El Rancho Vista Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pico Rivera, California.
- Location
- 8925 Mines Avenue, Pico Rivera, California 90660
- CMS Provider Number
- 555112
- Inspections on file
- 25
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at El Rancho Vista Health Care Center during CMS and state inspections, most recent first.
Unsafe food storage and handling practices were observed in the kitchen and resident refrigerator. Three packs of ham in the freezer were unlabeled, an employee wore a cuff bracelet while preparing food and assembling trays, and resident refrigerator items were marked with room numbers or initials instead of resident names, dates, and use-by dates when applicable. A non-resident beverage was also stored in the resident refrigerator, and the DON stated staff and resident items should not be mixed.
Clothing Protector Referred to as a Bib: A resident with dysphagia, GERD, and type 2 DM, who had intact cognition and could make medical decisions, was observed during a meal when a CNA placed a towel over the resident’s chest and said, “I’ll put your bib on.” The resident stated staff always called the clothing protector a bib, while the DSD and DON stated the item should not be called a bib because residents are adults and the term can undermine dignity.
Failure to Refer Incapacitated Resident for Patient Representative: A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder was documented by the H&P as lacking capacity to understand and make decisions, while the admission record listed the resident as self-responsible. The SSD stated the resident had no family or designated decision-maker and was never referred to OLTCPR, despite facility policy requiring notification when no representative could be found. The DON stated the resident needed a representative, such as a family member, friend, or OLTCPR appointee, to assist with medical decisions and care oversight.
Failure to Obtain Valid Informed Consent for Psychotropic Medication: A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder was documented in the H&P as lacking capacity to understand and make decisions, yet the consent for Zyprexa was obtained from the resident rather than a responsible party. RN and DON interviews confirmed the resident could not consent to the psychotropic medication, while the MAR showed Zyprexa was administered after the improper consent was documented.
A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder had a POLST indicating DNR, but the H&P stated the resident lacked capacity to understand and make decisions. The SSD and DON stated the POLST should be completed by the resident only if the resident had decision-making capacity, or by the responsible party if not. The resident signed the POLST despite lacking capacity to understand the DNR order.
Delayed Notification for Stroke-Like Change of Condition: A resident with CVA-related hemiplegia, dementia, dysphagia, and severe cognitive impairment developed left-sided weakness, facial drooping, and drooling during dinner. Staff recognized the symptoms as a possible stroke, but the physician was not notified immediately and the resident's RP was not given a complete clinical update about the seriousness of the condition or the risks of delaying transfer. The resident was later sent to the hospital by EMS after the RP arrived and requested transfer.
ABN forms were not provided for two residents when Medicare Part A skilled coverage ended. One resident had profound/severe cognitive impairment with dependence for ADLs, and the other had severe cognitive impairment and could not make medical decisions. The BOM stated both residents remained in the facility after their last covered day and received a NOMNC, but not an ABN, even though the forms were needed to explain which services Medicare would cover and which costs could become the resident's responsibility.
Unorganized Closet Prevented Door From Closing: A resident with cerebral palsy, DM, depression, and HTN had a closet that was not organized and could not fully close because of the resident’s belongings. The resident, who used a wheelchair and needed substantial assistance with personal care, stated the closet door had hit the resident’s hand multiple times while exiting the room and made the resident feel frustrated and unsafe. An LVN observed the same condition and stated the belongings should be organized so the door could close, while a CNA and the DON acknowledged residents have the right to a clean, safe, and homelike environment.
A resident with schizophrenia, bipolar disorder, and major depressive disorder had an active order for Mirtazapine, but the care plan still referenced Lexapro and depression manifested by self-expression of sadness. The MDSN and DON stated the care plan should have been revised to match the current medication and active orders, and the facility policy required updates based on the resident’s assessed needs.
Blood Pressure Medication Given Using an Outdated BP Reading: An LVN administered amlodipine to a resident with HTN after relying on a BP reading taken nearly an hour earlier instead of measuring it close to the time of administration. The resident’s order required the medication to be held if SBP was below 110, and the DON stated BP should be checked about five minutes before giving BP meds because it can fluctuate quickly.
Failure to continue weekly weights after a resident had a 3 lb loss in one week. The resident had dysphagia, GERD, and type 2 DM, required substantial help with eating, and was dependent on staff for multiple ADLs. The IDT review and SBAR documented the weight loss and high nutritional risk, but the resident was then followed with monthly weights, leaving the facility unable to tell whether the later 4 lb loss was gradual or sudden.
Failure to assess and respond to possible stroke symptoms: A resident with prior CVA-related hemiplegia/hemiparesis, dysphagia, dementia, and severe cognitive impairment developed left-sided weakness, facial drooping, and drooling. Nursing staff observed the symptoms, but neurological checks were not initiated, the physician was not notified until later, and the resident was transferred to the GACH by 911 after the RP requested it. The LVN stated the symptoms were consistent with a possible stroke but did not complete the neuro assessment, and the DON stated staff were expected to perform a thorough neurological assessment when deficits were identified.
Failure to Complete Annual CNA Performance Evaluations: The facility did not complete annual performance evaluations for two CNAs. A file review showed no annual evals for CNA 3 and CNA 4 for the review period, and the DSD confirmed both were missing. The ADM stated annual evaluations are important for identifying staff issues and additional training needs, and the facility policy requires each employee to receive an annual performance evaluation review.
Controlled meds were left unsecured in the DON’s office, with intact tablets still retrievable from the destruction bin and the bin not kept under double lock. A resident’s lisinopril was not available for timely administration, and the MAR was inaccurately completed to show doses were given when they were not. Another resident with a g-tube and GERD received famotidine via g-tube earlier than the ordered time, contrary to the MAR and the facility’s medication administration policy.
Medication Given Despite BP Hold Parameters: A resident with atrial fibrillation, hypertensive CKD, chronic ischemic heart disease, and bradycardia received amiodarone despite physician orders to hold the med when SBP was below 110 or HR was below 60. The MAR showed multiple administrations when SBP was below the ordered limit, and two LVNs stated they gave/documented the doses even though the parameters were not met.
Improper Storage of Unopened Insulin: An unopened NovoLog Flex Pen for a resident with DM and ESRD was found in a med cart instead of being refrigerated. An LVN said it had been delivered earlier that morning and kept there for convenience for the evening shift, and acknowledged unopened insulin is typically refrigerated until first use. Manufacturer guidance required refrigeration until initial use, and the facility’s med storage policy required storage that maintained product integrity and safety.
A resident with a history of CVA, hemiplegia/hemiparesis, dysphagia, dementia, and severe cognitive impairment developed left-sided weakness, facial drooping, and drooling during dinner. The SBAR and nursing notes documented RP notification, delayed MD notification, and transfer to the GACH, but did not show that the RN was notified or that an RN assessment/interventions were documented, even though the RN stated he assessed the resident and did not chart it.
Water pitchers for two residents with dysphagia and severely impaired cognition were found past their use-by date and not changed daily as required. CNA and DS interviews confirmed the pitchers contained thickened water, should have been replaced the prior day, and the facility policy required resident water pitchers to be sanitized at least once daily.
Failure to Document COVID-19 Vaccine Refusal: A resident with dementia, diabetes, and HTN had severely impaired decision-making and lacked capacity to make decisions. The IPN stated she offered the COVID-19 vaccine to the resident’s RP, who refused, but the refusal was not documented in the health record. The DON stated the declination should have been signed and the refusal documented with the risks and benefits explained and a timeline for reoffering the vaccine.
A resident with severe cognitive impairment and high fall risk experienced a change in condition, including episodes of kneeling and placing themselves on the floor. Although the care plan was updated to include frequent visual monitoring and placement near the nurse's station, it did not specify how often monitoring should occur. Staff confirmed increased supervision, but the care plan lacked clear, measurable timetables for interventions.
The facility failed to ensure safe kitchen practices, affecting all 67 residents. Observations revealed improperly labeled food in the refrigerator and freezer, with temperatures outside acceptable ranges. A dietary staff member did not change gloves between tasks, risking cross-contamination. These issues could lead to foodborne illnesses among residents.
A facility failed to develop a care plan for a resident diagnosed with C. diff, despite the resident's moderate cognitive impairment and need for assistance with daily activities. The absence of a care plan was identified during a review of the resident's medical record, and interviews with staff highlighted the importance of such a plan in managing the resident's condition.
A facility failed to provide care according to physician's orders for three residents. One resident did not have their blood sugar levels monitored despite having diabetes, another did not have their surgical dressing changed post-surgery, and a third received insulin too early before meals, risking hypoglycemia. The DON acknowledged the importance of following orders and standard practices to ensure residents' health needs are met.
Two residents in a facility were found to have incorrect low air loss mattress (LALM) settings, which did not reflect their actual weights. One resident, weighing 163 pounds, had a LALM set for 340 to 520 pounds, while another, weighing 130 pounds, had a LALM set at 220 pounds. These discrepancies were observed and confirmed by staff, including the Treatment Nurse and Director of Nursing, who acknowledged that incorrect settings could worsen pressure injuries. The facility's policy required LALM settings to match residents' weights, but this was not followed, leading to deficiencies in care.
A facility failed to label a resident's peripheral IV dressing with the date, time, and nurse's initials, as required by policy. The resident, with a history of knee replacement and end-stage renal disease, was receiving IV antibiotics for an infected knee arthroplasty. The omission was noted during an observation, and interviews with staff confirmed the labeling requirement to prevent infection by ensuring timely IV site rotation.
A facility failed to display No Smoking signs in a resident's room where an oxygen concentrator was in use, despite policy requirements. The resident had severe cognitive impairment and required significant assistance with daily activities. Staff acknowledged the oversight and the potential fire hazard posed by the lack of signage.
The facility failed to ensure safe medication administration for two residents. An LVN left medications at a resident's bedside without ensuring they were taken, leading to potential self-administration risks. Another resident's MAR inaccurately documented Ativan administration, which was unavailable, and Xanax was given instead. This documentation error could lead to mismanagement of the resident's anxiety and unnecessary dosage increases.
Two residents experienced significant medication errors in an LTC facility. A resident was not instructed to rinse their mouth after using a Budesonide-Formoterol Fumarate inhaler, risking oral thrush. Another resident received Metoprolol despite their SBP being below the ordered parameters, risking hypotension. Both errors were acknowledged by staff.
Expired IV solutions were found in the emergency kit at a nursing station, with one bag of 0.9% sodium chloride and two bags of 5% dextrose and 0.45% sodium chloride IV solutions being expired. LVN confirmed the expiration, and RN was responsible for checking the kit. The facility's policy required daily checks and removal of expired medications, but this was not followed, posing a risk to residents.
A resident with severe cognitive impairment experienced an unwitnessed fall, and the facility failed to notify the emergency contact as required by their policy. This oversight led to the family being unaware of the incident until they arrived to discharge the resident, causing concern about the resident's well-being and trust in the facility.
A resident with a history of subdural hemorrhage and dementia was transferred to a hospital after an unwitnessed fall. The facility failed to follow up on the resident's status, leading to misinformation about the resident's whereabouts and unmet discharge needs. The Admission Coordinator did not verify the resident's well-being with the family, and the facility lacked a specific policy for follow-up after hospital transfers.
A resident with Type 2 diabetes refused insulin administration multiple times, and the facility failed to notify the PCP as required by policy. The resident's blood sugar levels were elevated, and the lack of notification and documentation placed the resident at risk for complications. The DON acknowledged that a Change of Condition should have been created, and the PCP should have been informed.
A resident with Type 2 diabetes mellitus refused insulin injections on multiple occasions, but the facility failed to update the care plan to address these refusals. Despite the resident's cognitive intactness and need for assistance with daily activities, the care plan did not reflect the necessary interventions for insulin refusal, as confirmed by the DON. This oversight was contrary to the facility's policy for comprehensive care planning.
A facility failed to monitor a diabetic resident who refused insulin injections, as required by their Nursing Manual. The resident, who was cognitively intact and had a physician's order for insulin based on a sliding scale, refused the medication on multiple occasions. Despite this, there was no documentation of monitoring for hyperglycemia symptoms, which was confirmed by the DON.
Unsafe Food Labeling and Handling Practices
Penalty
Summary
Safe and sanitary food storage and preparation practices were not maintained in the kitchen and resident refrigerator areas. During the initial kitchen tour, three sealed packs of ham were observed in the freezer without labels showing the food item name, received date, or the manufacturer's use-by date. The Dietary Supervisor stated the ham should have been labeled with those details, and the facility policy required all food items in the storeroom, refrigerator, and freezer to be labeled and dated. During meal preparation and trayline, [NAME] 1 was observed wearing a cuff bracelet on the left wrist while removing and transferring peas, handling food trays on the steam table, and assembling plates. The Dietary Supervisor stated the bracelet was against the kitchen dress code because it could slip off into food, and stated it was an infection control issue because the bracelet could harbor bacteria and potentially transfer it to food. The facility policy on dress code allowed only limited jewelry, including a wristwatch, and did not permit excessive jewelry. In the designated resident refrigerator at Station 1, food and beverages were observed that were not labeled properly and one item did not belong to a resident. The refrigerator contained a green electrolyte beverage, yogurt containers, cola bottles, and mineral water, with markings such as room numbers or initials rather than resident names, dates placed in the refrigerator, and use-by dates when applicable. The LVN and DON stated resident food and beverages should be labeled with the resident's name, date placed in the refrigerator, and use-by date when applicable, and that staff or visiting clinician items should not be stored there. The DON also stated the yogurt should have been transferred to individual containers to ensure it was not ingested past its use-by date.
Clothing Protector Referred to as a Bib
Penalty
Summary
The facility failed to ensure Resident 70’s clothing protector was not referred to as a bib during meals. Resident 70 was admitted with diagnoses including dysphagia, GERD, and type 2 diabetes mellitus. The MDS dated 2/13/2026 indicated Resident 70’s cognition was intact, he required substantial assistance with eating, and he was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene. The H&P dated 2/9/2026 indicated Resident 70 had the capacity to understand and make medical decisions. During an observation on 4/20/2026 at 12:24 p.m., a CNA placed a towel over Resident 70’s chest and stated, “I’ll put your bib on.” During interview, Resident 70 stated he always wore a towel or bib when he ate to prevent food from spilling on his clothing, and that staff always called the clothing protector a bib. The DSD stated residents were supposed to have a dignified dining experience and that the clothing protector should not be called a bib because it could make residents feel less than or like a child. The DON stated any item used as a clothing protector during meals should never be referred to as a bib, and that calling it a bib was not appropriate because residents were adults and bibs were typically reserved for babies. The facility policy on dignity stated residents shall be treated with dignity and respect at all times.
Failure to Refer Incapacitated Resident for Patient Representative
Penalty
Summary
The facility failed to submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR) for one sampled resident who lacked decision-making capacity and had no legally authorized decision-maker. Resident 28 was admitted with diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder. The admission record identified the resident as self-responsible, while the History and Physical stated the resident did not have the capacity to understand and make decisions. The Minimum Data Set also documented delusions and assistance needs with multiple activities of daily living. During interview, the Social Services Director stated that when a physician determined a resident lacked capacity, the facility would first try to locate next of kin or another decision-maker, and if none was available, a referral would be sent to the OLTCPR. The Social Services Director also stated the resident would be placed under the bio-ethics committee while waiting for a representative. However, the Social Services Director acknowledged that Resident 28 did not have the capacity to make medical decisions when admitted and was never referred to the OLTCPR. The Director of Nursing stated that when a resident lacked the capacity to understand or make decisions, the facility was responsible for ensuring the resident had a representative, such as a family member, friend, or an appointed representative from the OLTCPR. The facility policy titled Lack of Capacity Process stated that after 72 hours, if no patient representative could be found, the facility would notify the Office of Patient Representative to assign one. The California Department of Aging webpage cited in the report stated that OLTCPR provides trained public representatives for residents who lack decision-making capacity and have no legally authorized surrogate.
Failure to Obtain Valid Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for Zyprexa from an individual with decision-making capability for Resident 28, who was documented as not having the capacity to understand and make decisions. Resident 28 was admitted with diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder. The H&P dated 4/7/2026 stated Resident 28 did not have the capacity to understand and make decisions, while the admission record incorrectly indicated the resident was self-responsible. The MDS dated 4/14/2026 noted cognition was intact and that the resident had delusions and required assistance with multiple activities of daily living. A physician order dated 4/15/2026 directed Zyprexa 5 mg by mouth at bedtime for schizoaffective disorder with paranoid delusions, and the MAR showed the first dose was given on 7/22/2025. RN 1 stated informed consent for psychotropic medication should be obtained from the resident or responsible party depending on capacity, and that Resident 28 should not have consented because he lacked the ability to make medical decisions. The consent form for Zyprexa indicated Resident 28 himself provided informed consent, and the DON confirmed Resident 28 did not have the capacity to understand and make decisions and therefore could not fully understand the use, side effects, and risks of Zyprexa.
POLST Completed by Resident Without Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that Resident 28’s POLST was reviewed and completed by an individual with decision-making capacity. Resident 28 was admitted with diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder. The resident’s MDS indicated cognition was intact and that the resident had delusions, while the H&P stated the resident did not have the capacity to understand and make decisions. During interview and record review, the SSD stated the POLST was to be completed by the resident if the resident had the capacity to understand and make decisions, or by the responsible party if the resident lacked that capacity. Resident 28’s POLST indicated a DNR order and was signed by the resident, even though the H&P stated the resident did not have the capacity to understand and make decisions. The DON stated it was inappropriate for Resident 28 to complete the POLST and that the resident had a DNR order despite lacking the capacity to understand what DNR meant.
Delayed Notification for Stroke-Like Change of Condition
Penalty
Summary
The facility failed to ensure timely physician and resident representative notification after a resident experienced a change of condition consistent with a stroke. Resident 5 had diagnoses including hemiplegia, hemiparesis following CVA, dysphagia, Alzheimer's disease, dementia, and sepsis. The resident's MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. The resident also had a POLST indicating DNR with comfort-focused treatment and transfer to the hospital only if comfort needs could not be met at the current location. According to the record, Resident 5 was transferred from bed to a wheelchair for dinner and later was observed with left-sided weakness and facial drooping. The SBAR note documented that at approximately 5:55 p.m. the resident was seen with left-sided weakness and facial drooping, and the resident's representative was notified and came to the facility. The note further indicated the physician was not notified until approximately 7:00 p.m., after the representative arrived and requested transfer to the hospital, and the resident was transported by 911 at approximately 7:30 p.m. The nursing progress notes and SBAR note did not show that the physician was informed immediately after the symptoms began. Interviews confirmed that staff recognized the symptoms as consistent with a possible stroke and that immediate physician notification and EMS activation were expected. RN 2 stated stroke symptoms are time-critical and require immediate notification and emergency response, and PA 1 stated licensed nursing staff were expected to notify the physician immediately and initiate EMS without delay when stroke symptoms were present. RP 1 stated she was not contacted before arriving at the facility and was not educated on the risks of delaying or declining hospital transfer, including information about stroke signs, symptoms, or seriousness. The DON and RN 1 stated the physician should have been notified when the change of condition was identified and that the resident's representative should have been given a complete clinical update, including the seriousness of the condition.
ABN Forms Not Provided When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to ensure Advance Beneficiary Notice (ABN) forms were provided when Medicare Part A coverage ended for two sampled residents, Resident 53 and Resident 58. Resident 53 was admitted and later readmitted to the facility, had diagnoses including dysphagia, Alzheimer's disease, and schizophrenia, and was documented in the H&P as having profound cognitive impairment. The MDS dated 1/22/2026 indicated severe cognitive impairment and dependence on staff for eating, toileting, hygiene, and bathing. Resident 53's SNF Beneficiary Notification Review form showed the last covered date for Medicare Part A skilled services was 2/6/2026, and that an ABN form was not provided. Resident 58 was admitted and later readmitted to the facility, with diagnoses including HTN, asthma, and dysphagia. The H&P dated 11/21/2025 stated the resident could make needs known but could not make medical decisions, and the MDS indicated severe cognitive impairment and substantial assistance needed for dressing, bathing, and toileting. Resident 58's SNF Beneficiary Notification Review form showed the last covered date for Medicare Part A skilled services was 1/23/2026, and that an ABN form was not provided. During interview, the BOM stated both residents remained in the facility after their last covered day of Medicare Part A services and were given a NOMNC, but not an ABN. The BOM and Administrator stated ABN forms should have been completed so the residents could be informed of which specific services would be covered by Medicare and which services they would be financially responsible for.
Unorganized Closet Prevented Door From Closing
Penalty
Summary
The facility failed to ensure a clean and homelike environment for one sampled resident with cerebral palsy, DM, depression, and HTN. The resident’s admission record showed the resident was admitted to the facility on [DATE], and the H&P dated 3/10/2026 indicated the resident had the capacity to understand and make decisions. The MDS dated 1/20/2026 indicated the resident’s cognitive skills for daily decision making were intact, and that the resident required substantial assistance from staff for personal hygiene, toileting, and bathing. During a concurrent observation and interview on 4/21/2026 at 11:02 a.m., the resident’s closet door was observed open and unable to close, limiting the available space to move freely in and out of the room. The resident stated belongings in the closet were not organized, the closet door could not fully close, and the resident had hit a hand on the closet door multiple times while trying to wheel out of the room. The resident also stated the inability of the closet doors to close made the resident feel frustrated and unsafe when entering and exiting the room. Later that day, an LVN observed the closet door open and unable to close due to the resident’s belongings and stated the belongings should be organized and the closet door should be able to close. Another LVN stated an opened closet door placed the resident at risk for safety and that staff should keep rooms clean to ensure a homelike environment. A CNA stated staff were responsible for organizing residents’ closets to ensure closet doors closed, and the DON stated residents had the right to a clean and safe environment. The facility policy stated residents are provided with a safe, clean, comfortable and homelike environment, including cleanliness and order.
Care Plan Not Revised for Current Antidepressant Order
Penalty
Summary
The facility failed to revise Resident 4’s comprehensive care plan to reflect the resident’s current use of Mirtazapine. Resident 4 was admitted and later readmitted to the facility with diagnoses including schizophrenia and bipolar disorder, and the MDS dated 4/7/2026 indicated moderately impaired cognition, dependence on staff for toileting, bathing, dressing, and personal hygiene, and symptoms of little interest or pleasure in doing things and feeling down, depressed, or hopeless for seven to 11 days. The MDS also indicated the resident received antidepressant medication. The H&P dated 2/15/2026 stated Resident 4 lacked capacity to understand and make medical decisions and had major depressive disorder. A physician order dated 4/14/2026 directed Mirtazapine 15 mg by mouth at bedtime for depression manifested by consuming less than half of meals. During interview and record review, the MDS Nurse stated the resident’s care plan should have been revised to reflect that Lexapro had been discontinued and Mirtazapine had been ordered, and that the entire care plan should have been reviewed and revised as needed to ensure proper monitoring for behavior and side effects. The DON stated diagnoses, changes in condition, and medications were care planned, and that the resident’s care plan should have been revised to match the active orders. The care plan titled Uses Antidepressant Medication, dated 1/1/2026, still indicated Lexapro related to depression manifested by self-expression of sadness, and the facility policy stated additional changes or updates to the comprehensive care plan would be made based on the assessed needs of the resident.
Blood Pressure Medication Given Using an Outdated BP Reading
Penalty
Summary
Licensed nursing staff failed to follow professional standards of practice when Resident 24 was given amlodipine 10 mg without obtaining a blood pressure reading close enough to the time of administration. Resident 24 was admitted with diagnoses including chronic subdural hemorrhage, hypertension, and compression of the brain, and the MDS indicated intact cognitive skills for daily decision making. The care plan directed staff to administer anti-hypertensive medications as ordered, and the physician order for amlodipine specified to hold the medication for systolic blood pressure less than 110. During observation, LVN 4 prepared and administered the amlodipine to Resident 24. A concurrent record review showed the blood pressure documented for that medication pass was 140/90 mmHg, but LVN 4 stated the reading had been obtained at approximately 7:50 a.m., nearly one hour before the medication was given. LVN 4 stated the blood pressure should have been measured closer to the time of administration to ensure safe administration. The DON stated it was best practice to measure blood pressure five minutes prior to blood pressure medication administration because blood pressure could quickly fluctuate based on the resident's activity and medical condition.
Failure to Continue Weekly Weights After Significant Weight Loss
Penalty
Summary
The facility failed to perform weekly weights for a resident after the resident experienced a 3 lb weight loss in one week. The resident was admitted with diagnoses including dysphagia, GERD, and type 2 diabetes mellitus. The MDS indicated the resident had intact cognition, required substantial assistance with eating, and was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene. The H&P indicated the resident had the capacity to understand and make medical decisions. The IDT Weight and Nutrition Review documented the resident had a 3 lb weight loss over one week and remained at high nutritional risk, with instructions to monitor weekly weights closely. The SBAR also documented the 3 lb loss from 119 lbs to 116 lbs and recommended consulting the RD. The care plan for weight loss indicated to weigh the resident as indicated. Facility staff stated residents were weighed weekly for four weeks after admission and then monthly unless weight loss occurred, at which point weekly weights should continue if indicated. The resident's recorded weights showed 118 lbs on 2/7/2026, 118 lbs on 2/13/2026, 119 lbs on 2/19/2026, 116 lbs on 2/26/2026, 116 lbs on 3/3/2026, and 112 lbs on 4/9/2026. The DON stated weekly weights should have continued for at least another four weeks after the 3 lb loss, and the facility was unable to determine whether the resident's 4 lb weight loss over a month was gradual or sudden.
Failure to Assess and Respond to Possible Stroke Symptoms
Penalty
Summary
Licensed nursing staff failed to demonstrate competency to prioritize and respond to signs and symptoms consistent with a possible CVA for one resident who had a history of hemiplegia and hemiparesis following a prior cerebral infarction, along with dysphagia, Alzheimer's disease, dementia, and sepsis. The resident's MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. On the evening of the event, the resident was observed by the RP with drooling from the left side of the mouth and not using the left arm, and nursing staff also observed left-sided weakness. The resident continued to show left-sided facial drooping, drooling, and weakness after the RP arrived at the facility. The SBAR documented that the RP requested transfer to the GACH, the physician was not notified until about 7:00 p.m., and the transfer order was obtained at 7:20 p.m. The resident was transported to the GACH by 911 at about 7:30 p.m. The SBAR and nursing progress notes did not indicate that neurological checks were initiated after the onset of symptoms. During interview, the LVN stated the resident's symptoms were consistent with a possible stroke and acknowledged that stroke symptoms are time-critical and require neurological assessments. The LVN stated she did not perform the neurological assessments because she thought the RN would do them and because she was busy with medications and blood sugar checks. The DON stated licensed nursing staff were expected to conduct a thorough neurological assessment after neurological deficits were identified, and the facility did not have a policy related to initiating neurological assessments for residents exhibiting signs and symptoms of a possible stroke. The LVN job description stated the licensed nurse was responsible for timely assessments, differentiating normal and abnormal findings, and reporting resident condition changes.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed for two Certified Nursing Assistants, CNA 3 and CNA 4. During a review of five employee files, the annual evaluation audit did not show a completed 2025-2026 evaluation for CNA 3, whose date of hire was 6/29/2015, or for CNA 4, whose date of hire was 3/15/2023. In an interview, the Director of Staff Development stated both CNAs did not have annual evaluations completed for the year 2025-2026 and stated annual evaluations should have been completed to ensure staff were compliant with facility policies and expectations. The Administrator stated annual evaluations were important because they gave management the opportunity to address issues staff needed to improve on or issues requiring additional training. The facility policy titled Annual Performance Evaluation dated 7/2019 stated that annually, each employee will receive a performance evaluation review.
Controlled Medication Security and Medication Administration Errors
Penalty
Summary
Pharmaceutical services were not provided in accordance with accepted professional standards and facility policies when controlled medications were not securely maintained and were not effectively destroyed. During observations of the DON’s office, the controlled medication destruction bin was left unsecured and accessible while the DON was not present. The bin contained multiple medications mixed with only a minimal amount of chemical solution, and several whole, undissolved tablets were visible on top of the contents. One observation identified five intact white oblong pills with imprint code IP 109 that were still retrievable from the bin. The DON stated controlled medications were typically destroyed in the presence of the pharmacist and that medications should be secured under double lock to prevent access. The pharmacist stated the chemical solution was intended to dissolve the controlled medications and that the bin should be kept locked to ensure security. Resident 46, who had diagnoses including CVA and hyperlipidemia and was cognitively intact for daily decision making, had an order for lisinopril 5 mg daily for hypertension. On review of the MAR, the dose was due at 9:00 a.m., but the medication had not been delivered to the facility after the order was placed four days earlier. The LVN stated the medication was not available in the facility’s emergency supply kit and confirmed it was important to have the medication readily available for timely administration. The LVN stated this placed the resident at risk for uncontrolled blood pressure. The MAR for Resident 46 also showed lisinopril documented as administered on two occasions when the medication was not actually given because it was not available. Two LVNs stated they documented the medication in error and confirmed the resident did not receive the ordered dose on those dates. Resident 16, who had diagnoses including gastrointestinal hemorrhage, g-tube status, and GERD and was severely cognitively impaired and entirely dependent on staff for ADLs, was observed receiving famotidine 20 mg via g-tube at 7:59 a.m. The MAR showed the medication was ordered for 11:00 a.m. The LVN admitted the dose was given early and stated the resident was at risk for gastrointestinal issues since the feeding was scheduled to stop shortly.
Medication Given Despite Blood Pressure Hold Parameters
Penalty
Summary
Medication administration was not carried out in accordance with the physician order for one resident with atrial fibrillation, hypertensive chronic kidney disease, chronic ischemic heart disease, and bradycardia. The resident’s order for amiodarone 200 mg by mouth twice daily directed staff to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. The resident’s assessment showed moderately impaired cognitive skills and maximal assistance needed for activities of daily living. The Medication Administration Record showed amiodarone was given on four occasions when the recorded systolic blood pressure was below the ordered parameter: 108/68, 102/76, 106/68, and 106/70. During interviews, two LVNs stated they documented and administered the doses despite the blood pressure readings being below the physician-ordered hold parameters, and both stated the medication should have been held. The facility’s medication administration policy stated medications would be administered according to physician orders, current best practices, and federal and state regulations.
Improper Storage of Unopened Insulin
Penalty
Summary
An unused and unopened NovoLog Flex Pen labeled for Resident 37 was observed inside the medication cart rather than being stored under refrigeration. During the observation and interview, the LVN stated the medication had not been used and had been delivered earlier that morning, but was kept in the medication cart for convenience for the evening shift. The LVN also stated that unopened insulin medications were typically stored in the refrigerator until first use and acknowledged that the lack of refrigeration had the potential to compromise the medication effectiveness for Resident 37. Resident 37 was admitted to the facility with diagnoses including diabetes and end stage renal disease. The resident’s MDS indicated intact cognitive skills for daily decision making and that the resident required maximal assistance for toileting, lower body dressing, and taking off footwear. Physician orders dated 2/25/2026 included insulin aspart injection solution 100 units per mL per sliding scale. Manufacturer guidelines for NovoLog indicated unopened insulin must be stored under refrigeration until initial use, and the facility’s Medication Storage policy stated medications would be stored in a manner that maintained product integrity, safety, and compliance with state Department of Health guidelines.
Incomplete Documentation of Stroke-Related Change in Condition
Penalty
Summary
The facility failed to ensure the medical record for one of six sampled residents was complete and accurately reflected care provided after a change of condition. Resident 5 had diagnoses including hemiplegia and hemiparesis following a CVA, dysphagia, Alzheimer's disease, dementia, and sepsis. The resident's MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. On 3/10/2026, while at dinner, Resident 5's RP observed drooling from the left side of the mouth and that the resident was not using the left arm. Nursing staff also observed left-sided weakness, and the resident was transported to the GACH. The hospital H&P documented decreased movement in the left upper and left lower extremities, and the hospital physician progress note later confirmed an acute right pontine infarct on MRI. The facility's SBAR note documented that at about 5:55 p.m. the resident was observed with left-sided weakness and facial drooping, the RP was notified, and the physician was not notified until about 7:00 p.m., with transfer ordered at 7:20 p.m. and 911 transport at about 7:30 p.m. However, the SBAR note and nursing progress notes did not show that RN 2 was made aware of the change in condition or that RN 2 assessed the resident. LVN 1 stated she made RN 2 aware but did not document it, and RN 2 stated he assessed the resident after being informed but did not document the assessment or interventions. The facility's Documentation Guidelines required staff to record observations promptly and accurately, and the RN Supervisor job description required accurate evaluation, reporting of condition changes, and assurance of complete medical records.
Water pitchers not changed and sanitized daily for two residents
Penalty
Summary
The facility failed to ensure timely replacement and sanitation of water pitchers for two residents with dysphagia and severely impaired cognition. Resident 10 was admitted and later readmitted to the facility, and his diagnoses included dementia, dysphagia, and UTI. His MDS dated 2/4/2026 indicated his cognitive skills for daily decision making were severely impaired and that he was dependent on staff for ADLs. During an observation on 4/20/2026 at 9:30 a.m., Resident 10's water pitcher was observed in his room labeled with a prepared date of 4/18/2026 and a use by date of 4/19/2026. Resident 53's record showed diagnoses of dysphagia and Alzheimer's disease, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for ADLs. During an observation on 4/20/2026 at 9:43 a.m., Resident 53's water pitcher in his room was also labeled with a prepared date of 4/18/2026 and a use by date of 4/19/2026. During interview, CNA 6 stated the pitchers contained thickened water and should be changed daily, and acknowledged they should have been changed on 4/19/2026. The Dietary Supervisor stated nursing staff was responsible for changing the pitchers each day and that the pitchers should have been changed at the end of the day on 4/19/2026. The facility policy stated residents' water pitchers would be sanitized at least once a day.
Failure to Document COVID-19 Vaccine Refusal
Penalty
Summary
The facility failed to document the responsible party’s refusal of the COVID-19 vaccine for one sampled resident. Resident 52 was admitted and later readmitted to the facility and had diagnoses including type 2 diabetes mellitus, dementia, and hypertension. The resident’s MDS showed severely impaired cognitive skills for daily decision making, and the H&P stated the resident did not have the capacity to understand and make decisions. RP 3 was the assigned responsible party for vaccine decisions. The Infection Preventionist Nurse stated she reviewed residents’ vaccines on admission and offered vaccines to the resident or responsible party within five days of admission. She reported that she spoke with RP 3 and offered the COVID-19 vaccine, and RP 3 refused, but this refusal was not documented in the resident’s health record. The DON stated the licensed nurse was responsible for asking about vaccines on admission and that the refusal should have been documented with the risks and benefits explained and a timeline for reoffering the vaccine. The resident’s immunization report showed the last COVID-19 vaccine was received on 12/22/2023, and the MDS was not updated on the resident’s COVID-19 vaccine status.
Failure to Develop Individualized, Measurable Care Plan After Change in Condition
Penalty
Summary
The facility failed to develop an individualized care plan for a resident following a change in condition, specifically after the resident exhibited behaviors such as kneeling and placing themselves on the floor, despite being identified as a high fall risk. The resident had a history of severe cognitive impairment, dependence on staff for activities of daily living, and diagnoses including metabolic encephalopathy, a right ulna fracture, and unsteadiness on their feet. The care plan in place noted the resident's risk for falls and listed general interventions such as anticipating and meeting needs, but did not specify the type or frequency of supervision or monitoring required. Further review revealed that after the resident began placing themselves on the floor, the care plan was updated to include frequent visual monitoring and placement near the nursing station for closer supervision. However, the care plan did not define how often this monitoring should occur. Staff interviews confirmed that 1:1 monitoring was implemented and that the resident was kept near the nurse's station, but the care plan lacked measurable, specific timetables for these interventions. The Director of Nursing acknowledged that the care plan should have included more specific monitoring intervals, especially given the resident's behaviors.
Deficiencies in Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to maintain safe and sanitary practices in the kitchen, affecting all 67 residents sampled. During a kitchen tour, it was observed that food in the refrigerator and freezer lacked proper labeling, including missing 'in' and 'use by' dates. Additionally, food items removed from their original packaging were not labeled with their contents. The Dietary Supervisor confirmed that all food should be dated and labeled according to the facility's policy. Furthermore, the refrigerator and freezer temperatures were found to be outside the acceptable range, with the refrigerator at 44 degrees Fahrenheit and the freezer at 10 degrees Fahrenheit, both of which exceed the recommended temperatures for maintaining food quality. Another issue observed was improper glove use by a dietary staff member, who failed to change gloves between tasks, such as cooking, plating food, and handling food request slips. This was confirmed by both the Dietary Supervisor and the staff member involved, who acknowledged the risk of cross-contamination. The facility's policy on glove use mandates that gloves are single-use and should be changed before starting a new task. These deficiencies in food handling and storage practices posed a risk of harmful bacteria growth and cross-contamination, potentially leading to foodborne illnesses among the medically compromised residents.
Failure to Develop Care Plan for Resident with C. diff Diagnosis
Penalty
Summary
The facility failed to develop a care plan for a resident diagnosed with Clostridioides difficile (C. diff), a condition that causes diarrhea and inflammation of the colon. This deficiency was identified during a review of the resident's electronic medical record, which lacked a completed care plan addressing the C. diff diagnosis. The resident, who was originally admitted to the facility and later readmitted with diagnoses of respiratory failure and atrial fibrillation, was found to have moderate cognitive impairment and required assistance with various daily activities. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) revealed that a care plan should have been developed for the resident's new diagnosis of C. diff. The IPN emphasized the importance of a care plan in monitoring residents and providing interventions and goals to minimize symptoms and prevent dehydration. The facility's policy on Comprehensive Person-Centered Care Planning indicated that care plans should be reviewed and revised with the onset of new problems or changes in condition, which was not adhered to in this case.
Failure to Provide Care According to Physician's Orders
Penalty
Summary
The facility failed to ensure that Resident 124 received appropriate monitoring of blood sugar levels as per the physician's orders. Despite being diagnosed with diabetes mellitus and having a care plan that required monitoring for hyperglycemia and hypoglycemia, there were no documented orders to check Resident 124's blood sugar levels. Interviews revealed that the resident expressed concern about not having their blood sugar checked, and the Licensed Vocational Nurse (LVN) admitted to not knowing the resident's blood sugar level and not having the necessary orders to perform the checks. The Director of Nursing (DON) acknowledged the importance of monitoring blood sugar levels for diabetic residents to ensure medication effectiveness. Resident 55 did not receive the necessary care for a surgical dressing change. The resident, who had undergone surgery over ten days prior, reported that the dressing had not been changed and appeared dirty. The Treatment Nurse (TN) confirmed that there were no orders for a dressing change and that the nursing staff should have followed up with the doctor to obtain the necessary orders. The DON stated that post-surgical dressings should be changed according to the doctor's orders and that the nursing staff should have contacted the doctor to get the appropriate orders. Resident 35 received regular insulin 30 minutes before their meal, contrary to the standard practice of administering insulin closer to mealtime to prevent hypoglycemia. The LVN administered the insulin without ensuring that food was available, and the resident did not have any food, snack, or juice at their bedside after receiving the medication. The DON confirmed that insulin should be administered 30 minutes before meals and that residents should have something to eat within that timeframe to prevent hypoglycemia. The facility's policy indicated that residents should receive treatment and care according to professional standards of practice, which was not adhered to in this case.
Improper LALM Settings for Two Residents
Penalty
Summary
The facility failed to ensure proper interventions for preventing the formation and worsening of pressure ulcers for two residents, Resident 54 and Resident 56. Resident 54 was observed on a low air loss mattress (LALM) set for a weight range of 340 to 520 pounds, despite weighing only 163 pounds. This incorrect setting was noted during multiple observations and was confirmed by the Treatment Nurse (TN) 1, who acknowledged that the LALM should reflect the resident's actual weight to minimize pressure and aid in wound healing. Resident 54 had a history of diabetes mellitus, quadriplegia, and anemia, and was at high risk for pressure injuries, with an existing unstageable pressure injury. Resident 56's LALM was also improperly set at 220 pounds, while the resident's actual weight was 130 pounds. This discrepancy was observed on two occasions and confirmed by TN 1, who stated that the LALM should be set between 120 to 150 pounds for Resident 56. The resident expressed discomfort with the mattress, indicating it was hard to move around in bed. Resident 56 had a history of respiratory failure and atrial fibrillation and required assistance with daily activities, making proper LALM settings crucial for preventing skin breakdown. The Director of Nursing (DON) confirmed that incorrect LALM settings would render the mattresses ineffective, potentially worsening residents' wounds. The facility's policy required staff to ensure LALMs were set according to residents' weights, but this was not adhered to, leading to the identified deficiencies. The failure to maintain correct LALM settings placed both residents at risk for further skin injury and compromised their care quality.
Failure to Label IV Dressing Properly
Penalty
Summary
The facility failed to properly label a peripheral intravenous (IV) line dressing for a resident, which is a critical step in ensuring the safe administration of IV fluids and medications. The deficiency was identified when the dressing on the resident's IV line, inserted in the right hand, was observed to lack the date, time, and initials of the inserting nurse. This omission was contrary to the facility's policy, which requires such labeling to track the duration the IV site has been in place and to ensure timely rotation as per physician's orders. The resident involved had a medical history that included an artificial right knee joint, end-stage renal disease, and arthritis. The resident was receiving cefazolin intravenously for an infected knee arthroplasty, with orders to rotate the IV site every seven days. Interviews with the RN and the Director of Nursing confirmed the labeling requirement and the potential risk of infection if the IV site is not rotated as scheduled. The facility's policy on IV Peripheral Therapy also mandates labeling the dressing with specific details, which was not adhered to in this instance.
Failure to Display No Smoking Sign for Oxygen Use
Penalty
Summary
The facility failed to display a No Smoking sign on the inside and outside of a resident's room where an oxygen concentrator was in use. This deficiency was observed during multiple visits, where it was noted that there was no signage on the room entrance door or inside the room, despite the presence of an oxygen concentrator at the bedside. The resident, who was admitted with diagnoses including pneumonia, pain, and anxiety, was observed to have severely impaired cognitive skills and required maximal assistance for daily activities. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of the required signage and acknowledged the potential danger posed by the lack of warning signs. The facility's policy on oxygen therapy, which mandates the display of No Smoking signs wherever oxygen is stored or administered, was not adhered to. This oversight had the potential to create a fire hazard, as oxygen concentrators are considered a fire risk.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure the safe administration of medications for two residents, leading to potential health risks. For Resident 124, the Licensed Vocational Nurse (LVN) left medications at the resident's bedside without ensuring they were taken. During observations, pills were found on the bedside table and bed, indicating that the resident did not take the medications as intended. The resident, who was alert and oriented, confirmed that the nurse left the pills at the bedside, and the LVN admitted to not watching the resident swallow the medication. This practice could lead to the resident self-administering medications unsafely or another resident taking the medication. For Resident 29, there was a failure in accurately documenting the administration of Ativan, an antianxiety medication. The Medication Administration Record (MAR) inaccurately indicated that Ativan was given when it was not available, and Xanax was administered instead. The Director of Nursing (DON) confirmed that both medications should not be administered together, and the inaccurate documentation could lead to mismanagement of the resident's anxiety and unnecessary dosage increases. The LVN acknowledged the error in documentation, which could result in the healthcare team receiving incorrect information about the resident's medication regimen. These deficiencies highlight lapses in medication administration and documentation processes, which are critical for ensuring resident safety and effective treatment. The facility's policies and procedures were not followed, as the LVN did not ensure the resident swallowed the medication and failed to accurately document medication availability and administration. These actions and inactions had the potential to adversely affect the residents' health and well-being.
Medication Errors in Resident Care
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident 65, staff did not instruct the resident to rinse their mouth thoroughly after using a Budesonide-Formoterol Fumarate inhaler, which is necessary to prevent oral thrush. During a medication pass observation, the resident was seen taking the inhaler without being advised to rinse their mouth, and the Licensed Vocational Nurse (LVN) confirmed that the instruction was not given. The Director of Nursing (DON) acknowledged that this was a medication error, as the lack of rinsing could lead to oral thrush. Resident 46 was administered Metoprolol outside of the ordered parameters, which required the medication to be held if the systolic blood pressure (SBP) was less than 110 mm Hg. The resident received the medication on multiple occasions when their SBP was below the specified threshold. LVN 2 admitted to administering the medication inappropriately, and the DON confirmed that the medication should have been withheld to prevent hypotension. Both residents had specific medical histories that were relevant to the deficiencies. Resident 65 had intact cognition and required assistance with daily activities, while Resident 46 had severely impaired cognitive skills and required maximal assistance. The facility's failure to adhere to medication administration guidelines resulted in significant medication errors for both residents.
Expired IV Solutions Found in Emergency Kit
Penalty
Summary
The facility failed to remove three bags of expired intravenous (IV) fluid solution from the IV emergency kit in the medication room at Nursing Station 1. During an observation and interview, it was noted that one bag of 0.9% sodium chloride IV solution and two bags of 5% dextrose and 0.45% sodium chloride IV solution were expired. Licensed Vocational Nurse (LVN) 4 confirmed the expiration and stated that the registered nurse (RN) was responsible for checking the IV emergency kit. Interviews with RN 1 and the Director of Nursing (DON) revealed that the RN was supposed to check the IV emergency kit every night shift and contact the pharmacy for replacements if any items were expired. The facility's policy and procedure indicated that expired medications should be removed from the medication room, and the emergency kits should be checked daily. However, the expired IV solutions were not removed, increasing the risk of administering ineffective medications to residents.
Failure to Notify Family of Resident's Fall
Penalty
Summary
The facility failed to inform the emergency contact of a resident, identified as Resident 34, about an unwitnessed fall that occurred on 2/22/2025. Resident 34, who was admitted with diagnoses including nontraumatic subdural hemorrhage, dementia, and a urinary tract infection, was found sitting on the floor next to his bed. The Minimum Data Set indicated that Resident 34 had severely impaired cognitive skills and was dependent on staff for daily activities. Despite the fall being documented in the Situation, Background, Assessment, Recommendation (SBAR) report, the family was not notified, which was against the facility's policy that required notifying the resident's attending physician and responsible party after a fall incident. The Director of Nursing acknowledged that the emergency contact, FM 3, was not informed of the fall, which led to the family being unaware of the incident until they arrived to discharge Resident 34. This oversight caused concern among the family members regarding the resident's well-being and trust in the facility's care. The facility's policy, titled Fall Management Program, clearly stated the requirement for notifying the resident's responsible party, which was not adhered to in this case.
Failure to Ensure Safe Discharge for Resident After Hospital Transfer
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, identified as Resident 34, who was transferred to a general acute care hospital (GACH) following an unwitnessed fall. Resident 34 had a history of nontraumatic subdural hemorrhage, dementia, and a urinary tract infection, and was severely impaired in cognitive skills, requiring assistance with daily activities. After the fall, the resident was transferred to GACH 1 for evaluation at the request of family members, but the facility did not adequately follow up on the resident's status or whereabouts after the transfer. The Admission Coordinator (AC) was responsible for contacting the GACH to gather information on the resident's status, but only did so two days after the transfer. The AC was misinformed that Resident 34 had been discharged home, and failed to follow up with the family to verify the resident's well-being or to provide necessary assistance. The facility was unaware that Resident 34 had been transferred to another hospital, GACH 2, for a neurosurgery consult, and subsequently discharged home from there. The Director of Nursing (DON) acknowledged that the facility was responsible for ensuring the resident's safety and should have conducted follow-ups to confirm the resident's status and needs. The facility lacked a specific policy for following up on residents transferred to a GACH, relying instead on standard practice. The Administrator confirmed that there was no policy detailing the follow-up process for such transfers. The facility's failure to conduct necessary follow-ups and ensure a safe discharge for Resident 34 resulted in a deficiency, as the resident's discharge needs were potentially unmet, and the facility was misinformed about the resident's whereabouts.
Failure to Notify PCP of Insulin Refusal
Penalty
Summary
The facility failed to notify the primary care physician (PCP) when a resident, who was cognitively intact and diagnosed with Type 2 diabetes mellitus, refused insulin administration as ordered. The resident's blood sugar levels were recorded at 204 mg/dL, 211 mg/dL, and 219 mg/dL at different times on the same day, each requiring 6 units of insulin according to the sliding scale order. Despite the refusals, there was no documentation indicating that the PCP was informed of these refusals, which was a requirement according to the facility's policy and procedure for medication administration. The Director of Nursing (DON) confirmed during an interview that a Change of Condition (COC) document should have been created when the resident refused the insulin injections, and the PCP should have been notified. The facility's policy, dated 2012, clearly stated that the licensed nurse must notify the PCP and document in the medical record if a resident refused medication. The lack of notification and documentation placed the resident at risk for potential complications from diabetes, as the PCP could have provided orders to help regulate the resident's blood sugar levels.
Failure to Update Care Plan for Insulin Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who refused insulin injections on multiple occasions. The resident, who was admitted with diagnoses including polyneuropathy and Type 2 diabetes mellitus, was cognitively intact and required assistance with activities of daily living. Despite a physician's order for insulin administration based on a sliding scale, the resident refused the insulin at three different times on a specific date. The care plan for the resident's diabetes did not address these refusals, and there was no updated care plan to guide staff on interventions for the resident's refusal of insulin. During a review of the resident's care plan and interviews with the Director of Nursing, it was confirmed that the facility did not initiate or update the care plan to address the resident's refusal of insulin. The facility's Nursing Manual requires person-centered, comprehensive, and interdisciplinary care plans to meet residents' health and safety needs. However, the lack of a care plan addressing the insulin refusal meant that necessary interventions were not communicated to staff, potentially impacting the quality of care provided to the resident.
Failure to Monitor Diabetic Resident After Insulin Refusal
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring proper monitoring of a diabetic resident who refused insulin injections. The resident, who was cognitively intact and required assistance with activities of daily living, was admitted with diagnoses including polyneuropathy and Type 2 diabetes mellitus. The resident had a physician's order for insulin administration based on a sliding scale, but refused the insulin on multiple occasions as documented in the Medication Administration Record (MAR). Despite the refusals, there was no documentation of monitoring for signs and symptoms of hyperglycemia, such as headache, increased hunger, thirst, and frequent urination, as required by the facility's Nursing Manual. The Director of Nursing confirmed the lack of documentation and monitoring for the resident's condition following the refusals. This oversight had the potential to lead to serious complications from uncontrolled blood sugar levels.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
