Garden Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Garden Grove, California.
- Location
- 12681 Haster Street, Garden Grove, California 92840
- CMS Provider Number
- 555667
- Inspections on file
- 24
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Garden Park Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to consistently implement and document fall-related interventions and assessments for three residents with recent falls. One resident had floor mats and a fall mattress in use without corresponding physician orders or care plan interventions, while the DON stated the resident was supposed to have a big boy bed instead of floor mats. Another resident on a blood thinner had care-planned orthostatic BP monitoring that was not carried out as ordered, incomplete 72-hour neuro checks after a fall, and a physician order for bilateral floor mats that was only partially implemented, with staff confirming only one mat was in place. A third resident with a fall-related head injury had orders and care plan interventions for 72-hour orthostatic BP monitoring and neuro checks, but the MAR lacked BP results despite being marked complete, and the neuro flowsheet contained multiple blank entries; an RN and the DON acknowledged that the ordered orthostatic BPs and neuro assessments were not fully completed.
A resident returned from the hospital with bilateral soft hand mittens in place, but staff did not obtain a physician’s order, informed consent, or complete required assessments and monitoring for restraint use. Facility records lacked any documentation of a medical symptom warranting restraints, a care plan, or scheduled removal and ROM exercises, despite policies requiring these elements. An LVN reported the resident arrived with mittens and that no consent or hand/wrist assessments were done, while another LVN stated she recognized the mittens as restraints without orders and said she told a CNA to remove them, which the CNA denied. The DON stated she was unaware of the mittens and confirmed that, per facility policy, any restraint use should have documented orders, consent, assessments, two-hour release for circulation checks, and a care plan.
A resident with moderately impaired cognition alleged physical abuse by a caregiver and identified her roommate as a witness. Although the roommate, who also had moderately impaired cognition, was interviewed by the SSA and reported hearing the resident yelling, the interview was not provided to the Abuse Coordinator and was instead discarded. This omission resulted in an incomplete investigation, as not all potential witness information was considered.
A resident with severe cognitive impairment and high assistance needs experienced a fall when their wheelchair became stuck in a carpet while being wheeled by a CNA. Although the resident was assessed immediately after the fall, licensed nurses did not continue required monitoring and assessment every shift for 72 hours as outlined in facility policy, resulting in a failure to provide necessary post-fall care.
The facility failed to maintain complete and accurate medical records for two residents in the Falling Star Program, which required hourly monitoring to prevent falls. Documentation was missing for specific dates, and staff interviews revealed lapses in the process, with CNAs either not receiving the necessary forms or failing to document the checks, despite claims of performing them.
A resident's care plan was not updated to address critically low hematocrit and hemoglobin levels, despite these results being reported to the physician. The facility did not complete a change of condition evaluation or revise the care plan accordingly, as confirmed by the DON during a review.
A facility failed to accurately conduct infection surveillance and assessment for a resident with a skin and soft tissue infection. Despite meeting criteria for infection in August and September, the resident's condition was not properly documented in the Infection Surveillance Monthly Reports. Interviews with the IP and DON confirmed these discrepancies, highlighting a lapse in the facility's infection control processes.
Failure to Implement and Document Fall-Related Interventions and Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and care to prevent or minimize injuries from falls, as required by facility policies on documentation, care plan revision upon status change, and the fall prevention program. The facility’s policies required licensed staff and the interdisciplinary team to document all assessments and services in the medical record, to review and revise care plans after a status change, and to implement fall interventions based on fall risk, including environmental measures and monitoring of vital signs. Despite these policies, surveyors identified multiple instances where fall-related interventions were not resident-centered, physician orders were not fully implemented, and required assessments were incomplete or missing. For one resident with a history of a fall and a documented unwitnessed fall with a bump on the left forehead, the care plan created after the fall did not include interventions for bilateral floor mats, even though therapy documentation showed the bed was lowered and bedside mats and an additional mattress were in place. Observations on two separate days showed the resident in bed with a fall mattress on one side and a floor mat on the other side of the bed. During interview and record review, the DON confirmed there was no physician order or care plan intervention for floor mats and stated the resident was not supposed to have floor mats because a big boy bed had been implemented instead, indicating that the fall-related environmental intervention in use was not reflected in the resident’s care plan. For another resident on an antiplatelet (blood thinner) for stroke prophylaxis, the facility documented two separate falls. After the first fall, the care plan called for vital signs every shift and orthostatic blood pressures (lying, sitting, standing) within the first 24 hours. The neurological flowsheet for that event showed repeated blood pressure readings only in the lying position and did not show orthostatic measurements as care planned. When the resident was transferred to an acute care facility and returned later the same day, the orthostatic blood pressure intervention was not continued or revised within the 24-hour period, and the DON later verified that the care plan should have been continued or updated. After a subsequent fall, the neurological flowsheet contained multiple blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response at several time points, indicating incomplete 72-hour neurological assessments. In addition, a physician order and care conference recommendation for bilateral floor mats were not fully implemented, as repeated observations showed only one floor mat in place, and an LVN and the DON confirmed that bilateral mats were ordered but not provided. For a third resident who experienced a fall with a bump and laceration to the left forehead, the change in condition evaluation documented provider recommendations to keep ice on the forehead, monitor blood pressures for 72 hours, and notify the physician. A subsequent physician order directed monitoring for orthostatic hypotension with blood pressures taken lying, sitting, and standing every shift for three days. The MAR showed a check mark indicating the task was completed, but no orthostatic blood pressure results were documented. The care plan for this resident’s fall included neuro checks per facility protocol and monitoring orthostatic blood pressure as ordered. However, the neurological flowsheet contained multiple blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response at several scheduled times. During interview, an RN stated the check mark on the MAR indicated completion of the task but acknowledged that the orthostatic blood pressure data could not be seen and verified that neurological assessments were incomplete and orthostatic blood pressures were not obtained per order. The DON later confirmed these findings.
Failure to Obtain Orders, Consent, and Monitoring for Use of Soft Mitt Restraints
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use and management of physical restraints for one resident who was readmitted to the facility and returned from an acute care hospital with bilateral soft hand mittens in place. The facility’s own policies on a restraint-free environment and informed consent require that physical restraints only be used to treat a specific medical symptom, with a practitioner’s order, informed consent, and clear parameters for use, monitoring, and release. The policies also require that behavioral interventions be exhausted before restraints are used, and that informed consent be verified and documented by licensed nursing staff, except in documented emergencies. For this resident, medical record review showed no physician’s order, no signed informed consent, no assessment, no monitoring documentation, and no care plan addressing the use of the bilateral soft mitten restraints. There was also no documentation that the mittens were removed at regular intervals, that the resident’s hands and wrists were assessed, or that range of motion (ROM) exercises were performed every two hours as required by the facility’s policy. Medication Administration Records and shift assignment sheets identified LVN staff assigned to and administering medications to the resident during the period in question, but the records still lacked any restraint-related documentation. In interviews, LVN 1 stated the resident arrived with bilateral hand mittens and acknowledged being unaware of any informed consent and that the resident’s hands and wrists were not assessed while the mittens were on. LVN 4 reported that the resident returned to the facility with mittens, recognized them as restraints, and stated there were no orders for restraints, so she said she instructed a CNA to remove them; however, CNA 1 denied being instructed to remove the mittens and only recalled seeing the mittens in the resident’s closet. The DON stated she was unaware the resident was admitted with mittens and asserted that the facility does not use mittens, further stating that if a resident were admitted with soft mitten restraints, there should be documentation of physician orders, consent, assessments, two-hour removal for circulation checks, and a care plan. The Administrator and DON later acknowledged the findings identified in the review.
Failure to Include Key Witness Interview in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident who reported being slapped, choked, and having her hands squeezed by a caregiver. The resident, who had moderately impaired cognition, stated that her roommate was present during the alleged incident and reported the event to facility staff. The facility's policy requires immediate investigation of abuse allegations, including interviewing all involved individuals and potential witnesses. During the investigation, the facility staff responsible for conducting witness interviews did not provide the Abuse Coordinator with the interview conducted with the resident's roommate, who was identified as a potential witness. The roommate, also with moderately impaired cognition, stated she did not see the abuse due to poor vision but heard the resident yelling about being hit. The interview with the roommate was conducted by the Social Services Assistant (SSA), but the documentation was not included in the investigation file and was instead placed in the facility's shred box by the Social Services Director (SSD) after being told by the MDS Coordinator that the roommate had no capacity to be interviewed. The Administrator, who served as the Abuse Coordinator, confirmed that the interview with the roommate should have been included in the investigation, as per facility policy. The omission of this interview meant that not all potential witness information was available to determine whether abuse occurred, and the facility's investigation was incomplete as a result.
Failure to Monitor Resident After Fall Incident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable well-being following a witnessed fall. The resident, who had severe cognitive impairment and required substantial to maximal assistance with mobility, experienced a fall when being wheeled by a CNA; the wheelchair became stuck in a carpet, causing the resident to slide forward. Although the resident did not hit their head or sustain injuries, the facility's policy required that after any fall, the resident should be assessed and monitored for pain, discomfort, vital signs, and changes in level of consciousness, with documentation of all assessments and actions. Despite these requirements, there was no documented evidence that licensed nurses continued to monitor or assess the resident after the fall incident. Both the RN and DON confirmed that the resident was not monitored every shift for 72 hours as required by facility policy following a change in condition such as a fall. The lack of continued monitoring and assessment was verified through medical record review and staff interviews, indicating a failure to follow established protocols for post-fall care.
Incomplete Monitoring Documentation for Residents in Falling Star Program
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately maintained for two residents, identified as Residents 9 and 10, who were part of the Falling Star Program. This program was designed to reduce the incidence of falls and required hourly monitoring of residents' locations, which was to be documented by the CNAs. However, there was no documented evidence of monitoring for both residents on specific dates in March 2025, indicating a lapse in the required hourly checks. Resident 9, who had moderate cognitive impairment and required substantial assistance with mobility, was readmitted to the facility and placed in the Falling Star Program following a fall incident. Despite the program's requirements, there were gaps in the documentation of Resident 9's location monitoring on March 9, 10, and 12, 2025. Interviews with facility staff revealed that the CNA responsible for Resident 9 on March 12 did not document the monitoring due to not receiving the necessary form from the charge nurse, although the CNA claimed to have performed the checks. Similarly, Resident 10, who lacked the capacity to understand and make decisions and also required substantial assistance with mobility, was admitted to the Falling Star Program after a fall. The facility's records showed missing documentation for Resident 10's location monitoring on the same dates as Resident 9. Interviews with staff indicated that the absence of documentation could mean the monitoring was either not performed or not recorded. The facility's DON confirmed the program's requirements and acknowledged the deficiencies in documentation for both residents.
Failure to Update Care Plan for Low Hematocrit and Hemoglobin Levels
Penalty
Summary
The facility failed to update the care plan for one of the sampled residents, identified as Resident 1, following a significant change in their medical condition. Resident 1 had laboratory results indicating critically low hematocrit and hemoglobin levels, which were reported to the physician. However, the medical record review revealed that the facility did not complete a change of condition evaluation or update the care plan to address these low levels. This oversight was confirmed during an interview and medical record review with the Director of Nursing (DON), who acknowledged that the necessary updates to the care plan were not made.
Inaccurate Infection Surveillance and Reporting
Penalty
Summary
The facility failed to accurately conduct surveillance and assessment of a skin and soft tissue infection for one of the sampled residents, identified as Resident 4. The facility's Infection Prevention and Control Program, revised in December 2022, mandates that RNs and LPNs participate in surveillance by assessing residents and reporting changes in condition. However, discrepancies were found in the Infection Surveillance Monthly Reports for August and September 2024. In August, Resident 4 was treated with doxycycline for an abscess on the lower back, which met the McGeer's Criteria for infection, yet the monthly report did not reflect this. Similarly, in September, Resident 4 exhibited symptoms meeting the Loeb's Criteria for a suspected skin and soft tissue infection, but the monthly report failed to include this case. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed these discrepancies. The IP acknowledged that the Infection Surveillance Monthly Reports did not align with the Infection Screening Evaluations for both months. The DON also verified the findings, indicating a lapse in the facility's infection surveillance and reporting processes, which posed a risk of not identifying and managing Resident 4's skin infection appropriately.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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