottom portions of tables and chairs, as well as planters. Similarly, Resident 2, also cognitively intact, reported seeing black widow spiders and cockroaches in the patio area daily, particularly under a gazebo structure used for smoking. The gazebo and surrounding areas were observed to have thick webs and webbed egg sacs. Interviews with maintenance staff revealed that the patio area was cleaned daily, which included emptying trash cans, disinfecting tables and chairs, pressure washing weekly, and knocking down cobwebs. However, the Facilities Maintenance Director acknowledged that the pest control services had changed in April 2024, and there was no tracking binder for the new company. The facility's policy on pest control, dated 2011, stated that the facility should maintain an effective pest control program to ensure the safety and well-being of residents, staff, and visitors. Despite these policies, the presence of spiders and webs indicated a failure to maintain a pest-free environment.
Resident Moved to Dining Room for Sleeping Due to COVID-19 Admission
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when the resident was moved to the dining room to sleep for one night. This incident occurred after a late admission tested positive for COVID-19, and the facility had no other rooms available. The Registered Nurse (RN) and the Director of Nursing (DON) confirmed that this was not the facility's normal process. The resident expressed feeling scared and rushed during the move, and the resident's representative stated that there was no consent given for the room change, describing the situation as humiliating for the resident. The resident's Nurses Note indicated that the family was informed about the need to move the resident to the dining room due to the roommate being on droplet isolation precautions. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate impairment. The facility's policy on Resident Rights emphasizes the right to a dignified existence and self-determination, which was not upheld in this situation. The Interdisciplinary Team (IDT) meeting note confirmed the temporary move due to unexpected circumstances.
Failure to Provide Timely Medical Attention for Resident Experiencing Seizures
Penalty
Summary
The facility failed to provide necessary care and services for a resident experiencing repeated seizures. The resident, who had a history of unspecified convulsions, muscle weakness, and chronic obstructive pulmonary disease, experienced multiple seizures that were not promptly identified or addressed by the registered nurse (RN). Despite the resident's seizures lasting between seven to ten minutes each and occurring back-to-back, the RN did not call the physician promptly, send the resident to a higher level of care, or ensure that qualified staff monitored the resident. Instead, the RN dismissed the seizures as pretended and was more concerned with drying her cell phone after spilling coffee on it. The resident's condition deteriorated significantly due to the lack of timely medical intervention. The resident required continuous oxygen and had difficulty swallowing after returning from the hospital. The resident's functional abilities also declined, necessitating increased assistance from staff for daily activities. The resident's seizures were severe enough to require hospitalization, where it was confirmed that the resident had recurrent breakthrough seizures and status epilepticus, a medical emergency. Interviews with various staff members, including licensed vocational nurses (LVNs) and certified nursing assistants (CNAs), revealed that the RN ignored multiple requests to send the resident to the hospital. The RN instructed CNA students, who were not adequately trained, to monitor the resident, further compromising the resident's safety. The facility's Director of Nursing (DON) confirmed that the RN's actions were inappropriate and did not align with the facility's policies and procedures for handling changes in a resident's condition.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat four residents with dignity and respect, as evidenced by multiple incidents involving a registered nurse (RN 1). Resident 2 reported that RN 1 dismissed his concerns about Resident 1's health, who was experiencing multiple uncontrolled seizures. RN 1 told Resident 2 to leave the room and did not check on Resident 1, who was later sent to the hospital. Resident 1 confirmed the account and expressed worry about his condition. Additionally, Resident 3 and Resident 7 described RN 1 as having a bad attitude and being intimidating, respectively. The facility's administrator acknowledged receiving complaints about RN 1 and stated that an investigation was ongoing. Further review of RN 1's employee file revealed a history of similar complaints and disciplinary actions. RN 1 had been written up for not responding promptly to a family's request during a change of condition, making discourteous remarks, and failing to stay on shift until properly relieved. The facility's social services director also documented numerous complaints from residents about RN 1's attitude. Despite these documented issues, no policy and procedure on dignity and respect were provided upon request.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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