Golden Sonora Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sonora, California.
- Location
- 19929 Greenley Road, Sonora, California 95370
- CMS Provider Number
- 555736
- Inspections on file
- 78
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at Golden Sonora Care Center during CMS and state inspections, most recent first.
Two residents with complex medical conditions did not have their ordered lab results properly reported to the MD or documented. One resident with hepatic encephalopathy, liver cirrhosis, and chronic kidney disease had daily ammonia levels ordered with instructions to notify the MD when levels were elevated, yet several high ammonia results were not documented as reported. Another resident with dementia and hyponatremia had weekly BMPs ordered, but there was no documentation that the BMP results on two occasions were faxed or communicated to the MD. Staff interviews confirmed that facility expectations required notifying the MD of lab results and documenting this communication, which did not occur in these cases.
A resident with hepatic encephalopathy, liver cirrhosis, and chronic kidney disease had a physician’s order for daily ammonia level testing, but the facility failed to obtain and submit blood specimens on multiple ordered days. The resident and a family member reported that tests were not being done at the facility and that the resident’s most recent ammonia level had only been checked at the hospital. Nursing staff acknowledged that nurses were responsible for drawing and delivering specimens to the hospital lab, documenting the draws, tracking results, and notifying management and the MD if unable to complete the tests. Review of records and confirmation from the outside laboratory showed no ammonia specimens were received from the facility on the missed days, confirming that the ordered daily labs were not carried out.
The facility removed assist rails from the beds of several cognitively intact residents with documented weakness, mobility impairments, and fall histories, despite existing consents, physician orders, and care plan interventions authorizing assist rails for bed mobility and ADL support. Residents reported that maintenance staff removed the rails even when they objected, and that they had previously relied on the rails to turn in bed, reposition, assist with transfers, and feel secure during incontinence care. After removal, residents described fear of falling, loss of independence, and humiliation related to needing more staff assistance. Nursing staff confirmed that assist rails were removed facility-wide, that residents were upset or devastated, and that the action was driven by corporate concerns about restraint use, while the maintenance director acknowledged he was instructed to remove rails and was unsure whether residents had been informed. These actions conflicted with the facility’s own resident rights policy regarding participation in care planning, dignity, self-determination, and reasonable accommodation of individual needs and preferences.
A resident was administered metoprolol despite physician-ordered parameters to hold the medication for low blood pressure or heart rate. On several occasions, the medication was given when the resident's vital signs were either below the specified thresholds or not documented, leading to an episode of hypotension that required emergency evaluation. Nursing staff confirmed awareness of the parameters but did not consistently follow them, contrary to facility policy.
A resident's responsible party and family were not immediately notified of the resident's death. The facility staff relied on hospice to make the notification, but the responsible party only learned of the death upon returning to the facility. Interviews and record reviews revealed inconsistent practices and a lack of direct communication with the family, despite facility policy requiring notification of the responsible party in such events.
Meal tray tickets containing sensitive personal and medical information for all residents were found discarded in a kitchen garbage can and subsequently transported to an unsecured, publicly accessible dumpster. The tickets included resident names, room locations, diet orders, fluid textures, food preferences, allergies, and special instructions. The CDM confirmed that these documents should have been shredded and that their disposal in the trash violated HIPAA and facility policy.
The facility failed to verify, complete, and implement PASRR screenings and recommendations for four residents with serious mental illness or intellectual disabilities. This included not identifying a resident's SMI on the PASRR, not completing required Level II evaluations due to unresponsiveness to state contacts, and not providing or following up on recommended specialized mental health services.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
Surveyors found that food and drink served to residents was not consistently palatable, attractive, or at a safe and appetizing temperature, failing to meet required standards for meal service.
The facility did not provide alternate meal options with similar nutritional value to the main entrée for 172 residents. Interviews with residents and the CDM revealed that alternate choices were limited to items like grilled cheese sandwiches, chef's salad, cottage cheese and fruit, and hamburgers, with some residents reporting only snack-type items and reduced portion sizes. Review of recipes showed a significant difference in protein content between alternate and main meals.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not have a program in place to monitor antibiotic use, lacking a system to track or evaluate antibiotic administration among residents.
Multiple flies were observed in the kitchen and dry storeroom, with staff swatting at flies during meal plating and food left mostly uncovered. The door to the dumpster area was found propped open, increasing the risk of pest entry. The Dietary Director confirmed an increase in flies and acknowledged the risk of food contamination, in violation of the facility's pest control policy.
A resident's urinary catheter bag was observed without a privacy cover, and staff confirmed that this did not align with facility policy requiring such covers to maintain resident dignity. The absence of the privacy cover was acknowledged by both nursing and administrative staff, highlighting a lapse in upholding the resident's right to dignity.
Residents who were clinically determined to be appropriate for self-administration of medications were not permitted to do so, contrary to regulatory requirements.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve grievances.
A resident with multiple chronic conditions, including COPD and chronic kidney disease, was admitted to hospice care but did not have a hospice care plan developed as required. Record review and staff interview confirmed the absence of a coordinated plan of care, despite facility policy mandating such plans for residents receiving hospice services.
A resident with multiple medical conditions had a pressure ulcer that was reclassified from unstageable to stage 4 after debridement, with new treatment orders issued. The care plan was not updated to reflect the current wound stage or treatment, as confirmed by nursing staff and leadership, despite facility policy requiring such updates for accurate care delivery.
The facility did not ensure that services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
A resident did not receive appropriate care or interventions to maintain or improve ROM or mobility, and the facility did not ensure services were provided to prevent a decline unless it was medically unavoidable.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents did not receive appropriate urological care as ordered, including missed documentation of catheter care and urine output for one resident, and delayed scheduling and communication of a urology consult for another. Staff interviews and record reviews confirmed lapses in following physician orders and facility policy, as well as inadequate communication regarding outside medical appointments.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Two dumpsters were observed overflowing with garbage, preventing the lids from closing and leaving one lid open. The dumpsters, located near the kitchen hallway, were not maintained according to facility policy or FDA guidelines, as confirmed by the dietary manager during an interview.
Two unlabeled urinals were found on a nightstand next to a resident's bed, and staff confirmed that urinals should be labeled to prevent cross contamination and infection. The infection preventionist and ADON acknowledged this was unsanitary and did not meet infection control standards, as outlined in facility policy.
A resident experienced a change in condition and was sent to the ER, but the facility failed to immediately notify the responsible party as required. Staff left voicemails on an office phone outside business hours, despite having received updated after-hours contact information, which was not added to the resident's record. This led to miscommunication and medical decisions being made without the responsible party's input.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to accepted professional standards, as observed by surveyors during their review of documentation and information handling practices.
A resident with recent subdural hemorrhage, muscle weakness, and impaired safety awareness was left unattended in the bathroom after being transferred to the toilet by a CNA. Despite being identified as a moderate fall risk, the resident was left alone for about two minutes, during which time a fall occurred, resulting in a scalp laceration that required emergency care.
A resident with multiple medical conditions, including dementia and a recent toenail wound, did not receive a physician-ordered podiatry consult. Despite documentation and staff acknowledgment of the order, the consult was not completed, and the omission was confirmed by facility leadership.
A facility failed to create baseline care plans within 48 hours for a resident admitted with multiple health conditions, including UTI, muscle weakness, and aphasia. The necessary care plans for communication, dehydration, skin, and incontinence were not initiated during the resident's stay and were only created five days after discharge. The ADON confirmed that these care plans should have been developed promptly to guide staff actions and meet the resident's immediate needs.
A resident with hypertension and a cerebral aneurysm did not receive proper blood pressure monitoring before administering amlodipine, leading to a stroke. The facility failed to set parameters for when to withhold the medication and did not consistently record blood pressure readings. A critically high blood pressure reading was not acted upon, resulting in the resident's transfer to a hospital for higher care.
A resident's personal belongings were lost due to the facility's failure to properly inventory and label clothing. The resident, who was fully continent, was found wearing an adult brief, and several personal clothing items were missing. The facility's process for managing residents' belongings was not followed, as the inventory list was not found in the resident's record, and clothing was not labeled before being sent to laundry services. Unlabeled clothing was stored in bags and could not be returned unless identified by residents.
A resident with schizophrenia and muscle weakness experienced an incident resulting in a laceration and abrasions. The facility failed to document follow-up assessments and social services interventions for 72 hours post-incident, as required by policy, potentially leaving the resident's injuries and psychosocial needs unaddressed.
A resident with prostate cancer and brain metastases was denied re-entry to a facility after hospitalization, despite being calm and cooperative. The facility failed to document the discharge reason or provide a written notice to the resident, their representative, or the LTC Ombudsman, violating the resident's right to return and appeal the discharge.
A facility failed to implement a care plan for a resident with dysphagia, despite the resident's risk of aspiration. The resident's medical records showed no care plan addressing this risk, confirmed by the ADON. The SLP provided ongoing staff training and posted signs for aspiration precautions, but the nursing staff did not update the care plan with these recommendations, contrary to facility policy.
A resident with dementia and dysphagia was found with a straw in her milk despite a posted sign indicating no straws, posing a risk of aspiration. The SLP had identified coughing with straw use and provided ongoing staff education on aspiration precautions, but the resident continued to be found with straws at her bedside.
The facility failed to provide residents with access to their personal funds during weekends and after hours, affecting 42 residents with funds in the facility trust account. Despite a policy requiring access to funds within 24 hours, several staff members were unaware of the procedures, leading to inconsistencies in cash availability at nurse's stations. This deficiency was highlighted by residents who reported difficulties in accessing their money, and staff interviews revealed a lack of communication and implementation of the policy.
The facility did not serve the correct double protein meals to 10 residents, instead providing double portions of each food item. This was observed during a lunch meal service, and the District Manager acknowledged the error, noting the absence of the Dietary Manager during tray line. A facility document emphasized the importance of tray line accuracy for maintaining nutritional adequacy.
The facility failed to follow proper food handling practices, affecting 171 residents. Food items lacked use-by dates, and expired products were not removed. The kitchen had unsanitary conditions, including a dusty fan and wet-stacked cups. Nursing station refrigerators contained unlabeled food and were unclean, posing a risk of foodborne illnesses.
The facility failed to maintain infection control protocols, including not using enhanced barrier precautions for a resident with a nephrostomy tube, transporting clean linen with an open cart cover, and neglecting hand hygiene during wound care for a resident with a stage 4 pressure ulcer.
A resident with a urinary catheter in a LTC facility was observed to have their urine collection bag uncovered on multiple occasions, which compromised their privacy and dignity. The resident's care plan included the use of a catheter, and both a CNA and the DON confirmed that the bag should have been covered. The facility's policy on dignity requires staff to assist residents in keeping urinary bags covered.
Two residents in a facility were found without their call lights within reach, despite their care plans indicating the necessity due to their medical conditions. One resident, with muscle weakness and difficulty walking, was observed trying to use a TV remote for help. Another resident, paralyzed on one side and on hospice care, was also found without access to their call light. Staff confirmed the oversight, and the DON acknowledged the failure to follow the facility's policy.
A resident's right to self-determination was not respected when they requested a shower instead of a bed bath, but staff did not honor this request due to time constraints. The DON and a CNA could not provide documentation of the resident receiving a shower or bed bath on the designated days, despite the facility's policy emphasizing the importance of supporting residents' rights and well-being.
A facility failed to coordinate PASRR assessments for a resident with schizophrenia, as her mental illness was not included in the PASRR Level I screening. Despite documentation indicating schizophrenia, the screening incorrectly showed no serious mental illness. Staff interviews revealed confusion over responsibility for PASRR accuracy, and the facility's policy was not effectively implemented.
A resident with COPD, pulmonary embolism, and diabetes was observed smoking unsupervised on the sidewalk outside the facility, despite a no-smoking policy. The resident, who used a walker and had an unsteady gait, kept cigarettes and a lighter in a bag tied to her walker. Facility staff, including the Administrator, were aware of the resident's actions and her refusal to use nicotine patches offered by the facility.
A resident with a PICC line did not receive dressing changes as ordered, risking infection. The dressing was not changed on the scheduled date, and staff confirmed it was only reinforced. Facility policy required weekly changes to prevent infection, but documentation showed a lapse in adherence to this protocol.
A facility failed to change a resident's oxygen tubing weekly as per physician's order. The resident, who was admitted with respiratory failure, was observed using oxygen tubing that had not been changed since 6/3/24. Both the LN and DON confirmed that the tubing should be changed weekly to prevent infection, highlighting a lapse in following professional standards of practice.
A resident with end-stage renal disease did not have complete pre and post-dialysis documentation for five out of six treatment days, leading to a communication gap between the dialysis center and the facility. Staff interviews confirmed the absence of necessary documentation, which is crucial for monitoring the resident's condition and responding to potential adverse outcomes.
A resident with pancreatic and lung cancer did not receive prescribed oxycodone for pain management due to a discrepancy in medication administration records. The medication card showed two remaining tablets, contradicting the documentation by an LN who claimed the medication was given. Interviews confirmed the resident experienced pain, and the facility's policy on controlled substance reconciliation was not followed.
Failure to Report and Document Critical Lab Results to Physician
Penalty
Summary
The deficiency involves the facility’s failure to ensure that laboratory results were reported to the physician and documented according to medical orders and professional standards of practice for two residents. For the first resident, who had hepatic encephalopathy, liver cirrhosis, and chronic kidney disease, the physician ordered daily ammonia level testing with instructions to notify the physician if results were at or above 65. Laboratory records showed ammonia levels of 66, 71, and 93 on specified dates, but progress notes contained no documentation that these elevated results were reported to the physician on those days. Nursing staff and the Unit Manager later confirmed that the order required notification to the physician for results at or above 65 and that there was no documentation of such notification for those dates. The first resident was also receiving Lactulose to manage ammonia levels, and nursing staff stated that the frequent ammonia testing was intended to allow the physician to adjust the medication dose based on the results. Interviews with multiple licensed nurses indicated that the usual practice when laboratory results are received is to send or fax them to the physician, notify the physician by phone if results are critical or urgent, and document the notification and any new orders in the progress notes. The Unit Manager confirmed that the nurses who received the laboratory results should have documented that the physician was notified, that results were sent, and whether any orders were given, and acknowledged that this documentation was missing for the elevated ammonia levels. For the second resident, who had dementia and a cognitive communication deficit, the physician ordered a basic metabolic panel (BMP) every Monday for management of hyponatremia. The medical record showed that BMP tests were completed on two Mondays, but there was no documentation in the progress notes that these results were received, faxed, or reported to the physician. The Unit Manager verified the existence of the standing BMP order and confirmed that there was no documentation that the results from those dates were reported or faxed to the physician. The Assistant Director of Nursing stated that staff were expected to document upon receipt of laboratory results whether the physician was notified and that results were faxed to the physician’s office, which did not occur in these instances.
Failure to Complete Ordered Daily Ammonia Laboratory Tests
Penalty
Summary
The deficiency involves the facility’s failure to obtain ordered daily ammonia laboratory tests for one of four sampled residents. The resident was admitted in 2025 with hepatic encephalopathy, liver cirrhosis, and chronic kidney disease. An order dated 3/21/26 directed staff to check the resident’s ammonia levels every day shift and notify the physician if levels were about 65. Review of the medical record showed no ammonia lab results for 3/25/26, 3/28/26, and 3/31/26, despite the standing daily order. During interviews, the resident and a family member reported that the resident was upset because his ammonia levels were not being checked daily as ordered, and that his last ammonia blood draw had occurred when he went to the hospital, not at the facility. The resident stated that his ammonia level had been 93 and then decreased to 44 at the hospital, and that on 3/31/26 he returned from an outside appointment before lunchtime and believed the facility had time to draw his blood but did not do so. The family member expressed concern that the resident had to go to the hospital just to have his ammonia level checked. Nursing and management staff confirmed that the daily ammonia lab order had been in place since 3/21/26 and that the missing results for 3/25/26, 3/28/26, and 3/31/26 meant the order was not followed. Staff explained that facility nurses were responsible for drawing blood, that specimens were to be delivered promptly to the hospital laboratory, and that nurses were expected to monitor residents, document blood draws, follow up on results, and notify management and the physician if they were unable to obtain a specimen or results. The contracted laboratory confirmed that no ammonia specimens for the resident were received from the facility on the three missing dates and stated that any non-viable specimen would have prompted notification to the facility to obtain a new sample.
Resident Rights Violated When Assist Rails Removed Against Residents’ Wishes
Penalty
Summary
The deficiency involves the facility’s failure to honor resident rights to self-determination, dignity, and participation in care planning when assist rails used for mobility and bed mobility were removed from multiple residents’ beds against their wishes. Five cognitively intact residents, each with documented weakness and mobility impairments, had previously consented to the use of assist rails, had physician orders in place, and in some cases had care plan interventions specifying assist rails for bed mobility and ADL function. Despite this, the facility directed that assist rails be removed, and maintenance staff carried out the removal, including in situations where residents verbally objected. One resident with anxiety, depression, muscle weakness, and a history of repeated falls had a BIMS score of 15, a signed consent form for assist rails, and a physician order allowing assist rails for bed mobility. This resident reported that the maintenance person removed the assist rails three days prior to the survey despite the resident’s request that they not be removed. The resident stated the rails were used to help turn in bed and to hold onto during incontinence care to feel safe and secure, and since removal, the resident experienced ongoing fear of falling out of bed and feeling scared. Another resident with hemiparesis, hemiplegia, difficulty walking, muscle weakness, and wheelchair dependence, also cognitively intact with a BIMS of 15, had consented to assist rails and had a physician order for their use. After a discharge and return to the facility, this resident found the rails had been removed, reported previously using them to pull up in bed, reposition, and stand and pivot, and stated that repeated requests to staff to have the rails replaced had not been honored, leading to concerns about getting weaker and feeling scared during turning and incontinence care without the rails. A third cognitively intact resident with muscle weakness, difficulty walking, and lack of coordination had a consent form, a care plan intervention for assist rails for bed mobility, and a physician order permitting assist rails. This resident reported that the rails were removed on a specific date and remained off until the day before the survey, during which time the resident experienced a near fall when trying to go to the bathroom and reported loss of independence, including no longer being able to change their own incontinent briefs and needing two staff for this care, which the resident described as humiliating. A fourth cognitively intact resident with difficulty walking, muscle weakness, depression, anxiety, and obesity had a care plan for assist rails on both sides of the bed for bed mobility, a consent form for bilateral grab/assist/mobility bars, and a physician order for assist rails. Nursing staff interviews confirmed that assist rails had been removed facility-wide, that residents had used them for mobility assistance and turning in bed, and that residents were upset, with one nurse stating a resident was devastated. The maintenance director stated he was directed to remove assist rails from residents who were not “required” to have them and was unsure if nursing staff had explained the removals to residents, acknowledging that some residents had a problem with the removal. The assistant director of nursing stated that residents who wanted to keep rails had been evaluated, had orders, and had care plans, but she was later told to re-evaluate whose rails were “necessary.” These actions conflicted with the facility’s written policy on resident rights, which includes the right to participate in the development and implementation of the person-centered care plan, to sign after significant changes to the plan of care, to a dignified existence and self-determination, to be treated with dignity and respect, to reasonable accommodation of individual needs or preferences, and to make choices about significant aspects of life in the center.
Failure to Hold Metoprolol per Physician Parameters Resulting in Hypotension
Penalty
Summary
The facility failed to ensure that medications with physician-ordered parameters were safely administered for a resident prescribed metoprolol for hypertension. The physician's order specified that metoprolol should be held if the resident's systolic blood pressure (SBP) was less than 100 or heart rate (HR) was less than 60. On multiple occasions, including specific dates, the medication was administered despite the resident's vital signs being outside of these parameters or not documented at all. For example, on one date, the resident's blood pressure was recorded as 90/66 and 89/65, both below the hold threshold, yet the medication was still given. Additionally, there were instances where vital signs were not recorded on the medication administration record (MAR) prior to administration. Interviews with licensed nurses confirmed that they were aware of the hold parameters and acknowledged that the medication should not have been administered when the resident's vital signs were outside the prescribed limits. The failure to adhere to these parameters resulted in the resident experiencing hypotension, requiring emergency evaluation and observation. Facility policy required medications to be administered as prescribed and in accordance with physician orders, which was not followed in this case.
Failure to Notify Responsible Party of Resident Death
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) or family member about the death of a resident who was under hospice care. The resident's contact list included seven individuals, with one family member designated as the RP. This RP was not contacted by the facility regarding the resident's passing; instead, she discovered the resident's death upon returning to the facility the following morning. The RP confirmed that neither she nor other family members were notified by the facility, and the hospice agency only contacted her after she arrived at the facility and learned of the death. Interviews with facility staff, including licensed nurses, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Service Assistant (SSA), and the Assistant Administrator (AADM), revealed inconsistent practices and expectations regarding notification of family members upon a resident's death. While some staff believed that hospice would notify the family, others stated that it was the facility's responsibility to ensure the RP or emergency contact was informed, regardless of hospice involvement. Documentation in the resident's medical record indicated that the family was present the night before the death, but this was confirmed to be inaccurate by both the RP and the ADON. A review of facility policies indicated that the nursing staff was required to notify hospice and the family in the event of a resident's death or change in condition. However, in this instance, the nurse contacted hospice but did not notify the RP or family, and there was no documentation of attempts to reach the RP or other contacts. The failure to notify the RP and family members directly violated the resident's right to have their responsible party informed of significant changes, including death.
Improper Disposal of Meal Tickets Compromises Resident Privacy
Penalty
Summary
The facility compromised the privacy and confidentiality of all 173 residents by improperly disposing of meal tray tickets containing sensitive personal and medical information. During a kitchen tour, surveyors observed meal tickets with resident names discarded in a garbage can in the dishwashing area. The path of the kitchen trash was traced to outside dumpsters located in an unsecured, publicly accessible parking lot. Review of the meal tickets revealed they included resident names, room locations, meal locations, therapeutic diet orders, fluid textures, food preferences, allergies, and special instructions, all of which are considered protected health information. The Certified Dietary Manager confirmed that the expectation was for meal tickets to be placed in a shred bin and acknowledged that discarding them in the trash violated HIPAA regulations. Facility policy also stated that residents have the right to privacy and confidentiality for all aspects of care and services.
Failure to Complete and Implement PASRR Requirements for Residents with SMI/ID
Penalty
Summary
The facility failed to ensure the accuracy and completion of the Preadmission Screening and Resident Review (PASRR) process for four residents with serious mental illness (SMI), intellectual disability (ID), or related conditions. For one resident, the PASRR Level I screening from the discharging facility did not indicate a diagnosis of SMI, despite the resident having a documented diagnosis of Depressive Schizoaffective Disorder. The facility did not have a process in place to verify the accuracy of PASRR documents received from other facilities, resulting in the omission of critical information. Another resident's PASRR Level I screening indicated the need for a Level II evaluation, but this was not completed because facility staff were unresponsive to multiple attempts by the state agency to schedule the evaluation. Similarly, a third resident required a Level II Mental Health Evaluation after a positive Level I screening, but the evaluation was not completed due to the facility's lack of response to the state's communication attempts. In both cases, the absence of follow-up and unclear staff responsibilities led to the closure of the cases without the required assessments being performed. For a fourth resident, the facility did not implement or follow up on specialized services recommended in the PASRR Level II Determination Report, such as psychotherapy, counseling, and neuropsychology consultation. There was no evidence that these recommendations were reviewed with the medical doctor or incorporated into the resident's care plan. Staff interviews confirmed that the recommended mental health services and consultations were not provided, and the facility's process for ensuring follow-up on PASRR recommendations was not followed.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the labeling and secure storage of medications and biologicals within the facility.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified through surveyor observation and review, indicating that the food and beverages did not consistently meet standards for taste, appearance, or temperature at the time of service.
Failure to Provide Nutritive Alternate Meal Choices
Penalty
Summary
The facility failed to provide alternate food choices with similar nutritive value to the main meal for 172 residents who received food from the kitchen. During a kitchen tour, the alternate menu was reviewed and found to include chef's salad, grilled cheese sandwich, cottage cheese and fruit, and hamburgers. The Certified Dietary Manager (CDM) confirmed these were the only alternate meal choices available. Residents reported that they previously received alternatives like sandwiches but now only receive snack-type items, and that portion sizes have decreased since a new company took over food services. Residents also stated that they are not receiving alternatives to the main meal anymore. Further interviews with the CDM revealed that the menu was provided by an external company and could be changed based on the cook's time constraints. The CDM confirmed that the alternate grilled cheese sandwich meal comes with a vegetable and side dish of the day, but no additional protein is added. A review of the corporate recipes showed that the grilled cheese sandwich provided 14 grams of protein, while the main entrée, sesame chicken, provided 35 grams of protein. This discrepancy in protein content indicates that the alternate meals did not match the nutritive value of the main meals.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. This lack of monitoring could result in inappropriate or unnecessary antibiotic administration, but the report only states the absence of a monitoring program and does not provide further details about specific residents or incidents.
Failure to Maintain Effective Pest Control in Food Preparation Areas
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by multiple observations of flies in the food preparation and storage areas. During several kitchen tours, flies were seen in both the kitchen and the dry storeroom, which was separated from the kitchen by a closed door. Additionally, the door to the dumpster area was found propped open with a rock, potentially allowing pests easier access to the facility. During a lunch plating observation, multiple flies were present in the kitchen, and staff were observed swatting at the flies while food was mostly uncovered. In an interview, the Dietary Director acknowledged an increase in the number of flies over the past few days and recognized the risk of food contamination, stating that meals should have been covered. Review of the facility's pest control policy indicated that all food preparation, service, and storage areas should be regularly monitored for pests, and any concerns should be reported immediately. The presence of flies in food areas was confirmed by both observation and staff interview, and the facility's own policy and external resources highlight the risk of contamination from flies.
Failure to Provide Privacy Cover for Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident's urinary catheter bag was observed hanging under the bed without a privacy cover. During multiple observations and interviews, both a CNA and a licensed nurse confirmed that the catheter bag was not covered, and acknowledged that it should have been concealed with a privacy cover to maintain the resident's dignity. The Assistant Director of Nursing also confirmed that facility policy requires the use of privacy covers for urinary catheter bags to preserve resident dignity. The facility's policies on resident rights and accommodation of needs emphasize treating residents with respect, kindness, and dignity, and specifically mention the importance of accommodating individual needs to maintain independence and well-being. Despite these policies, the lack of a privacy cover for the urinary catheter bag was observed and confirmed by staff, indicating a failure to uphold the resident's right to dignity as outlined in facility policy.
Failure to Allow Self-Administration of Medications
Penalty
Summary
Residents were not allowed to self-administer their medications, despite it being clinically appropriate to do so. The facility failed to permit self-administration of drugs for residents who were determined capable, as required by regulations.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on observations and findings that the facility did not have appropriate procedures in place to address and resolve resident grievances in a timely and non-discriminatory manner.
Failure to Develop Hospice Care Plan for Resident Receiving Hospice Services
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive hospice care plan for one of seven sampled residents who was receiving hospice care services. The resident in question was admitted with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and chronic kidney disease. Despite being admitted to hospice care due to a terminal diagnosis of COPD, a review of the resident's records and an interview with the assistant director of nursing (ADON) confirmed that no hospice care plan had been developed for this resident. The facility's own policies require the development of a coordinated plan of care (POC) with hospice providers, including directives for managing pain and other symptoms, as well as a comprehensive, person-centered care plan with measurable objectives and timetables. The ADON acknowledged during the review that the absence of a hospice care plan meant staff might not know what care and services to provide, potentially impacting the resident's care. The deficiency was identified through both record review and staff interview, with verification that the required hospice care plan was missing.
Failure to Update Care Plan After Change in Pressure Ulcer Status
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident with a pressure ulcer after a significant change in the wound's condition and treatment. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, acute posthemorrhagic anemia, and generalized muscle weakness, was admitted with an unstageable pressure ulcer on the right buttock. Following a wound assessment and debridement, the pressure ulcer was reclassified as a stage 4 wound, and new treatment orders were initiated. However, the care plan continued to reflect the previous unstageable status and did not incorporate the updated stage or new treatment interventions. Interviews with nursing staff, a nurse practitioner, and the assistant director of nursing confirmed that the care plan was not updated to reflect the current wound stage and treatment orders. Staff acknowledged the importance of timely care plan updates for accurate communication and guidance in wound care. Review of facility policies and job descriptions indicated that care plans should be revised to reflect changes in residents' conditions and treatments, but this was not done in this case.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, are not provided in the report.
Failure to Provide Care to Maintain or Improve Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions or services to prevent a decline in ROM or mobility, except in cases where such decline was medically unavoidable. The report notes that the required care was not provided, but does not specify the medical history or current condition of the resident involved.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Timely Catheter Care and Urology Consults
Penalty
Summary
The facility failed to provide appropriate health treatment and services to meet the urological needs of two residents. For one resident with a history of heart failure and urinary retention, physician orders required indwelling urinary catheter care and documentation of urine output every shift. However, review of treatment administration records over several months revealed multiple instances where catheter care and urine output were not documented as ordered. Interviews with nursing staff and the Assistant Director of Nursing confirmed that catheter care and output measurement were expected every shift, and that these tasks were not consistently documented in the resident's medical record. Another resident, admitted with hemiplegia following a stroke and experiencing recurrent urinary tract infections (UTIs), had orders for a urology consult and referral to a urologist. Despite these orders, the consult and referral were not carried out in a timely manner. The resident’s family member repeatedly expressed concerns to staff about the need for a urology evaluation due to ongoing UTIs and a suspected prolapsed bladder. Multiple staff interviews confirmed that the family’s requests were communicated, but the scheduling of the urology appointment was delayed, and there was a lack of timely communication regarding the appointment status to both the family and nursing staff. The facility’s process for scheduling and communicating outside medical appointments was found to be inadequate. The staff member responsible for scheduling did not have access to the electronic clinical record and did not consistently update nursing staff about appointment statuses. This led to a disconnect in communication, resulting in delays in care and lack of timely information for both staff and the resident’s family. The Assistant Director of Nursing acknowledged that the process did not meet expectations and that the facility’s policy for catheter care and timely medical consultations was not followed.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to properly maintain its garbage storage area, as observed during a kitchen tour when two out of six dumpsters were found overflowing with garbage. The excess waste prevented the lids from closing, with one lid resting approximately six inches above the bin due to garbage bags and the other lid left open. The dumpsters were located about 15 to 20 feet from the kitchen hallway door. This situation was confirmed during an interview with the certified dietary manager, who acknowledged the importance of keeping dumpster lids closed to limit pest attraction. A review of the facility's policy on garbage and refuse disposal indicated that all trash should be disposed of in external receptacles with lids covered when not in use. Additionally, the US Food and Drug Administration's Food Code was referenced, emphasizing the need for tight-fitting lids to prevent the attraction and breeding of pests. The observed failure to keep dumpster lids closed and prevent overflow was inconsistent with both facility policy and federal guidelines.
Unlabeled Urinals Found in Resident Room Breach Infection Control
Penalty
Summary
The facility failed to implement and follow proper infection prevention practices when two unlabeled urinals were observed on the nightstand next to a resident's bed. During an observation, it was noted that the urinals were not labeled with any identifying information such as a name, initials, or room number. This was confirmed by a licensed nurse, who acknowledged that urinals should be labeled to prevent use by other residents and to avoid cross contamination. The nurse further stated that using a urinal belonging to another resident could cause infection and illness. The infection preventionist and the assistant director of nursing both confirmed that the presence of unlabeled urinals did not meet the facility's infection control expectations and was considered unsanitary. Facility policies reviewed indicated that maintaining a clean, sanitary, and orderly environment is required, and that infection control practices must support prevention and transmission of infection. The failure to label urinals as required was identified as a breach of these policies.
Failure to Notify Responsible Party of Change in Condition and Emergency Transfer
Penalty
Summary
The facility failed to immediately notify the responsible party (RP) for a resident who experienced a change in condition and was sent to the emergency room. Specifically, after the resident had an unwitnessed fall, the facility did not contact the RP until the following day, despite having received written instructions with updated after-hours contact information. Instead, staff left multiple voicemails on the RP's office phone, which was only checked during regular business hours. The updated contact information, which included specific after-hours instructions, was not added to the resident's admission record, resulting in staff being unable to reach the RP in a timely manner during an emergency. Interviews with facility staff confirmed that the updated contact information was received but not incorporated into the resident's records. The facility's policies required immediate notification of changes in condition and documentation of such notifications, but these procedures were not followed. As a result, there was miscommunication between the facility, the RP, and the emergency room, and medical decisions were made for the resident without input from the RP.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Resident Fall Due to Inadequate Supervision in Bathroom
Penalty
Summary
A deficiency occurred when a resident with a recent history of traumatic subdural hemorrhage, muscle weakness, and impaired safety awareness was left unattended in the bathroom. The resident had been admitted to the facility only a few hours prior, with documented left-sided weakness, slurred speech, and cognitive impairment. Despite being identified as a moderate fall risk with deconditioning and gait/balance problems, the resident was transferred to the toilet by a CNA, who then left the resident alone in the bathroom at the resident's request for privacy. The CNA was away for approximately two minutes, during which time the resident fell and sustained a scalp laceration requiring emergency medical attention and laceration repair with staples. Interviews and record reviews confirmed that staff were aware of the resident's fall risk and cognitive limitations. The facility's policy and the Director of Staff Development indicated that staff should remain close to residents identified as fall risks, even if privacy is requested, and should stay within reach or just outside the bathroom door. However, this protocol was not followed, resulting in the resident being left unsupervised and subsequently experiencing a fall with injury.
Failure to Provide Physician-Ordered Podiatry Services
Penalty
Summary
The facility failed to provide podiatry services as ordered by the physician for one resident. The resident was admitted with diagnoses including dementia, glaucoma, hyperlipidemia, and depression. A skin/wound note documented an evaluation and treatment for the resident's right toenail, which had mild exudate. Following this, a physician's order was placed for a podiatry consult to address the toenail issue. Despite the physician's order, the resident was not seen by a podiatrist. This was confirmed through interviews and record reviews with the Social Services Director, Assistant Director of Nursing, and the Administrator, all of whom acknowledged that the order for a podiatry consult was not carried out. The staff confirmed that the failure to follow the physician's order could impact the resident's health and well-being.
Failure to Develop Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to create and implement necessary baseline care plans within 48 hours of admission for a resident, resulting in a lack of care plans for communication, dehydration, skin, and incontinence during the resident's stay. The resident was admitted with multiple diagnoses, including urinary tract infection, muscle weakness, aphasia, dysphagia, cerebral aneurysm, and adult failure to thrive. Despite these conditions, the care plans were not initiated until five days after the resident was discharged. The Assistant Director of Nursing (ADON) acknowledged that care plans should have been developed within the first 48 hours of the resident's admission. The ADON explained that care plans are essential for directing staff actions and ensuring that the resident's needs, such as using a whiteboard for communication, are met. The facility's policy requires a baseline care plan to be developed within 48 hours to meet the resident's immediate health and safety needs, but this was not adhered to in this case.
Failure to Monitor Blood Pressure Leads to Resident Stroke
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident diagnosed with hypertension and a cerebral aneurysm. The resident was prescribed amlodipine for blood pressure management, but the facility did not consistently monitor the resident's blood pressure before administering the medication. There were no parameters set in the medication order to guide when the medication should be withheld, and the resident's blood pressure was not regularly recorded. This lack of monitoring and absence of parameters led to the administration of amlodipine without assessing the resident's current blood pressure, which is critical in managing hypertension effectively. The resident's blood pressure was not taken consistently throughout their stay, and a critically high blood pressure reading of 272/114 was not acted upon by the nursing staff or reported to the medical doctor. Despite the resident's medical history and the potential risks associated with high blood pressure, the facility did not ensure that the resident's vital signs were monitored every shift as expected. This oversight resulted in the resident experiencing a stroke and requiring transfer to a hospital for a higher level of care. Interviews with facility staff, including licensed nurses and the Assistant Director of Nursing, revealed an understanding of the importance of monitoring blood pressure and the need for parameters in medication orders. However, these practices were not followed, leading to a significant lapse in care. The medical doctor also emphasized the necessity of regular monitoring and communication regarding the resident's condition, particularly given the resident's aneurysm and the associated risks of elevated blood pressure. The failure to adhere to these standards of care had a direct negative impact on the resident's health and well-being.
Failure to Protect Resident's Property from Loss
Penalty
Summary
The facility failed to protect a resident's property from loss, resulting in the resident losing personal items and potentially experiencing emotional distress. The resident, who was fully continent, was found wearing an adult brief, and their responsible party noticed the absence of several personal clothing items, including boxer briefs and sweatshirts. The responsible party had previously purchased and brought these items to the facility, but they were missing during a visit. The facility's process for managing residents' personal belongings was not followed. An inventory list of the resident's belongings was supposed to be completed upon admission and scanned into the electronic health record, but it was not found in the resident's record. Staff were expected to label clothing with the resident's name using a sharpie, but this was not done, leading to the loss of the resident's clothing. Interviews with staff, including CNAs and the Director of Nursing, revealed that the inventory process was not properly executed, and clothing was not labeled before being sent to laundry services. The Housekeeping Manager confirmed that unlabeled clothing was stored in bags and could not be returned to residents unless they complained and identified their items. The Director of Nursing and the Administrator acknowledged the issue and the lack of an inventory sheet in the resident's medical record. The facility's policy required that residents' belongings be inventoried and documented upon admission and updated as necessary, but this was not adhered to, resulting in the loss of the resident's personal items.
Incomplete Post-Incident Documentation for a Resident
Penalty
Summary
The facility failed to meet professional standards of care for a resident who was admitted with schizophrenia and muscle weakness. After an incident where the resident became enraged and was found on the floor with a laceration, the documentation of assessments and observations post-incident was incomplete. The resident was taken to the emergency room and returned with additional abrasions, but there was no documentation of follow-up care or assessments for 72 hours as required by the facility's policy. The interdisciplinary team recommended social services follow-up, but there was no documentation of this occurring. The lack of documentation meant that the resident's potential injuries, illnesses, and psychosocial needs were not assessed or addressed. The facility's policy required all services and changes in the resident's condition to be documented to facilitate communication among the care team, which was not adhered to in this case.
Failure to Ensure Resident's Right to Return After Hospitalization
Penalty
Summary
The facility failed to ensure the right to return for a resident after hospitalization, which led to a deficiency. The resident, who had been admitted to the facility with diagnoses including prostate cancer and secondary malignant neoplasm of the brain, was sent to the hospital due to aggressive behaviors. Despite being calm and cooperative upon evaluation in the emergency department, the facility refused to accept the resident back after discharge from the hospital. This refusal occurred without documented justification from a facility physician or proper communication with the hospice team. The facility did not provide a written Notice of Transfer or Discharge to the resident, the resident's representative, or the Long-Term Care Ombudsman. The lack of documentation and communication regarding the resident's discharge was confirmed by interviews with the Medical Director, Social Services Director, and the Administrator. The facility's policy required that reasons for transfer or discharge be documented in the resident's medical record, which was not adhered to in this case. Additionally, the facility's failure to provide a discharge notice deprived the resident and their representative of information regarding their rights to appeal the transfer or discharge. The Administrator acknowledged that a written discharge notice was not provided and that the conversation with the resident's representative was not documented. This oversight prevented the resident's family from coordinating care and deprived the Ombudsman of the opportunity to advocate on the resident's behalf.
Failure to Implement Care Plan for Resident with Dysphagia
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident with dysphagia, a condition characterized by difficulty swallowing. This deficiency was identified during a review of the resident's admission records, which indicated diagnoses including dementia, generalized muscle weakness, and dysphagia. Despite these conditions, there was no care plan in place to address the resident's risk of aspiration, a serious condition where food or liquid is accidentally inhaled into the airway, potentially leading to pneumonia. The Assistant Director of Nursing confirmed the absence of an aspiration care plan, acknowledging that such a plan is necessary for staff to be aware of the resident's dietary limitations and interventions needed to prevent aspiration. Interviews with staff revealed ongoing issues with compliance to speech therapy recommendations. The Speech Language Pathologist (SLP) had conducted in-services to educate staff on aspiration precautions and had posted a sign above the resident's bed to communicate these precautions. However, the Administrator indicated that the nursing staff was responsible for entering the SLP's recommendations into the care plan, which had not been done. The facility's policy on comprehensive person-centered care plans, revised in March 2022, states that care plans should be revised as residents' conditions change, highlighting a lapse in adherence to this policy.
Failure to Adhere to Aspiration Precautions for a Resident
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards, as evidenced by the presence of a straw in the resident's milk despite a posted sign indicating no straws. The resident, who was admitted with diagnoses including dementia, generalized muscle weakness, and dysphagia, was observed with a straw in her milk during a lunch meal. The Director of Nursing confirmed the presence of the straw and acknowledged that the resident was not supposed to have straws due to the risk of aspiration. The Speech Language Pathologist (SLP) had previously identified that the resident coughed when using a straw and had posted a sign above the resident's bed to prevent staff from providing straws. Despite ongoing staff education on aspiration precautions, the resident continued to be found with straws at her bedside. The SLP's evaluation and treatment notes consistently indicated the resident's need for modified diet and aspiration precautions, including the recommendation against straw use. The failure to adhere to these precautions posed a risk of aspiration, which could lead to serious health complications.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds during weekends and after business hours, affecting 42 residents with funds in the facility trust account. Interviews and record reviews revealed that residents could only access their funds during business hours through the business office. Although the Business Office Manager Assistant (BOMA) stated that cash was available at the nurse's stations after hours, several licensed nurses were unaware of this provision, indicating a lack of communication and implementation of the policy. The facility's policy required that residents have access to funds within 24 hours, but this was not consistently practiced. Specific instances included Resident 28, who reported being unable to access cash on weekends, and Resident 98, who was unclear about the process for accessing funds. Interviews with various staff members, including licensed nurses and the Assistant Director of Nurses (ADON), highlighted inconsistencies in the availability of cash at nurse's stations and a lack of awareness among staff about the procedures for providing residents with their funds. The facility's policy indicated that residents should have access to a certain amount of money within 24 hours, but this was not effectively implemented, potentially impacting residents' ability to engage in activities and meet their needs.
Failure to Serve Correct Double Protein Meals
Penalty
Summary
The facility failed to ensure that the lunch meal served on June 19, 2024, met the nutritional needs of 10 residents who had orders for double protein. Instead of receiving double protein, these residents were served double portions of each food item on their meal trays. This discrepancy was observed during the lunch meal service in the kitchen. The District Manager, during an interview, acknowledged that staff should have prepared and served meals according to the orders and that the Dietary Manager should have been present during the tray line to ensure accuracy. A review of the facility's document titled 'TRAYLINE ACCURACY/MENU COMPLIANCE' from 2010 indicated that the goal of tray line accuracy is to maintain residents' nutritional adequacy.
Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food handling practices, affecting 171 residents who received food from the kitchen. Multiple food items in the refrigerator, freezer, and dry storage area were found without labels indicating a use-by date, making them available for resident consumption. Additionally, expired food products, such as balsamic vinegar, lemons, and sour cream, were not removed from the kitchen, posing a risk of being served to residents. The kitchen environment was also found to be unsanitary. A fan above the double coffee maker was observed to have accumulated dust and lint, and the coffee makers beneath it were uncovered. Plastic cups were stacked wet after washing, which could lead to contamination. Furthermore, opened boxes of plastic silverware were left uncovered in the dry storage area, increasing the risk of contamination. In the nursing stations, the [NAME] Unit's refrigerator contained unlabeled food items, and the East Unit's refrigerator was found with hair, spilled liquid, and stains. These conditions were confirmed by the facility's staff, including the Assistant Manager, Licensed Nurse, and Director of Nursing, who acknowledged the potential for foodborne illnesses due to these deficiencies. The Registered Dietitian emphasized the importance of labeling food products with use-by dates and maintaining a clean and sanitary kitchen environment.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain its infection control program in several instances. For Resident 126, who had a nephrostomy tube and was at high risk for infection due to ureter cancer and type 2 diabetes, the facility did not ensure enhanced barrier precautions were followed during a dressing change. A licensed nurse performed the dressing change without wearing a gown, which was required under the enhanced barrier precautions. Additionally, the nurse failed to date, time, and initial the new dressing, which is crucial for ensuring that dressing changes occur as scheduled and to minimize infection risk. Another deficiency was observed when a clean linen cart was transported with its cover flap open, exposing the clean linen to potential contamination. This was noted during an observation near the East Unit Nurses Station. The facility's policy required that clean linen carts be covered to prevent contamination, but this protocol was not followed, posing a risk of transferring harmful bacteria to the clean linen. Furthermore, during wound care for Resident 2, who had a stage 4 pressure ulcer and osteomyelitis, a licensed nurse failed to perform hand hygiene between glove changes. After cleansing the wound, the nurse changed gloves without washing hands, which is against the facility's wound care policy. This lapse in hand hygiene could contribute to the spread of infection, especially given the resident's existing severe wound condition.
Failure to Maintain Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
The facility failed to maintain privacy and dignity for a resident with a urinary catheter, as the resident's urine collection bag was observed to be uncovered on multiple occasions. The resident, identified as Resident 2, was admitted to the facility with diagnoses requiring assistance with personal care. The care plan for Resident 2, initiated on February 22, 2024, included the use of a catheter and aimed to keep the resident free from catheter-related trauma. Observations on June 18 and June 19, 2024, revealed that Resident 2's urinary collection bag was not covered with a privacy bag, which was confirmed by a certified nursing assistant (CNA) who acknowledged that the bag should be covered to maintain dignity. The Director of Nursing (DON) also confirmed that the uncovered urine collection bag was a dignity issue and stated that the expectation was for the bag to be covered. The facility's policy on dignity, revised in February 2021, indicated that staff are expected to promote dignity by helping residents keep urinary bags covered.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of needs for two residents, Resident 103 and Resident 169, by not ensuring their call lights were within reach. Resident 103, who was admitted with multiple diagnoses including muscle weakness and difficulty walking, was observed sitting at the edge of his bed without a visible call light. Instead, he attempted to use the television remote control to call for help. A Certified Nursing Assistant (CNA) confirmed that Resident 103's call light was on the floor and out of reach, which contradicted the care plan that required the call light to be within reach due to the resident's risk of falls. Similarly, Resident 169, who had a history of stroke, paralysis on the right side, and was on hospice care, was found in bed with the call light on the floor, out of reach. The resident required supervision for daily activities and was dependent on staff for assistance. The care plan for Resident 169 also indicated the need for the call light to be within reach due to the high risk of falls. Both the CNA and a Licensed Nurse (LN) acknowledged the importance of having the call light accessible, especially given Resident 169's condition. The Director of Nursing (DON) confirmed that the facility's policy and procedure for ensuring call lights are within reach was not followed, acknowledging the oversight in care for both residents.
Failure to Honor Resident's Shower Request
Penalty
Summary
The facility failed to respect the right to self-determination for one resident, identified as Resident 150, who requested a shower instead of a bed bath. Despite the resident's request, a Certified Nursing Assistant (CNA) informed Resident 150 that there was not enough time to provide a shower. This incident was confirmed during an interview with Resident 150, who stated that he was not given his shower on his designated shower days. The Director of Nursing (DON) and CNA 2 were unable to provide documentation confirming that Resident 150 received a shower or bed bath on the specified days. The DON acknowledged that the expectation was for CNAs to provide showers if requested by residents. The facility's policy on dignity, which emphasizes care that promotes residents' well-being and supports their rights, was not adhered to in this instance. Resident 150's care plan indicated a need for extensive assistance with showers, which was not fulfilled.
Failure to Coordinate PASRR Assessments for Resident with Schizophrenia
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for a resident diagnosed with schizophrenia. The resident's PASRR Level I screening assessment did not include her mental illness diagnosis, which is a serious mental illness affecting thought, feeling, and behavior. This oversight was identified during a review of the resident's admission record, Minimum Data Set (MDS), care plan, and history and physical documentation, all of which indicated the presence of schizophrenia. However, the PASRR Level I screening, dated several months prior, incorrectly indicated no serious mental illness. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring the accuracy of PASRR forms. The Health Information Services (HIS) staff mentioned performing audits to ensure PASRR forms were received but was unsure who was responsible for verifying their accuracy. The Assistant Director of Nurses (ADON) confirmed the omission of the mental illness diagnosis in the PASRR and explained the process for updating PASRRs when new diagnoses are identified. The facility's policy indicated that the Administrator is accountable for monitoring the PASRR completion process, but this was not effectively implemented in this case.
Resident Smokes Unsupervised Despite No-Smoking Policy
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for Resident 80, who was observed smoking unsupervised on the sidewalk in front of the facility. Resident 80, who has chronic obstructive pulmonary disease, pulmonary embolism, and diabetes mellitus, was seen walking with an unsteady gait using a walker. Despite the facility's no-smoking policy, Resident 80 left the building twice a day to smoke on the sidewalk, keeping cigarettes and a lighter in a canvas bag tied to her walker. The facility staff, including the Administrator, were aware of Resident 80's actions and her refusal to comply with the no-smoking policy, as well as her refusal to use nicotine patches offered by the facility. Interviews with facility staff, including licensed nurses and certified nursing assistants, revealed that residents were informed of the no-smoking policy and offered nicotine patches to help them quit smoking. However, Resident 80 continued to smoke outside the facility, and staff were aware of her non-compliance. The facility's policy on accidents and incidents requires investigation and reporting of such events, but there is no indication in the report that an incident report was completed for Resident 80's actions. This oversight potentially placed Resident 80 at risk for accidental burns and injuries.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice for a resident with a Peripherally Inserted Central Catheter (PICC line). The deficiency was identified when the dressing for the PICC line was not changed according to physician orders. The resident, who was admitted with a diagnosis of bacteremia, had a PICC line dressing dated 6/8/2024, which was confirmed by a Licensed Nurse (LN) during an observation and interview. The facility's policy required the dressing to be changed weekly, but the Medication Administration Record (MAR) showed no documentation of a dressing change on the scheduled date of 6/7/2024, with the next recorded change occurring on 6/14/2024. Interviews with nursing staff and the Assistant Director of Nurses (ADON) revealed that the dressing had been reinforced rather than changed, contrary to the facility's protocol and physician orders. The ADON confirmed that the expectation was for daily assessment and weekly dressing changes to prevent infection and ensure the catheter remained unobstructed and properly positioned. The facility's policy on Central Venous Catheter Dressing Changes emphasized the importance of maintaining sterile dressings to prevent catheter-related infections, specifying that dressings should be changed every 5-7 days.
Failure to Change Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for one resident, identified as Resident 52. Resident 52 was admitted with a diagnosis of respiratory failure and required oxygen therapy. During an observation, it was noted that the oxygen tubing in use was dated 6/3/24, indicating it had not been changed weekly as per the physician's order. The Licensed Nurse confirmed the tubing should be changed weekly to prevent infection. The Director of Nursing also stated that all residents' oxygen tubing should be changed weekly and dated to avoid infection. The failure to change the oxygen tubing weekly as ordered had the potential to negatively impact Resident 52's health and safety.
Incomplete Dialysis Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care had complete and consistent documentation of their pre and post-dialysis assessments. This deficiency was identified for one resident who was admitted with end-stage renal disease. The facility's records showed that the required documentation, which included the resident's weight, blood pressure, temperature, heart rate, and catheter site assessment, was incomplete for five out of six days of treatment. Specifically, there was missing post-dialysis documentation on certain days, and no pre or post-dialysis documentation on others. This lack of documentation resulted in a communication gap between the dialysis center and the facility. Interviews with facility staff, including a Licensed Nurse and the Assistant Director of Nurses, confirmed the absence of necessary documentation and highlighted the potential risks associated with this oversight. The staff acknowledged that without proper documentation, they could not effectively monitor the resident's condition or respond to potential adverse outcomes, such as changes in blood pressure or bleeding at the catheter site. The facility's policy on the care of residents with end-stage renal disease emphasized the importance of maintaining communication between the facility and the dialysis center, which was not adhered to in this case.
Failure to Administer Pain Medication
Penalty
Summary
The facility failed to ensure the accurate dispensing and administration of narcotic drugs for a resident diagnosed with pancreatic and lung cancer. The resident, identified as Resident 545, did not receive the prescribed pain medication, oxycodone, for pain management. The discrepancy was discovered during a review of the medication card and the Antibiotic or Controlled Drug Record, which showed that two tablets remained on the medication card when there should have been none. The Licensed Nurse (LN) 13 had documented that the medication was administered, but the remaining tablets indicated otherwise. Interviews with the resident and staff revealed that the resident experienced pain and did not sleep well, suspecting that the medication was not administered. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed the discrepancy, noting that LN 13 had signed out the medication but failed to administer it. The facility's policy on reconciling controlled substances was not followed, as the medication count did not match the records, and the discrepancy was not reported as required.
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.
