Golden Rose Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1899 N Raymond Ave, Pasadena, California 91103
- CMS Provider Number
- 055862
- Inspections on file
- 86
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Golden Rose Care Center during CMS and state inspections, most recent first.
A resident with COPD, dysphagia, ventilator dependence, and impaired cognition did not have a completed POLST form maintained in the medical record as required by facility policy. When the resident experienced chest pain and required EMS transfer to a GACH, staff, including an LVN, the administrator, and an NP, confirmed that the POLST—completed and dated earlier—was not available in the chart. This resulted in an incomplete medical record and the absence of readily accessible, actionable medical orders reflecting the resident’s end-of-life care preferences during an emergency.
A resident with severe cognitive impairment and a right elbow skin tear had a physician order for daily wound care, but nursing staff failed to consistently provide and document the ordered treatment on multiple days, and there was a lapse in having an active wound care order for a period of time. Review of the TAR and notes showed missing initials and entries for the ordered treatments, and staff confirmed that no treatment order was in place during part of the wound’s course, contrary to the facility’s wound management policy requiring necessary treatment and prompt physician guidance.
A resident with diabetes, protein-calorie malnutrition, and high Braden risk, fully dependent for mobility and enrolled in a turning/repositioning program, was not repositioned every two hours as required by the care plan and facility policy. Surveyors observed the resident lying on the same side for several hours, while the responsible party and roommate reported no repositioning during that time. A CNA stated she typically changed/repositioned the resident only around the start and near the end of the shift, and facility leadership confirmed residents were supposed to be repositioned q2h to prevent skin issues and pressure injuries.
A resident with paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and multidrug-resistant infection required ordered wound care to the sacral area. During an observed dressing change, a treatment nurse removed a soiled dressing and continued the wound care procedure without changing gloves or performing hand hygiene, despite facility PPE policy requiring single-use gloves and handwashing before and after glove removal. In interviews, the nurse and the DON confirmed that gloves should have been removed and hand hygiene performed before applying new gloves and continuing treatment.
A resident with multiple chronic conditions missed a scheduled dental cleaning because the Social Worker did not notify them of the appointment after receiving an email reminder. The resident was out on pass during the visit, and the facility's policy indicated the Social Worker was responsible for coordinating and communicating such appointments.
A resident with a history of G-tube dislodgement and severe cognitive impairment did not have a comprehensive, individualized care plan addressing her repeated behaviors of pulling at her G-tube. Despite multiple incidents and staff awareness of the issue, no specific interventions or interdisciplinary team meetings were documented to address the problem, leading to inconsistent care.
A resident with complex medical needs was transferred to a hospital, and although a 7-day bed hold was requested and confirmed, the facility assigned the resident's bed to another individual after only three days. When the hospital attempted to discharge the resident back, staff reported no available bed, resulting in the resident remaining hospitalized beyond the intended period.
A resident who was fully dependent on staff for personal care due to complex medical conditions was found with long, dirty fingernails and old nail polish, despite a care plan requiring regular nail maintenance. Staff interviews and observations confirmed that nail care was not provided as required by facility policy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not maintain a working call light system for three nursing stations over several days, as confirmed by maintenance records, staff interviews, and direct observation. Despite policy requirements for immediate repair and hourly safety checks, the system remained non-operational, with incomplete documentation and delayed repairs, leaving multiple rooms without a functional alerting device for resident assistance.
The facility did not ensure timely and appropriate access to call lights for five residents, including delays in answering call lights, placing call lights on the side of a contracted limb, not keeping call lights within reach for residents in bed or wheelchairs, and failing to provide a suitable call device for a resident with hand mittens. These actions did not align with care plans or facility policy, impacting residents with significant cognitive and physical impairments.
Two residents were affected when staff failed to provide bedside fluids for a resident with multiple medical conditions and did not follow the facility's significant weight loss policy for another resident with ESRD on dialysis. Observations confirmed the absence of water at the bedside despite care plan requirements, and staff interviews revealed that required assessments and notifications were not completed after significant weight loss, contrary to facility policy.
Surveyors found that kitchen staff failed to label open food items with required information and did not discard expired foods, as confirmed by the Dietary Supervisor. Multiple items, including beets, cottage cheese, ranch dressing, tortillas, and peanut butter, were either expired or lacked proper labeling, in violation of facility policy and FDA Food Code.
Four outdoor trash dumpsters were observed overfilled with trash bags stacked above the brim, making it impossible to close the lids. The Dietary Supervisor confirmed that the lids should be closed but could not do so due to the excess trash, acknowledging the need for proper disposal to prevent pest infestation. Review of facility policy and FDA guidelines indicated that garbage should be stored in covered containers, but this was not followed.
Staff failed to maintain resident dignity and privacy by feeding a resident while standing above their eye level and by entering two residents' rooms without knocking. The affected residents had severe cognitive impairment and required extensive assistance, and staff acknowledged these actions were not in line with facility policy.
Several residents experienced unsanitary room conditions, including visible trash and soiled areas, and were unable to access hot water for bathing and hygiene. Residents and staff reported that water temperatures in showers and sinks were consistently below policy requirements, resulting in discomfort and missed showers. Facility policies required a clean, homelike environment and suitable water temperatures, but these standards were not met.
Three residents did not receive proper pharmaceutical services, including one who missed multiple doses of Marinol due to pharmacy delivery delays and lack of timely physician notification, another who received several scheduled medications late, and a third who had medications left at the bedside after refusal, contrary to facility policy.
Staff failed to follow infection prevention and control protocols, including not changing gloves or performing hand hygiene between tasks such as incontinence care, tracheostomy care, and medication administration for multiple residents. Staff also exited resident rooms wearing PPE and handled contaminated items without proper doffing or hand hygiene, contrary to facility policy.
A resident with mental health diagnoses and moderate cognitive impairment did not receive a required PASARR Level II evaluation because facility staff did not respond to multiple attempts to schedule the assessment. The case was closed without completion of the evaluation, and the responsible staff member did not submit a new screening as required by facility policy.
Two residents did not have individualized care plans addressing their specific needs: one with severe cognitive impairment and total dependence lacked a care plan for incontinence, while another with end stage renal disease and significant weight loss had no care plan for fluid restriction or weight management. Nursing staff and the DON confirmed these omissions, despite facility policies requiring comprehensive, resident-centered care plans.
A resident with a history of sepsis, tracheostomy, and severe cognitive impairment was weaned off a ventilator and placed on continuous oxygen via tracheostomy, but the care plan was not updated to reflect this change. The DON confirmed the care plan still focused on ventilator dependence, despite physician orders and current therapy indicating oxygen use via tracheostomy.
A resident at very high risk for pressure ulcers, with significant physical and cognitive impairments, was found with a low air loss mattress set incorrectly for their weight, contrary to physician orders and facility policy. Additionally, no care plan was developed to address the resident's risk for pressure ulcers, as confirmed by the DON and record review.
A resident with right-sided weakness and muscle atrophy was not provided with the physician-ordered PRAFO boot for their right lower extremity, as required by their care plan. Instead, a soft heel protector was used for a week because the PRAFO boot could not be found, and staff did not notify nursing or rehabilitation or arrange for a replacement. This resulted in the resident not receiving the correct orthotic support as ordered.
A resident with end stage renal disease and on dialysis did not receive a physician-ordered fluid restriction due to staff failing to activate the order and communicate it to dietary services. As a result, the resident received unrestricted fluids for over two weeks, contrary to facility policy and medical orders.
A resident with PTSD and major depressive disorder did not have a trauma-informed care plan addressing her triggers, such as loud noises and being touched. Staff were unaware of her diagnosis and had not received training on trauma-informed care or PTSD. The resident was repeatedly exposed to loud music during facility activities, which she reported as a trigger, and was told to keep her door open despite discomfort. The facility's policy requiring identification of triggers and staff training was not followed.
A resident with severe cognitive impairment and multiple high-risk diagnoses did not receive a monthly medication regimen review by a licensed pharmacist for two consecutive months. The DON confirmed the omission, noting that the resident's medications were not included in the MRR, despite facility policy requiring monthly reviews for all residents.
A resident with multiple complex diagnoses was switched from Megestrol to Marinol for poor appetite, but the medication order incorrectly listed the indication as vomiting, which the resident was not experiencing. The DON confirmed that the order should have been clarified to reflect the correct indication, as required by facility policy, but this was not done, resulting in a deficiency related to unnecessary medication use.
A resident with severe malnutrition and muscle wasting did not have her food preferences assessed or honored after starting an oral diet. Despite expressing dissatisfaction with the meals and making specific requests, her preferences were not documented or communicated by staff, and the required dietary evaluation was not completed, contrary to facility policy.
A resident with multiple infections and severe cognitive impairment was administered meropenem IV for pneumonia, even though only one of the three required criteria for antibiotic therapy was met. The Infection Preventionist Nurse confirmed that all criteria should have been met and there was no documentation of physician notification prior to starting the antibiotic, contrary to facility policy.
Two residents who were dependent on staff for care, including one with a tracheostomy and another with severe cognitive impairment, were found with their call lights out of reach. Staff and policy confirmed that call lights should be accessible at all times, especially for nonverbal or immobile residents, but observations showed this was not consistently done.
A resident with severe cognitive impairment and multiple medical conditions, fully dependent on staff for ADLs, was not provided incontinence care according to facility policy. Observations and staff interviews confirmed the resident was routinely left in a urine-soaked brief and wet linens, despite policies requiring changes every 2 to 4 hours or as needed to maintain cleanliness and prevent skin issues.
Two residents did not receive necessary care when staff failed to reevaluate and treat wounds, and did not implement interventions after reports of pain and confusion. One resident with severe cognitive impairment and self-inflicted wounds was not reassessed or provided with an updated care plan when treatments were ineffective. Another resident with cognitive impairment and a history of shoulder injury did not receive appropriate assessment or monitoring after complaints of pain and confusion, and the care plan was not updated.
A facility failed to keep its medication error rate below 5%, with four late medication administrations out of 33 observed opportunities. A resident with severe cognitive impairment and multiple chronic conditions did not receive four scheduled medications within the required time window, as a nurse administered them more than an hour after the scheduled time, contrary to facility policy.
The facility did not consistently post accurate and current Nurse Staffing Information in a prominent location, as required by policy. On several occasions, the posted information was outdated and did not match the actual staffing assignments and sign-in sheets for various shifts in both subacute and SNF units. Leadership confirmed that the postings should reflect the true number of direct care staff present each day.
A resident with a stage 4 pressure ulcer and paraplegia did not have wound care treatments documented for a 14-day period, despite physician orders and facility policy requiring daily treatment and documentation. The treatment nurse confirmed that care was provided but not recorded, and the DON acknowledged the lapse in documentation.
A resident with a documented DNR order and advance directive specifying no life-prolonging measures was given CPR by staff after being found on the floor, despite the facility having acknowledged and documented the resident's wishes. The DON confirmed that this action was contrary to both the physician's order and the facility's policy.
Staff failed to report allegations of physical and verbal abuse involving two residents by a family member within the required 2-hour timeframe to the State Survey Agency and ombudsman. The incidents included hair-pulling, yelling, and pushing, with both residents experiencing emotional distress. Despite staff awareness and internal reporting, the DON did not notify authorities as required by policy.
A resident with significant medical needs and cognitive impairment was unable to summon staff for incontinence care due to a disconnected call light cord. Staff confirmed the call light was not working, and facility policy requires call systems to be functional and accessible to residents.
A respiratory therapist left therapy notes containing sensitive health information for several residents unattended on top of a therapy cart in a hallway, making the information visible to anyone passing by. Staff interviews confirmed this was a breach of HIPAA and facility policy, as medical records should be kept secure and confidential at all times.
Three residents with complex medical conditions did not receive their scheduled 9 AM medications within the required 60-minute window due to delays by an LVN, technical issues with the electronic MAR, and missing medication supplies. Nursing staff confirmed the late administration and the facility's policy requiring timely medication administration.
A resident with a history of breast cancer, who required significant assistance with daily activities, reported being treated roughly by a CNA during care, including having her legs thrown onto the bed and a pillow tossed at her face. This interaction left the resident feeling humiliated and emotionally distressed, in violation of facility policy requiring respectful and dignified treatment of all residents.
A resident with a documented egg allergy was served meals containing egg-based products due to the failure to update and communicate allergy information on diet orders and tray tickets. Staff interviews revealed that dietary and nursing staff did not verify or modify meal preferences, resulting in the resident experiencing an allergic reaction and requiring medical attention.
A Kitchen Aid was observed opening a trash lid and then preparing food without performing hand hygiene. The staff member admitted to not washing hands after touching the trash, and the Administrator confirmed that proper hand hygiene is required before and during food preparation. Facility policies reviewed by surveyors emphasized the importance of hand hygiene in preventing infection.
A facility failed to provide adequate supervision and enforce policies, resulting in a resident consuming alcohol on the premises and multiple residents being left unsupervised in the smoking area. Despite a zero-tolerance policy for alcohol and a requirement for staff supervision during smoking sessions, residents were left without oversight, leading to safety risks. Additionally, the facility did not update care plans or enforce smoking policy compliance, allowing a resident to keep smoking materials in his room.
A facility failed to place a resident's advance directive in their medical chart, leading to CPR being administered against the resident's DNR wishes during a respiratory arrest. The directive was later found mixed with hospital records, highlighting a lapse in ensuring the resident's treatment preferences were accessible.
A facility failed to ensure a resident's POLST was complete with a physician's signature, leading to a conflict in honoring the resident's DNR wishes during a respiratory arrest. The resident, who required assistance for daily activities, had a POLST indicating DNR and comfort-focused treatment, but it was unsigned, resulting in CPR being administered. Interviews revealed a lack of responsibility in ensuring the POLST's completion, and the physician was unaware of the DNR status.
A facility failed to create a care plan for a resident at risk of elopement, despite the resident's fluctuating decision-making capacity and expressed desire to leave. The resident, with diagnoses including seizures and diabetes, ambulated out of the facility without supervision. The DON acknowledged the risk during an IDT meeting, but no care plan was developed, contrary to facility policies.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to complete the required neurological assessments as per policy. The resident's neurological assessment flowsheet showed multiple missed checks, which were confirmed by nursing staff. The facility's policy required a 72-hour neuro check following such incidents to monitor for potential head injuries or changes in condition.
A facility failed to document and report irregularities in a resident's medication regimen review, specifically concerning Lorazepam. The resident's orders lacked a diagnosis and specific target behavior, and the consulting pharmacist did not identify or report these issues during the monthly review. This oversight prevented necessary discussions with the resident's psychiatrist and posed a risk of unnecessary medication administration.
A resident was prescribed Lorazepam without a specific diagnosis or target behavior in the physician's order, and the PRN order was not discontinued after 14 days as required. The facility also failed to monitor for adverse reactions or the occurrence of target behaviors, contrary to its policy on Psychotherapeutic Drug Management.
Failure to Maintain Completed POLST in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a completed Physician Orders for Life-Sustaining Treatment (POLST) form in a resident’s medical record in accordance with its own policy and accepted professional standards. The resident was admitted with COPD, dysphagia, and ventilator dependence, and an MDS assessment showed impaired cognitive skills for daily decision-making and dependence on staff for several ADLs. The facility’s policy required that the current original POLST be placed in the front section of the resident’s medical record, with a copy retained in the advance directive/legal section or scanned into the EHR. Despite this, during an emergency transfer to a GACH for chest pain, the resident’s POLST, dated a few days prior, was not available in the medical record. Staff interviews confirmed that the POLST was missing at the time it was needed. An LVN reported that the POLST was not available in the chart when EMS arrived and stated that having the POLST in the chart was important to know the resident’s wishes. The Administrator acknowledged that the resident had a POLST dated earlier in the month but that it was not in the resident’s medical record, and stated it was important to have the POLST in the chart to provide actionable medical orders and ensure the resident’s care preferences were honored during an emergency. The NP also confirmed that the POLST was not available in the chart on the day of the emergency and stated that it was important for the POLST to be readily available so that all appropriate and desired care could be provided. This failure to maintain the POLST in the medical record resulted in incomplete medical records for the resident.
Failure to Provide and Document Continuous Wound Care for Elbow Skin Tear
Penalty
Summary
The facility failed to obtain and provide continuous wound treatment for a resident’s right elbow skin tear in accordance with physician orders and facility policy. The resident, who had severe cognitive impairment and was dependent for all ADLs, had a physician’s order dated 1/7/2026 for daily wound care to the right elbow skin tear, including cleansing with normal saline, patting dry, applying Xeroform, and covering with a dry dressing for 30 days. Review of the Treatment Administration Record (TAR) and progress notes showed that wound treatments were not documented as provided on 1/19/2026, 1/27/2026, and from 2/6/2026 to 2/14/2026. Treatment Nurse 1 confirmed that there were no initials on the TAR and no progress note documentation indicating that the ordered wound care was performed on those dates. Further review revealed that there was no active treatment order for the right elbow wound between 2/6/2026 and 2/14/2026, despite the ongoing need for care. Registered Nurse 2 confirmed the absence of a treatment order during that period and stated that staff, including LVNs, treatment nurses, and RNs, are responsible for monitoring wound treatment, communicating with the physician, and clarifying continuation of wound care. The facility’s wound management policy, revised 11/1/2017, stated that residents with wounds are to receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers, and that the attending physician will be notified promptly to advise on appropriate treatment. Staff interviews indicated that continuous treatment and documentation are necessary to assess wound progress and that if wound treatment is not documented, it is considered not to have occurred.
Failure to Reposition High-Risk Resident Every Two Hours
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention care by not turning and repositioning a high‑risk resident every two hours as required by the resident’s care plan and the facility’s positioning policy. The resident had diagnoses including diabetes mellitus and protein‑calorie malnutrition, was assessed as high risk for pressure injuries on a Braden Scale assessment, and the MDS documented dependence for all mobility and ADLs, as well as participation in a turning and repositioning program. The resident’s care plan, revised 7/14/2024, directed staff to turn and reposition the resident every two hours and as needed. The facility’s Positioning and Body Alignment policy, reviewed 1/1/2026, required position changes every two hours. On the survey date, the resident was observed at 10:40 AM lying on her right side. At 11:12 AM and again at 1:20 PM, the resident was still on her right side, and the responsible party and roommate reported that staff had not changed or repositioned the resident since 10:40 AM. The responsible party stated CNAs typically turned the resident only twice during the morning shift, around 8:00 AM and 2:00 PM. CNA 1 later reported she had changed/repositioned the resident at 8:00 AM and 2:00 PM, acknowledging this was not consistent with the every‑two‑hour requirement. The DSD and DON both stated residents should be repositioned every two hours, and the continence management guideline indicated pad/brief changes every 2–4 hours, while the DON noted the policy did not clearly state “every 2 hours and as needed” for changes. This combination of observations, staff statements, and record review showed the resident was not turned every two hours as required, creating the potential for skin tears and pressure injuries.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to wound care for one resident. The resident had multiple serious medical conditions, including paraplegia, a Stage 4 sacro-coccygeal pressure ulcer, bacteremia, immunodeficiency, and resistance to multiple antimicrobial drugs. The resident’s MDS showed severe cognitive impairment and dependence on staff for activities of daily living, and physician orders directed daily and as-needed wound care to the sacro-coccyx pressure injury, including cleansing with normal saline, patting dry, applying collagen powder and Thera honey, and covering with a foam dressing. During a wound care observation, the treatment nurse removed the resident’s soiled dressing and then continued the wound care procedure without changing gloves or performing hand hygiene, contrary to the facility’s Personal Protective Equipment policy. In interviews, the treatment nurse acknowledged she should have performed hand hygiene and donned a new pair of gloves after removing the dirty dressing and before continuing wound care. The DON also stated that gloves were intended for one-time use during removal of the soiled dressing and that the nurse should have removed the gloves, washed hands, and applied new gloves before proceeding, consistent with the written policy that gloves are single-use and that hands are to be washed before and after glove removal. The report stated these failures had the potential to increase the risk of infection for the resident and spread microorganisms to staff and other residents.
Failure to Notify Resident of Scheduled Dental Appointment
Penalty
Summary
The facility failed to notify a resident of a scheduled routine dental cleaning appointment, resulting in the resident missing the appointment and not receiving the planned oral hygiene care. The resident, who had diagnoses including paraplegia, type 2 diabetes, morbid obesity, and COPD, was assessed to have intact cognition and required partial assistance with oral hygiene. The dental appointment was scheduled and communicated to the facility's Social Worker (SW) via email, but the SW did not check the email until late in the day and did not inform the resident of the upcoming appointment. As a result, the resident was out on pass during the scheduled dental visit and missed the appointment. Interviews confirmed that the SW was responsible for notifying residents of dental appointments and that the facility's policy required the SW to coordinate dental services. The administrator acknowledged that the SW is expected to be aware of and communicate upcoming appointments to residents, and that missing such appointments can affect the quality of care.
Failure to Develop Comprehensive Care Plan for G-Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident with a history of gastrostomy tube (G-tube) dislodgement. Despite multiple documented incidents of the resident pulling or dislodging her G-tube, there was no care plan addressing this issue from the time of admission through several months of care. The resident had diagnoses including type 2 diabetes mellitus, gastrostomy malfunction, and unspecified dementia, and was assessed as having severely impaired cognitive skills and being dependent on staff for all activities of daily living. Multiple SBAR documents and staff interviews confirmed repeated episodes of G-tube dislodgement and behaviors such as pulling at the tube or linens, especially during care activities like dressing changes. Staff interviews revealed that the resident had a strong grip and would often grab her G-tube, requiring additional staff assistance during care to prevent dislodgement. Despite these ongoing issues, several staff members, including licensed nurses and the MDS nurse, were unaware of any care plan specifically addressing G-tube dislodgement or the resident's behavior of pulling at the tube. The care plan for G-tube dislodgement was not created until months after the initial incidents, and even then, it did not include interventions tailored to the resident's specific behaviors. Record review and interviews with the Registered Nurse Supervisor confirmed that no interdisciplinary team (IDT) meetings had been conducted to address the resident's frequent G-tube dislodgement, and the care plan lacked resident-centered interventions. The facility's own policy required comprehensive, individualized care plans to be developed and updated as needed, but this was not followed in the resident's case, resulting in inconsistent implementation of care.
Failure to Honor Bed Hold Policy for Hospitalized Resident
Penalty
Summary
The facility failed to follow its own bed hold policy for a resident who was transferred to a general acute care hospital (GACH) due to tachycardia and hypertension. The resident, who had significant medical needs including respiratory failure, ventilator dependence, and a persistent vegetative state, had a signed bed hold consent indicating a 7-day bed hold was requested and confirmed. Facility records and staff interviews confirmed that the resident's bed was held for only three days before being assigned to a new resident, despite a physician's order and facility policy requiring a 7-day hold. When the hospital notified the facility that the resident was ready for return within the 7-day period, staff reported that the bed was no longer available, as it had already been given to another resident. This resulted in the resident being unable to return to the facility as planned and remaining in the hospital for additional days. Facility staff, including the administrator, acknowledged that the bed should have been reserved for the full 7 days as per policy and the signed consent.
Failure to Provide Adequate Nail Care and Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for all activities of daily living due to multiple medical conditions including chronic respiratory failure, tracheostomy, muscle wasting, diabetes, and psychosis, was not provided with adequate nail care. The resident's care plan specifically required staff to check, trim, and clean nails on bath days and as necessary, and to report any changes to the nurse. However, during an observation, the resident was found with long, dirty fingernails, some stained brown, and old, partially removed nail polish. The resident indicated through nonverbal cues that staff had not attempted to provide nail care, and staff interviews confirmed that the resident's nails were not properly maintained. Interviews with facility staff, including a CNA, the Director of Rehabilitation, and the DON, revealed that CNAs were responsible for nail care and that the resident's nails should have been cleaned, trimmed, and old polish removed. Staff acknowledged that the resident's nails were not in compliance with facility policy, which requires nail care to keep nails clean and trimmed. The failure to provide this care was directly observed and confirmed through staff interviews and record review.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Maintain Functional Call Light System Across Multiple Nursing Stations
Penalty
Summary
The facility failed to maintain a functional call light system for three nursing stations over a period of seven days. According to maintenance records and staff interviews, the call light system at Stations 1, 2, and 3 became non-operational and remained so despite multiple unsuccessful troubleshooting attempts by the Maintenance Director and external technicians. Observations confirmed that the call light system was not working in all three stations during this period. The maintenance logbook did not show evidence of required testing of the nurse call system during the outage. The transformer for the system was found to be damaged and disconnected, and only partial repairs were made by the end of the period, with several rooms still lacking a functional call light system. Staff interviews, including those with the Maintenance Director, Environmental Health Consultant, Administrator, Director of Staff Development, Registered Nurse Supervisors, and the Director of Nursing, confirmed that the call light system was not operational and emphasized the importance of the system for resident safety and timely care. The facility's policy required immediate reporting and replacement of defective call lights, as well as hourly safety checks and documentation until the system was restored. However, the policy was not followed, as the system remained non-functional for an extended period and the required documentation and immediate repairs were not completed.
Failure to Accommodate Resident Needs for Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents by not ensuring timely and appropriate access to call lights and specialized call devices. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, had a care plan requiring the call light to be within reach. However, observations showed that the resident's call light was not answered promptly, with a delay of at least seven minutes during an episode of coughing and distress. The facility's policy required call lights to be answered within five minutes, and the DON confirmed that such a delay was unacceptable, especially in emergencies. Another resident with a contracture in the right arm and severe cognitive impairment was found with the call light placed on the contracted side, making it inaccessible. The RN confirmed that the call light should have been placed on the resident's strong side to allow activation if assistance was needed. Additional observations revealed that two other residents did not have their call lights within reach. One of these residents, who was dependent in most activities of daily living and had severe cognitive impairment, was found yelling for help because the call light was on a roommate's bed. The other resident, who required moderate assistance and was cognitively intact, was left in a wheelchair without the call light within reach and was unable to call for help. A fifth resident, who had a tracheostomy, gastrostomy, and was dependent in all activities of daily living, was observed with bilateral hand mittens to prevent removal of medical devices. Despite a care plan indicating the need for an adequate call light, the resident was provided with a push-button call light, which was not appropriate due to the mittens. The respiratory therapist and RN both confirmed that a touch pad call light was needed for this resident. Facility policies required call systems to be accessible and within reach, but these requirements were not met for the residents involved.
Failure to Provide Fluids and Follow Weight Loss Protocols
Penalty
Summary
The facility failed to ensure proper hydration and nutrition for two residents, resulting in deficiencies related to both fluid and nutritional management. For one resident with multiple complex medical conditions, including metabolic encephalopathy, type 2 diabetes, acute kidney failure, hypotension, and a stage 4 pressure injury, staff did not provide a water pitcher or fluids at the bedside as required. Multiple observations over two days confirmed the absence of water at the bedside, despite care plan interventions and signage instructing staff to keep the resident hydrated. Interviews with staff, including CNAs, the Director of Staff Development, and the DON, confirmed that there were no fluid restrictions and that water should have been available at all times. Staff acknowledged that the lack of water could lead to dehydration and related complications, and facility policy required water containers to be provided and maintained daily. For another resident with end stage renal disease and dependence on dialysis, the facility did not follow its significant weight loss policy after the resident experienced a weight loss of nearly 7% in one month. The resident's medical record did not show evidence of a change of condition assessment, notification of the physician or registered dietician, a nutritional assessment, or weekly weights as required by facility policy. Interviews with nursing and dietary staff confirmed that these steps were not taken, and the failure was attributed to a lack of communication and awareness among staff. The facility's policy required prompt notification and assessment in cases of significant weight loss, but these procedures were not followed for this resident. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The failures to provide fluids and to follow weight loss protocols were not isolated incidents but were confirmed by multiple staff members and documented in facility policies. The lack of adherence to established care plans and policies placed the residents at risk for dehydration and continued weight loss, as noted in the findings.
Failure to Label and Discard Expired Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices in accordance with its own policy and professional standards. During an inspection of the kitchen, multiple food items were found either unlabeled or past their use by dates. Specifically, a clear container of beets and four bags of corn tortillas were found with expired use by dates, while an opened tub of cottage cheese, a gallon container of buttermilk ranch dressing, and a four-pound jar of peanut butter were either expired or lacked required labeling such as the food item name, open date, or use by date. The Dietary Supervisor confirmed that these items were opened and should have been labeled and discarded if expired, as per facility policy. A review of the facility's policy and the 2022 FDA Food Code confirmed that all food items must be labeled and dated, and expired foods must be discarded. The Dietary Supervisor acknowledged that the failure to label and discard expired foods was not in accordance with policy and could result in serving expired food to residents. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Disposal and Containment of Garbage
Penalty
Summary
During an observation with the Dietary Supervisor, four outdoor trash dumpsters were found overfilled with trash bags stacked above the brim, preventing the lids from being closed. The Dietary Supervisor confirmed that the lids should be closed and was unable to close them due to the excess trash. In a follow-up interview, the Dietary Supervisor acknowledged the need for proper trash disposal to prevent pest infestation and contamination. Review of the FDA Food Code and the facility's own policy confirmed that garbage and refuse should be stored in covered containers to minimize odors and prevent attracting pests, but these procedures were not followed as observed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor residents' rights to dignity, respect, and privacy for three residents. In one instance, a certified nursing assistant (CNA) was observed feeding a resident with severe cognitive impairment and multiple diagnoses, including metabolic encephalopathy, dementia, and Parkinson's disease, while standing above the resident's eye level. The CNA acknowledged that she should have been seated at the resident's eye level during feeding, as per facility policy and the resident's care plan, which required extensive assistance with eating. Additionally, a licensed vocational nurse (LVN) was observed entering the rooms of two different residents, both with severe cognitive impairment and dependent on staff for all activities of daily living, without knocking on their doors. The LVN admitted that staff are required to knock before entering to provide privacy and maintain residents' dignity. Another registered nurse confirmed the importance of this practice, emphasizing that privacy and dignity must be maintained even if the resident is not alert. A review of the facility's policy on resident rights confirmed that each resident must be treated with respect and dignity, and their individuality must be recognized. The observed actions by staff were inconsistent with this policy, resulting in a failure to maintain privacy and dignity for the affected residents.
Failure to Maintain Cleanliness and Adequate Hot Water for Resident Care
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for several residents, as evidenced by direct observations and resident interviews. In one instance, a resident with severe cognitive impairment and high dependence for activities of daily living was found in a room with visible trash, including crushed crackers, a used plastic glove, dried brown smears by the commode, and brown clumps under the bed. Both the DON and an LVN confirmed that such conditions were unsanitary and not conducive to residents' well-being, and that housekeeping should have been notified immediately to address the issue. Additionally, multiple residents reported a lack of hot water in their rooms and shower areas, which persisted for at least a week. Residents described being unable to shower or perform personal hygiene tasks comfortably due to the absence of hot water, with some stating they had to use cold water for bathing and incontinence care. Observations confirmed that water temperatures in various rooms and showers were significantly below the facility's policy requirements, with readings as low as 71.6 to 85 degrees Fahrenheit, far below the expected minimum of 110 degrees Fahrenheit. Facility policies reviewed indicated a requirement to provide a safe, clean, and homelike environment, including maintaining water temperatures suitable for residents' needs. Despite these policies, the facility did not ensure that resident rooms were kept clean or that water temperatures were adequate for daily living activities, directly impacting the comfort and hygiene of several residents with varying degrees of cognitive and physical impairment.
Failure to Provide Timely and Safe Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents by not ensuring timely administration and proper handling of medications as ordered by physicians. For one resident with severe cognitive impairment and poor appetite, the facility did not administer Marinol as ordered for eight days due to the medication not being available and waiting for pharmacy delivery. Nursing staff did not notify the physician within 24 hours of the medication's unavailability, as required by facility policy, resulting in 15 missed doses. Another resident, also with severe cognitive impairment and dependent on staff for daily activities, did not receive scheduled medications at the prescribed times. The medications, which included apixaban, spironolactone, finasteride, and bethanechol, were administered more than an hour after the scheduled time. The nurse acknowledged that the late administration could affect the resident's health, and the facility's policy allows for a one-hour window before or after the scheduled time, which was not adhered to in this case. A third resident, who had intact cognitive skills but required assistance with daily activities, was found with a medication cup containing two pills left on the bedside table after refusing to take them. The resident had not requested to self-administer medications, and facility policy prohibits leaving medications at the bedside. Staff interviews confirmed that medications should not be left unattended and should be properly documented and disposed of if refused.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Multiple staff members failed to adhere to standard infection prevention and control practices during direct care of several residents. Certified Nursing Assistant 4 (CNA 4) did not change gloves or perform hand hygiene after providing incontinence care to two residents, subsequently touching their bed sheets, bed remotes, and bodies with contaminated gloves. CNA 4 acknowledged during interview that gloves should have been changed and hand hygiene performed to prevent the spread of infection. The Infection Preventionist Nurse (IPN) confirmed that gloves soiled with urine and feces must be removed and hand hygiene performed before touching other surfaces or the resident. The Respiratory Therapist Director (RTD) was observed providing tracheostomy care to a resident and, without changing gloves or performing hand hygiene, touched the resident's personal items such as a cell phone and television remote. RTD then used the same gloves to prepare a sterile drape and handle a speaking valve, actions which he admitted could spread infection to the resident. The IPN stated that gloves should have been changed and hand hygiene performed after contact with personal items to prevent transmission of microorganisms to the tracheostomy area. Additional deficiencies included CNA 5 exiting a resident's room while still wearing PPE and handling dirty linen in the hallway, which she acknowledged was inappropriate due to the risk of spreading infection. Licensed Vocational Nurse 4 (LVN 4) was observed on two occasions failing to change gloves and perform hand hygiene between tasks during medication administration and gastrostomy tube care for two residents. LVN 4 admitted that gloves should have been changed to reduce the risk of introducing bacteria. The facility's policies and procedures require glove changes and hand hygiene after contact with blood, body fluids, and environmental surfaces, and specify that gloves are single-use only.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASARR) Level II evaluation was completed for a resident with diagnoses including anxiety disorder, unspecified psychosis, and end stage renal disease. The resident's admission record and Minimum Data Set (MDS) indicated moderate cognitive impairment and the use of antipsychotic and antianxiety medications. Documentation showed that a PASARR Level I screening determined a Level II Mental Health Evaluation was necessary, and the facility was notified that an evaluator would contact them to schedule the assessment. However, the Level II evaluation was not completed because facility staff were unresponsive to multiple attempts by the evaluator to arrange the assessment within the required timeframe. As a result, the case was closed, and the facility was informed that a new Level I screening would be needed to reopen the case. The staff member responsible for PASARR follow-ups was unaware that the case had been closed and did not submit a new screening, contrary to facility policy, which requires completion of the PASARR Level II prior to admission and incorporation of its recommendations into the resident's care plan.
Failure to Develop Individualized Care Plans for Incontinence, Fluid Restriction, and Weight Loss
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans with measurable objectives, timeframes, and interventions for two of eighteen sampled residents. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, including toileting, there was no care plan addressing bowel and bladder incontinence, despite direct observation of staff providing incontinence care. Both the registered nurse and the director of nursing confirmed that a care plan for incontinence was missing and acknowledged its importance for ensuring continuity of care. Another resident, diagnosed with end stage renal disease and dependent on dialysis, experienced a significant weight loss of nearly 7% in one month and had a physician order for a strict fluid restriction. Despite these critical needs, there was no care plan in place to address the resident's fluid restriction or significant weight loss. The absence of these care plans was confirmed during interviews and record reviews with nursing staff and the director of nursing, who stated that care plans are essential for communicating interventions and ensuring staff follow prescribed care. Facility policies and procedures reviewed during the survey required the interdisciplinary team to ensure care plans documented renal conditions, necessary precautions, and individualized goals for managing significant weight changes. The policies also mandated that each resident have a comprehensive, person-centered care plan based on assessed needs, but these requirements were not met for the two residents identified.
Failure to Update Care Plan After Change in Respiratory Status
Penalty
Summary
The facility failed to revise the care plan for one resident to reflect a significant change in respiratory status following the discontinuation of ventilator support and the initiation of oxygen therapy via tracheostomy. The resident, who had a history of sepsis, urinary tract infection, ESBL, tracheostomy, and gastrostomy, was originally admitted and later readmitted with these diagnoses. Physician orders indicated the resident was to receive four liters per minute of humidified oxygen via tracheostomy, and the Minimum Data Set documented severe cognitive impairment and high levels of dependence for daily activities. Despite the resident being weaned off the ventilator in the hospital and currently receiving oxygen via tracheostomy, the care plan continued to focus on ventilator dependence and was not updated to reflect the current respiratory needs. This was confirmed during interviews and record reviews, where the DON acknowledged the care plan required revision to ensure appropriate care and staff implementation. The facility's policy required care plans to be updated with changes in resident status, but this was not done in this case.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers for a resident identified as being at very high risk. Specifically, the resident, who had a history of hemiplegia, hemiparesis, muscle wasting, and was dependent on staff for most activities of daily living, was found to have a low air loss (LAL) mattress set at 350 pounds, despite their actual weight being 144.4 pounds. This incorrect setting was not in accordance with the physician's order, which required the mattress to be set according to the resident's weight and monitored daily. Staff interviews confirmed that an improperly set mattress could be too hard and increase the risk of pressure ulcer development. Additionally, the resident's medical record did not contain a care plan addressing their risk for pressure ulcer development, despite assessments indicating a very high risk and facility policy requiring individualized care plans for such risks. The Director of Nursing confirmed the absence of a care plan and acknowledged that one should have been in place to guide staff interventions. Facility policies reviewed also emphasized the need for appropriate support surfaces and comprehensive care planning for residents at risk of skin breakdown, which were not followed in this case.
Failure to Provide Prescribed Foot Orthosis for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with a history of muscle wasting, atrophy, and right-sided weakness following a hemorrhagic stroke was not provided with the prescribed Pressure Relief Ankle Foot Orthosis (PRAFO) boot for their right lower extremity. The physician's order and care plan specified the use of the PRAFO boot for two hours, three times a week, to support, align, and protect the resident's right foot. However, during multiple observations and interviews, it was confirmed that the resident did not have the PRAFO boot available or in use, and instead, a soft heel protector was used for an entire week because the PRAFO boot could not be located. The Restorative Nursing Assistant (RNA) did not notify nursing or rehabilitation staff about the missing device or arrange for a replacement, and acknowledged that the evaluation of the resident's use of the PRAFO boot was inaccurate due to the substitution. The lack of the correct orthotic device was confirmed through record review, staff interviews, and direct observation. The Director of Nursing (DON) stated that the appropriate steps were not taken to locate or replace the PRAFO boot, and the facility's policy indicated that splints are used to prevent contractures and protect joint alignment. The manufacturer's guide for the PRAFO boot also emphasized its role in supporting and positioning the lower leg, ankle, and foot, and minimizing pressure areas. The failure to provide the prescribed orthosis as ordered constituted a deficiency in care for the resident.
Failure to Implement Physician-Ordered Fluid Restriction for Dialysis Resident
Penalty
Summary
Facility staff failed to implement a physician-ordered fluid restriction for a resident dependent on renal dialysis. The resident, who had end stage renal disease and moderately impaired cognitive skills, was admitted with a fluid restriction order of 1000ml per day, divided between dietary and nursing. Despite this order being placed on 5/19/2025, the restriction was not initiated or communicated to dietary staff until 6/4/2025. During this period, the resident continued to receive meals and fluids without any restriction, as evidenced by observations and review of dietary tray cards, which did not reflect the fluid restriction order. Interviews with nursing and dietary staff revealed a lack of awareness and communication regarding the fluid restriction order. The order was not activated in the resident's electronic chart, resulting in both nursing and dietary departments failing to enforce the restriction. The facility's policies required that fluid restrictions for dialysis residents be implemented as ordered and reflected on dietary records, but these procedures were not followed, leading to the resident not receiving the prescribed care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD) and major depressive disorder. The resident's admission record and social service assessment documented PTSD with specific triggers, including being touched, loud noises, and yelling. Despite this, the resident reported never having a care plan discussion regarding PTSD, and staff interviews revealed a lack of awareness about the resident's diagnosis and triggers. The resident also stated that loud music played in the hallway triggered her PTSD and caused migraine headaches, and she was told by a social worker to keep her door open during these activities, despite her discomfort. Observations confirmed that loud music was played daily in the hallway as part of a facility activity, which the resident identified as a trigger. Staff members, including a CNA and LVN, were unaware of the resident's PTSD or had not received training on trauma-informed care or PTSD. The Director of Nursing confirmed that no comprehensive care plan addressing the resident's PTSD and its triggers had been developed, and acknowledged that the daily activity could trigger the resident's symptoms. A review of the facility's policy on trauma-informed care indicated that staff should identify triggers and implement adjustments to reduce trauma-related distress, and that training should be provided to employees. However, the policy was not followed, as staff had not received the required training and no trauma-informed care plan was in place for the resident, resulting in ongoing exposure to known PTSD triggers.
Failure to Complete Monthly Medication Regimen Review for a Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for one of five residents for the months of February and March 2025. Specifically, the medication regimen for a resident with diagnoses including encephalopathy, schizophrenia, and major depressive disorder was not reviewed during these months, as evidenced by the absence of documentation in the MRR records. The resident was noted to have severely impaired cognitive skills and was dependent on staff for multiple activities of daily living. The resident was also prescribed high-risk medications, including antipsychotics, antianxiety agents, antidepressants, and an anticoagulant. During interviews and record reviews, the DON confirmed that all residents should be included in the monthly MRR and acknowledged that the resident's medications were not reviewed for the specified months. The DON stated that the consultant pharmacist typically sends the MRR via email, but she did not verify that all residents were included, resulting in the omission. The facility's policy required monthly pharmacist review of each resident's medication regimen to identify irregularities and clinically significant risks, but this process was not followed for the resident in question.
Failure to Clarify Medication Indication for Marinol
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications by not clarifying the order indication for Marinol. The resident, who had diagnoses including encephalopathy, schizophrenia, and recurrent major depressive disorder, was initially prescribed Megestrol for poor appetite. Following a medication regimen review, Megestrol was discontinued due to associated risks, and Marinol was started. However, the order for Marinol was written for 'vomiting,' even though the resident was not experiencing vomiting, and the intended use was for poor appetite. During interviews and record reviews, it was confirmed that the Director of Nursing (DON) recognized the discrepancy in the medication order and acknowledged that the licensed nurse should have clarified the indication with the physician. The facility’s policy required that medication orders include the condition or diagnosis for which the medication is ordered, but this was not followed. As a result, the staff were not properly informed of the correct indication for Marinol, leading to a deficiency in medication management for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of a resident who was admitted with severe protein calorie malnutrition and muscle wasting. The resident's admission record and subsequent medical documentation did not include an updated Nutritional Quarterly Progress Evaluation reflecting her food preferences after she was started on an oral diet. Despite the resident expressing her dissatisfaction with the meals and specifically requesting certain breakfast items, there was no evidence that her preferences were assessed or honored by the dietary staff. The dietary director confirmed that no updated evaluation had been completed, and the facility's policy required the use of a dietary questionnaire to determine food preferences for residents on oral diets. Interviews with the resident, the dietary director, the DON, and an LVN revealed that staff were aware of the importance of honoring food preferences to prevent weight loss and ensure resident satisfaction. However, the staff did not communicate the resident's preferences to the dietician, speech therapist, or physician, nor did they take steps to ensure her choices were incorporated into her meal plan. The facility's policy and procedure required the dietary department to provide meals consistent with resident preferences, but this was not followed in the case of this resident.
Failure to Follow Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to follow its antibiotic stewardship program protocols for prescribing antibiotics to a resident prior to the administration of antibiotic therapy. Specifically, a review of the resident's records showed that the resident was prescribed and administered meropenem IV for pneumonia, despite only meeting one of the three required criteria for antibiotic therapy as documented on the surveillance data collection form. There was no documentation that the physician was notified about the resident not meeting all required criteria before the antibiotic was started. The resident involved had a history of pneumonia, sepsis, urinary tract infection, and ESBL resistance, and was severely cognitively impaired and dependent on staff for daily activities. The Infection Preventionist Nurse confirmed during interview and record review that all three criteria must be met for antibiotic therapy to be initiated, and acknowledged the lack of documentation regarding physician notification. The facility's policy required the Infection Preventionist Nurse to review infection control surveillance forms to determine if the infection met the associated criteria, which was not followed in this case.
Call Light System Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for assistance with activities of daily living. For one resident with a tracheostomy, aphonia, and moderate cognitive impairment, the call pad was observed hanging by the side of the bed, out of the resident's reach while she was sleeping. Staff interviews confirmed that residents in the subacute unit, many of whom are non-verbal and require the call pad to alert staff for help, should always have the call pad within reach. Facility policy also requires that call cords be placed within the resident's reach to enable prompt communication with nursing staff. Another resident, who had severe cognitive impairment, dysphagia, dementia, and was dependent for mobility and personal care, was observed with the call light on the floor, out of reach. Staff interviews confirmed that the call light should have been clipped to the bed and accessible, as it is the resident's first line of help. The Director of Nursing and other staff acknowledged the importance of ensuring call lights are within reach, especially for residents who are nonverbal or unable to walk, to allow them to request assistance when needed.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on assistance for activities of daily living (ADLs) did not receive adequate incontinence care in accordance with the facility's policy. The resident, who had significant medical conditions including anemia, gastrostomy, tracheostomy, and toxic encephalopathy, was noted to be severely cognitively impaired and fully dependent on staff for personal care tasks such as toileting hygiene and dressing. Observations and interviews revealed that the resident was routinely changed only twice per shift, despite the facility's policy requiring incontinence pad or brief changes every 2 to 4 hours or as needed to keep the resident clean and dry. Multiple observations confirmed that the resident was frequently found with a brief full of urine, and both the gown and bed linens were wet with urine at the time of care. Staff interviews corroborated that this was a recurring issue, with the resident's brief and linens consistently wet during scheduled changes. The Director of Nursing acknowledged that the resident required more frequent changes than were being provided to maintain skin integrity and cleanliness, as outlined in the facility's continence management and perineal care policies.
Failure to Provide Timely Wound Care and Interventions for Pain and Confusion
Penalty
Summary
The facility failed to provide necessary care and treatment for two residents by not reevaluating and treating wounds and not implementing interventions after reports of pain and confusion. For one resident with severe cognitive impairment and multiple mental health diagnoses, the care plan indicated that skin tears should be treated per protocol and the physician notified. Despite ongoing observations of the resident scratching herself, resulting in bleeding wounds on her arms and legs, there was no evidence of reevaluation or notification to the physician when treatments proved ineffective. The resident's care plan also lacked documentation for a prescribed ointment, and both the registered nurse and the director of nursing acknowledged that a care plan should have been in place to ensure continuity of care. For another resident with severe cognitive impairment and multiple medical conditions, including a history of shoulder dislocation and chronic respiratory issues, the facility did not provide appropriate interventions after the resident and family reported pain and episodes of confusion. Nursing notes indicated that the family expressed concerns about a possible fall and ongoing pain, but there was no documentation of a change of condition assessment, physician notification, or implementation of monitoring protocols such as neuro checks or 72-hour monitoring. Staff interviews confirmed that these steps were not taken, and the care plan was not updated to reflect the resident's current status. Facility policies required notification of the physician and the interdisciplinary team, assessment and documentation of changes in condition, and updates to care plans when there is a significant change in a resident's status. In both cases, these procedures were not followed, resulting in a lack of timely and appropriate care for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 12.12%. During a medication pass observation, four medication errors were identified out of 33 opportunities. Specifically, a resident with multiple diagnoses, including chronic obstructive pulmonary disease, chronic respiratory failure, atrial fibrillation, and urinary retention, did not receive four scheduled medications—apixaban, spironolactone, finasteride, and bethanechol—at the prescribed time. These medications were scheduled for administration at 9 AM but were instead given between 10:18 AM and 10:24 AM, outside the facility's policy window of one hour before or after the scheduled time. The resident in question was severely cognitively impaired and dependent on staff for all activities of daily living. The nurse administering the medications acknowledged that the medications were given late and described the potential impact of delayed administration for each medication. Facility policy required medications to be administered within a specific time frame, and the observed deviation from this policy led to the identified deficiency.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted Nurse Staffing Information was accurate and updated daily, as required by its policy and procedure. Observations revealed that the staffing information displayed in the front lobby was not current on multiple occasions, with postings showing outdated dates. Specifically, on several days, the posted information did not reflect the actual number of staff present for various shifts in both the subacute and skilled nursing facility units. Record reviews confirmed discrepancies between the posted staffing information and the actual Nursing Staffing Assignment and Sign-in Sheets for those dates and shifts. Interviews with the Director of Staff Development (DSD), Director of Nursing (DON), and Administrator confirmed that the posted information should accurately represent the number of staff working each day to inform residents, visitors, and staff. The facility's policy, revised in October 2022, requires daily posting of the total number and actual hours worked by licensed and unlicensed nursing staff in a prominent location. The failure to maintain accurate and timely postings had the potential to leave residents and visitors uninformed about the actual staffing levels providing direct care.
Failure to Document Wound Care Treatment for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to accurately document wound care treatment for one resident with a stage 4 pressure ulcer. The resident, who had a history of paraplegia, neuromuscular bladder dysfunction, and a stage 4 pressure ulcer on the right buttock, was admitted and readmitted to the facility with these diagnoses. Physician orders indicated daily wound care treatment for the pressure ulcer, and the treatment was to be documented in the resident's medical record. However, from 5/14/2025 to 5/27/2025, there was no documentation in the medical record to confirm that the wound care treatment was provided, despite the treatment nurse stating that the care was given during this period. Record reviews showed that the last documented wound care was on 5/13/2025, and subsequent treatment records were missing for the following 14 days. The facility's policy required that all treatments be documented upon completion, but this was not followed. Both the treatment nurse and the Director of Nursing confirmed that the required documentation was not completed, resulting in a lack of proof that the prescribed wound care was administered during the specified period.
Failure to Honor Advance Directive and DNR Order
Penalty
Summary
Facility staff failed to honor a resident's advance directive and physician's Do Not Resuscitate (DNR) order. The resident, who had diagnoses including cerebral infarction, endocarditis, hypertensive heart disease, and ulcerative colitis, was documented as having intact cognitive skills and had executed an advance directive indicating a wish not to prolong life. The resident's medical record included a DNR order, and the facility had acknowledged receipt of the advance directive. Despite these clear instructions, the resident received cardiopulmonary resuscitation (CPR) after being found on the floor by staff. Interviews with the family member and the Director of Nursing confirmed that CPR was administered against the resident's documented wishes and medical orders. The facility's policies required adherence to advance directives and DNR orders, but these were not followed in this instance. The Director of Nursing acknowledged that CPR should not have been performed, as it was contrary to both the resident's advance directive and the physician's order.
Failure to Timely Report Allegations of Abuse Involving Two Residents
Penalty
Summary
The facility failed to report allegations of physical and verbal abuse involving two residents within the required 2-hour timeframe to the State Survey Agency and the state ombudsman, as mandated by the facility's abuse policy. The incidents involved a family member (FM) who was observed by a Certified Nursing Assistant (CNA) and another resident engaging in abusive behavior towards a resident, including pulling the resident's hair, pushing her head down, and yelling at her. The CNA reported the incident to the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS), who in turn informed the Director of Nursing (DON). However, no immediate report was made to the appropriate authorities as required by policy. Resident 1, who had a history of acute respiratory failure, anxiety disorder, and hypertension, was cognitively impaired and required significant assistance with daily activities. The abuse incident occurred while the resident was brushing her teeth and vomiting, during which the family member became angry, pulled her hair, and pushed her head down while yelling. The CNA intervened and later contacted the police when she did not receive a response from the facility administrator. The police arrived, and the resident was placed on monitoring for emotional distress. Interviews with staff confirmed that the incident was not reported to the Department of Public Health (CDPH) within the required timeframe, and the DON acknowledged forgetting to make the report. A second resident, who had a history of falls and fractures, also reported being verbally abused by the same family member, who yelled at her and told her to "shut up" multiple times. This resident expressed anxiety and distress related to the family member's presence. The facility's policy clearly states that all allegations of abuse, including those involving family members, must be reported immediately, but this protocol was not followed in these cases. The failure to report these incidents as required constituted a deficiency in the facility's abuse prevention and reporting practices.
Failure to Ensure Functioning Call Light System for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning call light system for one of four sampled residents. The resident, who had diagnoses including respiratory failure, tracheostomy, and muscle wasting, was assessed as having moderately impaired cognitive skills and was dependent on staff for all personal care activities. On the date of the incident, the resident was observed attempting to use the call light to request assistance for incontinence care, but no staff responded. Upon investigation, it was found that the call light cord was partially disconnected from the wall, rendering it nonfunctional. The resident expressed a need for assistance due to discomfort in the perineal area. Staff interviews confirmed that the call light was not properly connected, preventing it from alerting staff to the resident's needs. Facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, acknowledged the importance of ensuring call lights are plugged in, working, and within reach, especially for residents who cannot communicate verbally. Review of facility policy indicated that a working call system should be available to enable residents to alert nursing staff promptly from their beds.
Unattended Medical Records Expose Resident Information
Penalty
Summary
Facility staff failed to protect the medical records of six residents when a respiratory therapist left therapy notes containing sensitive information unattended on top of a therapy cart in a hallway. The unattended document included residents' names, room numbers, medications, oxygen requirements, diagnoses, and vital signs such as oxygen saturation, heart rate, respiratory rate, and breath sounds. This cart was located in a public area where other staff, residents, and visitors frequently passed by, making the information easily accessible to unauthorized individuals. Observations confirmed that the paper with residents' information was left open and unattended on the therapy cart. A licensed vocational nurse acknowledged that anyone walking by could see the residents' medical information and identified this as a violation of HIPAA regulations. The nurse further stated that staff are aware they should not leave papers with residents' information exposed, and that this was a breach of privacy. Interviews with another respiratory therapist and the director of nursing confirmed that the proper procedure is to keep such documents secured inside a locked drawer of the therapy cart, not left out in the open. Both staff members emphasized the importance of maintaining confidentiality and privacy of residents' health information. A review of the facility's policy and procedure also indicated that staff should not divulge clinical information in public areas and must keep medical records secure and confidential.
Failure to Administer Medications Within Prescribed Timeframe
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents when a Licensed Vocational Nurse (LVN) did not administer scheduled medications within 60 minutes of the prescribed 9 AM time. This was observed for three residents with complex medical histories, including Huntington's disease, dementia, diabetes mellitus, chronic obstructive pulmonary disease, and schizophrenia. The facility's policy required medications to be administered within 60 minutes of the scheduled time, except for those ordered before, with, or after meals. For one resident with Huntington's disease, dementia, and anxiety disorder, the medication administration was observed at 10:02 AM, over an hour past the scheduled time. The LVN prepared and administered several medications, including Buspirone, Cholecalciferol, Tetrabenazine, Zoloft, and Zyprexa, after the scheduled window. Another resident with diabetes, autistic disorder, and dementia had multiple 9 AM medications, such as Aspirin, Cholecalciferol, Finasteride, Gabapentin, Glipizide, and others, not administered by 10:30 AM. The LVN was unable to locate one of the medications (chewable aspirin) during the medication pass. A third resident with COPD, schizophrenia, and major depressive disorder also did not receive their 9 AM medications by 10:18 AM, as indicated by blank documentation on the medication administration record. The LVN reported technical issues with the electronic medication administration record (MAR) as the reason for the delay. Interviews with nursing staff and the Director of Nursing confirmed that medications were administered late and emphasized the importance of timely administration as per physician orders and facility policy.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during the provision of care. The resident, who had a diagnosis of left breast cancer and required varying levels of assistance for activities of daily living, reported that the CNA threw her legs onto the bed and roughly tossed a pillow at her face while assisting with perineal hygiene. The resident described feeling humiliated and emotionally distressed as a result of this interaction. She did not report the incident immediately due to shock but later informed social services after reflecting on the potential for similar treatment of others. The resident's care plan indicated a risk for emotional distress and skin issues related to rough handling during care. Interviews with facility staff, including the DON and Administrator, confirmed awareness of the incident and acknowledged that the CNA was an agency staff member. The facility's policy required all employees to treat residents with kindness, respect, and dignity, and to honor residents' rights, regardless of diagnosis or condition. The actions of the CNA were inconsistent with these expectations and resulted in the resident experiencing emotional harm.
Failure to Communicate and Accommodate Resident Food Allergy
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to eggs was not properly accommodated during meal service. The resident's admission and allergy records clearly indicated an egg allergy, but this information was not reflected on the resident's diet order or meal tray ticket. As a result, the resident was served potato salad containing mayonnaise, an egg-based product, during lunch. After consuming a portion of the meal, the resident experienced symptoms consistent with an allergic reaction, including throat itchiness, shortness of breath, and throat constriction, prompting her to seek assistance from nursing staff. Interviews with facility staff revealed that the dietary kitchen assistant, who was in charge at the time, did not have access to or the ability to modify resident meal preferences or allergy information. The kitchen staff relied solely on the tray card for guidance, which did not list the egg allergy. The certified nursing assistant who served the meal did not verify the ingredients with the kitchen staff before serving the tray. Additionally, the following morning, the resident's breakfast tray again lacked an indication of the egg allergy on the preference card, despite the allergy being documented in the resident's records. The facility's policies required that resident allergies be reflected on tray cards and that food service staff be aware of such allergies. However, the failure to update and communicate the resident's egg allergy on the tray ticket and to verify meal ingredients led to the resident being served food containing eggs on multiple occasions. This lapse in communication and adherence to policy resulted in the resident experiencing an allergic reaction and requiring medical intervention.
Failure to Perform Hand Hygiene Prior to Food Preparation
Penalty
Summary
A Kitchen Aid (KA) was observed in the kitchen opening the trash lid and then proceeding to cut zucchini squash on a cutting board without performing hand hygiene. This action was directly witnessed by surveyors during a kitchen observation. When interviewed, the KA acknowledged not performing hand hygiene after touching the trash lid and stated that staff are required to perform hand hygiene before handling food to prevent the spread of infections. The Administrator (ADM) confirmed during an interview that kitchen staff should thoroughly perform hand hygiene with soap and water before, during, and after food preparation. A review of the facility's policies indicated that hand hygiene is considered the primary means to prevent the spread of infection and is required to ensure a safe and sanitary environment. The facility's Infection Prevention and Control Program also mandates maintaining practices to prevent the development and transmission of disease and infection.
Failure to Supervise and Enforce Policies Leads to Resident Safety Risks
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for three residents, leading to multiple incidents of non-compliance with facility policies. Resident 1 was able to obtain and consume alcohol on facility grounds, despite the facility's zero-tolerance policy for alcohol without a physician's order. This incident occurred on 3/9/2025, when Resident 1 was observed drinking vodka in the parking lot, which was reported by other residents and confirmed by the Maintenance Assistant. The Director of Nursing acknowledged that Resident 1 did not have a physician's order to consume alcohol, and the consumption was contraindicated due to the resident's medication regimen. Additionally, the facility failed to supervise Residents 1, 2, and 3 while they were outside by the parking lot and in the smoking area on multiple occasions. On 3/9/2025 and 3/12/2025, these residents were left unsupervised, which allowed Resident 1 to consume alcohol and potentially engage in other unsafe behaviors. Interviews with various staff members, including the Housekeeping staff and Kitchen Staff, confirmed that there was no staff present to monitor the residents during these times, contrary to the facility's policy that requires supervision during smoking sessions. The facility also did not implement its policy and procedure regarding smoking compliance and failed to update Resident 1's care plan to reflect necessary interventions. Despite Resident 1's history of non-compliance with the smoking policy, including keeping smoking materials in a locked drawer in his room, the facility did not enforce the policy that required smoking materials to be kept in a secure place by staff. The interdisciplinary team meetings intended to address Resident 1's smoking violations were not conducted as planned, and the care plan was not updated to ensure the resident's safety.
Failure to Implement Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directives was placed in the resident's chart alongside the Physician Orders for Life-Sustaining Treatment (POLST). This oversight led to a conflict in carrying out the resident's wishes for medical treatment when the resident went into respiratory arrest with no pulse detected. Despite having an advance directive indicating a Do Not Resuscitate (DNR) order, the facility staff provided CPR to the resident due to the absence of the directive in the medical records. The resident, who had intact cognitive skills for daily decision-making, was admitted with diagnoses of acute embolism and thrombosis of the right internal jugular vein and paroxysmal atrial fibrillation. The resident's family member confirmed that a notarized copy of the advance directive was provided to the facility, but it was not included in the resident's medical records. The Director of Nursing and Social Services Director acknowledged the absence of the advance directive in the chart, which should have been available to guide staff during emergencies. The directive was later found mixed with the resident's hospital records after the surveyor's exit.
Incomplete POLST Leads to Conflict in Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life-Sustaining Treatment (POLST) was complete with the necessary physician's signature, which is required to confirm the resident's do not resuscitate (DNR) status. This deficiency was identified for one of the two sampled residents, who had a POLST indicating DNR, comfort-focused treatment, and no artificial means of nutrition. However, the POLST was left unsigned by the physician, leading to a conflict in carrying out the resident's wishes when they went into respiratory arrest with no pulse detected, and CPR was administered by facility staff. The resident involved had an intact cognitive ability for daily decision-making and was dependent on assistance for various activities of daily living. The incident occurred when the resident went into respiratory arrest, and the facility staff initiated CPR, contrary to the resident's documented wishes. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the responsibility for ensuring the POLST was complete, including obtaining the physician's signature, was not fulfilled. The resident's physician was unaware of the DNR status due to the lack of a signature, which is necessary for the POLST to be a legally effective document that guides the facility's actions during emergencies.
Failure to Develop Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop an individualized, resident-centered care plan for a resident at risk of elopement. The resident, who was admitted with diagnoses including seizures, diabetes, and muscle wasting, was noted to have fluctuating capacity to understand and make decisions. Despite being independent in cognitive skills for daily decision-making, the resident expressed a desire to be discharged home and was able to ambulate independently. The facility's Director of Nursing acknowledged that the resident was at risk for elopement during an IDT meeting, yet no care plan addressing this risk was developed. The facility's policies and procedures require the identification of residents at risk for elopement and the documentation of preventive interventions in the resident's medical record. However, the resident's risk for elopement was not documented, and no care plan was created to address this risk. This oversight was highlighted when the resident ambulated out of the facility, indicating a failure to implement the facility's policies and procedures effectively.
Failure to Complete Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure a neurological assessment was completed for a resident who experienced an unwitnessed fall, as per the facility's policy and procedure. The resident, who was admitted with a history of falling, anxiety, and muscle wasting, was found sitting on the floor next to her bed. The facility's policy required a 72-hour neuro check following such incidents, but the documentation showed that multiple scheduled assessments were missed. The neurological assessment flowsheet for the resident indicated that the last documented neuro check was conducted shortly after the fall, with subsequent scheduled checks left blank. Interviews with the Quality Assurance Nurse and Licensed Vocational Nurse confirmed that the flowsheet had incomplete documentation, with a total of ten missed assessments. The nurses acknowledged the importance of following the neuro check schedule to monitor for any changes in the resident's condition following the fall. Further interviews with the nursing staff revealed that the neuro check was not endorsed to the incoming nurse, and the scheduled assessments were not conducted. The facility's policy required neuro checks to be performed following an unwitnessed fall to detect any potential head injuries or changes in the resident's level of consciousness. The failure to complete these assessments as scheduled was verified by the nursing staff, who emphasized the importance of timely care and treatment to ensure resident safety.
Failure to Document and Report Medication Irregularities
Penalty
Summary
The facility failed to properly document and report irregularities in the medication regimen review for a resident, specifically concerning the use of Lorazepam. The resident, who was admitted with diagnoses including anxiety and muscle wasting, had orders for Lorazepam that were incomplete, lacking a diagnosis and specific target behavior. This oversight was identified during a review of the resident's records, which showed that the orders did not include necessary monitoring instructions for the medication's use and potential adverse reactions. The consulting pharmacist did not identify or report these irregularities during the monthly drug regimen review conducted at the end of November. The pharmacist missed the opportunity to clarify the Lorazepam order with the prescribing physician, which should have included the resident's diagnosis and specific behaviors to monitor. This omission meant that there was no recommendation made to the attending physician regarding the need for monitoring specific behaviors and potential adverse reactions associated with Lorazepam use. Interviews with facility staff, including a registered nurse and a quality assurance nurse, confirmed that the lack of documentation and reporting by the pharmacist prevented necessary discussions with the resident's psychiatrist. The facility's policy on psychotherapeutic drug management requires the pharmacist to review and make recommendations, but this was not adhered to in this case, leading to a potential risk of unnecessary medication administration and harm to the resident.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs, specifically Lorazepam, as per the facility's policy and procedure on Psychotherapeutic Drug Management. The resident, who was admitted with a history of falling, anxiety, and muscle wasting, was prescribed Lorazepam without a specific indication for a diagnosis in the physician's order. Additionally, the order lacked a specific target behavior, such as restlessness or attempts to get up from bed without assistance, which are manifestations of the resident's anxiety. The resident's Lorazepam PRN order was not discontinued after 14 days from the start date, as required by the facility's policy. There was no documentation from the resident's physician to justify extending the PRN order beyond this period. The Quality Assurance Nurse confirmed that the Lorazepam order was incomplete and emphasized the importance of having a complete physician order to ensure the correct medication is administered for the correct indication. Furthermore, the facility did not have an order to monitor or document any adverse reactions to the anti-anxiety therapy, nor was there an order to monitor the occurrence of target behaviors for the use of Lorazepam. The Registered Nurse highlighted the necessity of including specific target behaviors in the physician's order to guide licensed nurses on when to administer the medication and to monitor its effectiveness. The facility's policy requires that psychotropic medication orders include a diagnosis and indications for the disorder being treated, and PRN orders for such drugs are limited to 14 days unless extended with documented rationale.
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.
