Grace Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 2939 S. Peach Avenue, Fresno, California 93725
- CMS Provider Number
- 555352
- Inspections on file
- 31
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Grace Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and declining mobility was allowed to self-propel in a facility wheelchair without proper assessment, fitting, or supervision. Staff did not evaluate the safety or appropriateness of the wheelchair, nor did they update the care plan or refer for physical therapy despite documented functional decline. This led to the resident's legs becoming entangled in the wheelchair, resulting in fractures and hospitalization.
The facility failed to ensure the Director of Nursing (DON) maintained an active RN license, resulting in the DON working with an expired license. The Assistant Director of Nursing (ADON) knew of the inactive license but did not inform leadership, and the Administrator (ADM) was unaware. The facility's policy requires active licenses for nursing staff to ensure quality care, which was not adhered to, posing a risk to resident safety and care quality.
A nurse in a LTC facility was found to have misappropriated controlled medications, including alprazolam and tramadol, from several residents without administering or documenting their disposal. This affected residents with conditions such as anxiety and chronic pain, as they did not receive their prescribed medications. The discrepancies were discovered through inventory and record reviews, revealing forged signatures and altered dates. Interviews confirmed the nurse's responsibility, highlighting a failure in the facility's processes to prevent such incidents.
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. A resident's hydrocodone-acetaminophen tablets were unaccounted for upon discharge, and the facility's system for storing and destroying controlled drugs was inadequate. Additionally, the emergency kit usage and replenishment process was not properly documented, risking medication availability in emergencies.
Three residents in an LTC facility were administered controlled pain medications without proper clinical justification or monitoring. One resident's oxycodone was changed from as needed to routine after only two days, another resident received an additional routine hydrocodone-acetaminophen order despite limited use, and a third resident's tramadol order was increased without sufficient justification. The facility failed to document pain assessments, update care plans, or monitor for side effects.
A suspended LVN, under investigation for drug diversion, was allowed to work a 12-hour shift with residents, despite explicit instructions from the OA to remain off-duty. The DON, who permitted this, was later suspended for insubordination, as the facility's policy requires employees under investigation to have no resident contact.
Two licensed nurses in the facility failed to properly disinfect glucometers after performing blood glucose tests on residents. RN 3 used a non-approved disinfecting wipe, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time. Both nurses had not received competency-based training on glucometer use, leading to potential risks of spreading bloodborne diseases.
The facility failed to provide essential competency training to three nursing staff members, including training on glucometer use and medication administration. The DON bypassed the established orientation protocol, leading to untrained staff working with residents. The facility's assessment indicated that all residents required medication management, yet the necessary training was not provided.
The facility's QAPI program was found deficient as staff, including CNAs, an LN, and a Registered Nurse Supervisor, were unaware of the program and lacked a tool for measuring performance improvement. Despite a bulletin board display on reducing pressure ulcers, the DON could not specify the performance improvement measurement tool, indicating a failure in the program's implementation.
The facility did not perform reference checks for two newly hired nurses, an LVN and an LN, as required by their policy. The LVN's file lacked any reference checks, while the LN, a recent graduate, had personal references listed but not verified. The DSD admitted to not checking personal references, contrary to the facility's policy mandating background and reference checks for all applicants.
The facility failed to provide mandatory infection control training for two nurses, as their records lacked documentation of training on hand hygiene and PPE. The DSD confirmed the absence of training, and the IP admitted to not ensuring all staff received it, despite the facility's assessment stating such training is mandatory.
A facility failed to ensure a dietary cook was competent in food service, leading to incorrect portion sizes, unfortified diets, and improper food preparation. The cook served incorrect portions, did not fortify foods as required, and failed to follow pureed food recipes. Additionally, the cook did not check food temperatures before serving, and the kitchen ran out of the main dish, resulting in unrequested meal substitutions.
The facility failed to meet the nutritional needs of residents by serving incorrect portion sizes, not following fortified diet orders, and providing alternate meals without resident requests due to insufficient main dish preparation. These actions were contrary to the dietary orders and expectations set by the Registered Dietitian and Dietary Service Supervisor.
A long-term care facility failed to maintain effective infection control, as evidenced by a resident's wheelchair with dried fecal matter, used urinals improperly placed, a laundry room with pooled dirty water, and a nephrostomy catheter bag on the floor. Staff interviews confirmed these practices violated facility policies and posed infection risks.
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Additionally, a water leak from a washing machine in the laundry room led to pooled water, posing safety hazards. Despite staff awareness, these issues persisted due to inadequate maintenance follow-up and documentation.
Two residents in the facility lacked comprehensive care plans, leading to deficiencies in their care. One resident, with multiple health issues, did not have a care plan for the anticoagulant apixaban, while another resident on Enhanced Barrier Precaution due to skin issues lacked a care plan to guide staff. The absence of these care plans was confirmed by facility staff, highlighting a failure to adhere to policy requirements for developing individualized care plans.
The facility failed to adhere to professional standards for two residents. A resident's medication was left unattended, contrary to policy, risking improper administration. Another resident, with a condition requiring padded side rails, was observed without them, despite physician orders. Staff interviews confirmed awareness of policies, yet practices did not align, leading to these deficiencies.
The facility failed to properly label medications for 11 residents, as inhalers lacked expiration dates, potentially leading to the use of expired medications. Additionally, a medication cart was left unattended with keys on top, risking unauthorized access. These issues were confirmed by staff and violated the facility's policies on medication storage and labeling.
The facility failed to maintain sanitary food preparation practices for 54 residents due to the absence of an air gap in the kitchen's two-compartment prep sink. The Dietary Service Supervisor and Maintenance Supervisor were aware of the issue, which was noted in a previous survey. The Registered Dietitian highlighted the necessity of an air gap to prevent contamination, as required by facility policy and the FDA Food Code.
A resident with moderate cognitive deficit was not provided privacy during personal hygiene care, as a CNA left the door open and the privacy curtain was not fully drawn, exposing the resident to the hallway. The facility's policy on resident rights was not upheld, as confirmed by interviews with staff.
A resident with quadriplegia and no cognitive impairment was neglected when staff failed to provide supplies for his suprapubic catheter care, resulting in him being soiled with urine. Despite his independence and ability to manage his own care, the resident's requests for supplies were ignored by multiple staff members, leading to his distress and embarrassment.
A facility failed to notify the LTC-Ombudsman of a resident's emergency hospital transfer for a urinary tract infection. The resident had severe cognitive impairment and multiple medical conditions. Staff interviews revealed a lack of awareness about the notification requirement, which was confirmed by the DON. CMS guidelines mandate that such notices be sent to the Ombudsman.
A facility failed to meet required timelines for MDS assessments for a resident discharged to home. The MDSN did not complete or transmit the discharge MDS assessment, with the last assessment being a quarterly one. The DON and ADM acknowledged the MDSN's responsibility for timely completion and transmission of assessments, as per facility policy.
A facility failed to re-evaluate and document a resident's Level I PASARR, despite the resident having diagnoses of dementia, psychosis, depression, and anxiety. Staff interviews revealed confusion and lack of responsibility for PASARR assessments, with no designated person to complete them. The facility's policy required mental disorder screening upon admission, but this was not followed, resulting in the deficiency.
A resident with moderate cognitive impairment was using a bed rail without proper assessment, documentation, or informed consent. The facility failed to obtain a physician's order, create a care plan, conduct a safety evaluation, or secure informed consent for the use of the side rail, contrary to their policy. Staff interviews confirmed these omissions, which could potentially place the resident at risk.
A resident missed a dose of acetylsalicylic acid 325 mg due to the facility running out of the medication. The responsibility for re-ordering medications was with the nurses, and the facility's policy required reordering at least three days before the last dose. The Director of Nursing confirmed that the Associate Director of Nursing was sent to obtain the medication from a local pharmacy.
A resident's low air loss (LAL) mattress cover was found torn, potentially compromising its function and cleanliness. Staff interviews confirmed the importance of the LAL mattress for the resident's skin health, as the resident had a history of skin issues. The facility's policy required repair or replacement of worn components, which was not followed.
The facility was found non-compliant with regulations limiting resident room capacity to four. Eight rooms housed eight residents each, despite ensuring accessibility and privacy. Staff and residents reported no issues with care or space, but privacy curtains were noted as not always closing completely.
A facility failed to report an allegation of physical abuse within the required 24-hour timeframe. An LVN reported the allegation to the ADM, and the SSD was also aware, but the report to the CDPH was delayed. The resident involved had moderate cognitive impairment and reiterated the abuse claim during an interview.
Failure to Assess and Supervise Wheelchair Use Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who self-propelled in a wheelchair. Nursing staff were aware that the resident used a wheelchair equipped with foot pedals and self-propelled throughout the facility, but did not assess the safety or appropriateness of the wheelchair for the resident's physical size, abilities, or declining mobility. The resident was not evaluated or fitted for a personal wheelchair and instead used wheelchairs available for general use in the facility. Staff did not identify or address the resident's declining upper and lower extremity mobility as documented in the Minimum Data Set (MDS), nor did they refer the resident for a physical therapy assessment or update the care plan to address wheelchair use and safety. As a result of these failures, the resident experienced an unwitnessed, avoidable accident in which their legs became entangled in the wheelchair while self-propelling, leading to severe pain and a right lower leg injury. The resident was subsequently diagnosed with acute right tibial and proximal fibular fractures, requiring hospitalization and resulting in loss of mobility and increased isolation. Interviews with nursing staff and CNAs revealed that none were aware of a safety assessment for the resident's wheelchair use, and there was no documentation of a physical therapy referral, physician notification regarding the resident's functional decline, or a care plan component addressing wheelchair safety. Facility policy required that recommendations for assistive device use be based on comprehensive assessment and documented in the care plan, including evaluation of appropriateness for the resident's condition and personal fit. However, these policies were not followed, as confirmed by staff interviews and record reviews. The lack of assessment, supervision, and individualized equipment fitting directly contributed to the resident's accident and subsequent injury.
Failure to Maintain Active License for Director of Nursing
Penalty
Summary
The facility failed to designate a full-time Registered Nurse (RN) as the Director of Nursing (DON) for all 58 residents when the current DON's license expired. The Assistant Director of Nursing (ADON) was aware of the inactive license but did not notify leadership, allowing the DON to continue working with an expired license. The Administrator (ADM) was unaware of the situation and confirmed that the DON should not have been working without an active license. The Owner/Operator RN 1 also confirmed the DON worked during the month with an inactive license and highlighted the failure of the Director of Staff Development (DSD) to communicate the issue to leadership. The facility's policy requires nursing service personnel to have the necessary qualifications, including an active RN license, to ensure quality resident care. The DON's job description mandates maintaining an active RN license and being onsite full-time. The lack of an active license for the DON resulted in a potential risk of inadequate supervision and guidance for staff, which could affect resident safety and care quality. The facility's policy and job descriptions were not followed, leading to the deficiency.
Medication Misappropriation by Nurse in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, which are considered their property. A licensed nurse, identified as LVN 1, was found to have removed various controlled medications from the medication cart without administering them to the residents or properly documenting their disposal. This included medications such as alprazolam, tramadol, hydrocodone-acetaminophen, and oxycodone, which are used for treating anxiety, pain, and other conditions. The discrepancies were discovered through a review of the medication inventory count sheets and electronic medical records, revealing that the medications were neither given to the residents nor wasted according to facility policy. The report highlights specific instances involving multiple residents, each with their own medical conditions and needs for the medications. For example, Resident 67, who was severely cognitively impaired, did not receive their prescribed alprazolam for anxiety, as the medication was removed by LVN 1 without proper documentation. Similarly, Resident 59, also severely impaired, was deprived of their alprazolam, which was crucial for managing their anxiety disorder. Other residents, such as Resident 69 and Resident 71, who suffered from chronic pain, did not receive their tramadol, leading to potential untreated pain. Interviews with the Consultant Pharmacist, Assistant Director of Nursing, and Director of Nursing confirmed that LVN 1 was responsible for the missing medications, and there were indications of forged signatures and altered dates on the inventory sheets. The facility's processes were insufficient to prevent or detect this diversion of medications, which posed a risk to the residents' health and safety. The report does not mention any corrective actions or follow-up measures taken by the facility to address these deficiencies.
Inadequate Controlled Drug Management and Documentation
Penalty
Summary
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. Specifically, the facility could not account for 32 tablets of hydrocodone-acetaminophen 5-325 mg prescribed to a resident, who was admitted with a diagnosis including contracture of the right upper arm muscle. The resident was discharged without a record of the controlled drugs being transferred, and both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and the importance of maintaining accurate records to prevent medications from falling into the wrong hands. Additionally, the facility did not adhere to its policy and procedure for the destruction of controlled drugs. Controlled medications awaiting destruction were inadequately logged and stored, with the DON admitting to giving the key to the storage cabinet to nursing staff without a proper log of the medications stored. The Consultant Pharmacist (CP) confirmed that the facility's disposition log was inadequate for accurately tracking controlled drug medications, and the DON acknowledged the lack of a proper system to ensure controlled medications were not taken from the cabinet without authorization. The facility also failed to maintain an adequate system for the use and replenishment of the emergency kit (e-kit) containing controlled drugs. The DON was unable to provide e-kit usage records for several months, and the process for documenting and replacing used e-kits was not followed by nursing staff. The CP emphasized the importance of documenting every medication taken from the e-kit for billing, inventory tracking, and preventing drug diversion. The failure to replace the e-kit within the required timeframe could potentially impact the availability of necessary medications in emergency situations.
Inappropriate Medication Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that three residents were administered medications appropriately, leading to potential unnecessary drug use. Resident 55's oxycodone order was changed from as needed to routine without clinical justification, and there was no monitoring for side effects. Despite the resident not complaining of pain, the order was altered after only two days and five doses, without proper documentation or communication with the physician. The Medical Director did not recall authorizing this change, and the nursing staff did not update the care plan or document the rationale for the change. Resident 57's hydrocodone-acetaminophen order was similarly altered, with an additional routine order added without clinical justification. The resident, who was developmentally delayed, had only requested the medication three times as needed, yet a routine order was obtained. There was no documentation of a pain assessment or a diagnosis of chronic pain, and the Medical Director did not recall prescribing the routine order. The Assistant Director of Nursing acknowledged the inappropriateness of the routine order given the resident's limited use of the medication. Resident 59's tramadol order was increased from three times daily to four times daily without sufficient justification. The resident had only requested the medication four times as needed over a period of several weeks. The Assistant Director of Nursing admitted that the change was unwarranted based on the resident's usage. The Director of Nursing confirmed that the nursing staff did not follow proper procedures for documenting pain assessments or updating care plans, and there was no monitoring for side effects of the medications administered to the residents.
Suspended LVN Worked During Investigation
Penalty
Summary
The facility administration failed to prevent a Licensed Vocational Nurse (LVN) from working while suspended and under investigation for drug diversion. The LVN, suspected of diverting opioids and other medications, was suspended on September 25, 2024. Despite this, the Director of Nursing (DON) requested the LVN to return to work on September 28, 2024, to provide orientation to a newly hired LVN. This resulted in the suspended LVN working a 12-hour shift with approximately 30 residents, potentially compromising the integrity of the ongoing investigation. The Owner/Administrator (OA) had explicitly instructed the DON that the LVN should not be present in the facility during the suspension. The DON's decision to allow the LVN to work was against these instructions, leading to her suspension on October 7, 2024. The facility's policy mandates that any employee accused of resident abuse or theft is placed on leave with no resident contact until the investigation is complete. The DON's actions were considered insubordination, as there were other nurses available to provide the necessary orientation.
Improper Disinfection of Glucometers by Nursing Staff
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers by two licensed nurses, RN 3 and LN 22, after obtaining blood samples from residents. This oversight was identified through observations, interviews, and record reviews. Both nurses were responsible for administering medications and performing blood glucose fingerstick tests on residents. RN 3, who had been employed for three months, and LN 22, who had been employed for one week, had not received competency-based training on the use of glucometers. During observations, RN 3 used a disinfecting wipe that was not approved for killing bloodborne germs, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time as indicated on the product label. The Infection Prevention Nurse confirmed that the disinfecting wipes used by RN 3 were not suitable for eliminating bloodborne pathogens, and both nurses failed to follow the manufacturer's instructions for proper disinfection. The technical brief for the glucometer and the technical data bulletin for the germicidal wipes both emphasized the necessity of cleaning and disinfecting the glucometer after each use to prevent the transmission of bloodborne pathogens. The failure to properly disinfect the glucometers posed a risk of spreading bloodborne diseases to other residents undergoing blood glucose testing.
Deficiency in Staff Competency Training
Penalty
Summary
The facility failed to ensure that three nursing staff members, including a Licensed Vocational Nurse, a Licensed Nurse, and a Registered Nurse, received essential competency training. The Director of Staff Development (DSD) was responsible for overseeing the orientation of new nursing staff, which was supposed to include two classroom days before working on the floor. However, the Director of Nursing (DON) instructed one of the nurses to start working with residents after only one day of classroom orientation, bypassing the established protocol. This decision was made without consulting the DSD, as the DON needed a nurse on the floor immediately. Additionally, the facility did not provide competency-based training for the use of glucometers, which are essential for monitoring and treating diabetes, to the three nursing staff members. The DSD confirmed that there were no records of glucometer competencies for these staff members, despite the presence of residents requiring such monitoring. Furthermore, there were no records of medication administration competencies for these nurses, who were responsible for administering medications through various methods and routes. The facility's assessment indicated that all residents received medication management, and the training program was supposed to include medication administration and diabetic blood glucose testing.
Deficiency in QAPI Program Awareness and Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of awareness among staff members about the program and the absence of a tool for measuring performance improvement. During interviews, four staff members, including two Certified Nursing Assistants (CNAs), a Licensed Nurse (LN), and a Registered Nurse Supervisor, were unable to articulate knowledge of the facility's QAPI plan. The CNAs and LN were not aware of the program at all, while the Registered Nurse Supervisor knew the acronym but could not describe the plan or the performance improvement measurement tool. An observation of a facility bulletin board revealed a display related to QAPI, including an initiative to reduce pressure ulcers by 50% over the next quarter. However, during an interview, the Director of Nursing (DON) acknowledged that while the facility collects QAPI data on falls and pressure ulcers, they were unable to specify the performance improvement measurement tool used for pressure ulcers. This lack of awareness and understanding among staff members indicates a deficiency in the facility's implementation of its QAPI program, which is crucial for improving resident safety.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to conduct reference checks for two of the five sampled employees, specifically a Licensed Vocational Nurse (LVN) and a Licensed Nurse (LN), prior to their employment. During an interview, the Owner/Administrator expressed that it was expected for all candidates to have their previous employment and personal references checked. However, upon reviewing the personnel file of LVN 1, it was found that no reference checks were performed. The Director of Staff Development (DSD) acknowledged the absence of reference checks and admitted to not knowing where LVN 1's references were. Similarly, the personnel file of LN 22, who had just graduated from nursing school and had no prior nursing experience, showed that only personal references were listed, and these were not checked. The DSD confirmed that personal references for LN 22 were not verified, stating a preference for checking only employment references. The facility's policy and procedure document, dated March 2019, mandates background screening and reference checks for all applicants with direct access to residents, which was not adhered to in these cases.
Inadequate Infection Control Training for Nursing Staff
Penalty
Summary
The facility failed to implement an effective training program for infection control and prevention, specifically for two licensed nurses, a Licensed Vocational Nurse (LN 22) and a Registered Nurse (RN 3). During a review of their employee records, it was found that neither nurse had documented training on hand hygiene and personal protective equipment (PPE), which are critical components of infection control. The Director of Staff and Development (DSD) confirmed that the training was not completed as there were no signatures in the records to indicate otherwise. The Infection Preventionist (IP) acknowledged that hand hygiene and PPE training should be mandatory for all staff but admitted to not ensuring that all staff received this training. The facility's Facility Assessment, dated September 2, 2024, stated that staff training on infection control, including written standards, policies, and procedures, is part of their program. However, the lack of documented training for LN 22 and RN 3 indicates a failure to adhere to these standards, placing residents at risk for potential infection spread due to inadequate staff training.
Dietary Service Deficiencies in Portion Control and Food Preparation
Penalty
Summary
The facility failed to ensure that Dietary Cook (DC) 1 was competent in carrying out the functions of food and nutrition services safely and effectively. DC 1 served incorrect portion sizes for residents on large portion diets, providing one and a half servings of the main dish instead of the prescribed one serving. This was contrary to the facility's policy, which specified that large portions should include extra servings of vegetables, not the main dish. Additionally, DC 1 did not fortify foods for residents on fortified diets by failing to add the required extra butter to vegetables, which was necessary to meet the residents' higher nutrient demands. DC 1 also did not follow the pureed food recipe for residents on pureed diets, omitting the smooth Mexican tomato sauce that was supposed to enhance the flavor of the pureed foods. Furthermore, DC 1 neglected to check the temperature of pureed foods before serving, which is a critical step to ensure food safety and prevent foodborne illnesses. The facility's policy required all food temperatures to be checked prior to serving to ensure they were safe for consumption. Lastly, the kitchen ran out of the main dish, chile relleno casserole, and DC 1 had to serve an alternate meal, a beef, bean, and cheese burrito, to the last three residents. This was not in accordance with the facility's policy, which stated that alternates should only be provided upon resident request or if they did not like the main dish. The Dietary Service Supervisor (DSS) was responsible for ensuring that the kitchen staff were fully trained and that the menu was followed, but these deficiencies indicate a lack of proper oversight and training.
Nutritional Deficiencies in Meal Service
Penalty
Summary
The facility failed to ensure that the food served met the daily nutritional needs of several residents. Specifically, residents on large portion diets were served more than the required portion size of chile relleno casserole, which could lead to exceeding their recommended daily caloric intake. This was observed during a tray-line observation where the dietary staff served one and a half slices of the casserole instead of the prescribed one slice. The Registered Dietitian confirmed that the menu and portion sizes should have been followed to prevent potential weight gain or elevated lab levels. Additionally, the facility did not adhere to fortified diet orders for certain residents. During an observation, it was noted that the dietary staff failed to add extra butter to vegetables for residents on fortified diets, which was necessary to meet their additional caloric needs. The Dietary Service Supervisor acknowledged that the fortified diet order was not followed, and the expectation was to adhere to the menu and spreadsheet instructions. Furthermore, the facility ran out of the main dish, chile relleno casserole, and served alternate food to some residents without their request. This occurred because there was not enough of the main dish prepared, leading to the substitution of beef, bean, and cheese burritos. The Dietary Service Supervisor and Registered Dietitian both stated that it was not acceptable to provide alternate meals without resident requests, and the expectation was to have enough food to serve all residents according to the menu.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In one instance, Resident 4's wheelchair was found with dried fecal matter on the seat, which was not cleaned according to the facility's policies. Interviews with staff, including a Certified Nursing Assistant (CNA), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that such contamination could lead to the spread of infections like C-Diff and E-Coli. The facility's policy required that resident-care equipment be cleaned and disinfected, but this was not adhered to in this case. Another deficiency was observed in Resident 33's room, where two used urinal bottles were found on the bedside table next to drinking cups and personal hygiene supplies. One of the urinals had brown matter buildup, indicating it had not been cleaned or replaced as per the facility's guidelines. Staff interviews revealed that urinals should be changed weekly and not placed on bedside tables to prevent cross-contamination. The presence of dirty urinals next to personal items posed a significant infection control issue, as confirmed by the IP and DON. Additionally, the facility's laundry room had a leak causing dirty water to pool on the floor, which could lead to contamination of freshly washed linens. Laundry staff and the Assistant Director of Nursing (ADON) acknowledged the unsanitary conditions and the potential for mold or pathogen growth. Furthermore, Resident 214's nephrostomy catheter bag was found on the floor, which could lead to contamination and infection. Staff interviews confirmed that the catheter bag should not have been on the floor, as it posed an infection risk. The facility's policies on infection control were not followed, contributing to these deficiencies.
Deficiencies in Privacy and Safety Measures
Penalty
Summary
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Observations revealed that privacy curtains were either missing strings or had tangled strings, making them non-functional. Certified Nursing Assistants (CNAs) reported these issues to the Maintenance Supervisor (MS) and housekeeping, but the problems persisted due to a lack of parts for repairs. The MS confirmed the issues and stated that the facility had ordered new parts to address the problem. The Director of Nursing (DON) and the Administrator acknowledged the importance of maintaining privacy for residents, as it is a fundamental resident right. Additionally, the facility failed to address a water leak from one of the washing machines in the laundry room, leading to pooled water on the floor. This situation posed a safety hazard, with risks of slips, electrocution, and potential growth of mold and bacteria. Laundry staff and the Assistant Director of Nursing (ADON) were aware of the leak, which had been ongoing for about a year, but no repair request was documented in the maintenance log. The Maintenance Supervisor identified the source of the leak as a missing plug in the washing machine, and the DON emphasized the need for immediate action on such issues. The facility's policies and procedures for maintaining a homelike environment and ensuring safety were not effectively implemented. The maintenance department was responsible for keeping the building and equipment in safe and operable condition, but failed to address the reported issues in a timely manner. The lack of documentation and follow-up on maintenance requests contributed to the ongoing deficiencies, impacting the safety and comfort of residents and staff.
Deficiencies in Care Planning for Anticoagulant and Infection Control
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident 53, who was admitted with multiple diagnoses including End Stage Renal Disease, Acute Pulmonary Edema, Atrial Fibrillation, and Depression, did not have a care plan for the anticoagulant medication apixaban. This oversight was identified during a review of the resident's records, where it was noted that the care plan was missing despite the facility's policy requiring one for anticoagulant use. Interviews with the LVN, MDS, and DON confirmed the absence of the care plan, which is necessary to monitor for potential adverse reactions. Resident 51, who was admitted with heart failure, morbid obesity, and osteoarthritis, was placed on Enhanced Barrier Precaution (EBP) due to skin issues. However, there was no care plan in place to guide staff on how to manage the resident's needs under EBP. The Infection Preventionist, who was responsible for initiating such care plans, acknowledged the absence of the care plan during a review of the resident's clinical record. The DON and RNS also confirmed that the care plan was missing, emphasizing the importance of care plans in directing nursing staff on resident care. The facility's policy and procedure documents indicate that comprehensive care plans should be developed within seven days of completing a resident assessment. The lack of care plans for both residents 53 and 51 highlights a failure to adhere to these policies, potentially putting the residents at risk by not addressing their specific medical and care needs adequately.
Medication Safety and Bedrail Padding Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice for two residents, Resident 27 and Resident 44. For Resident 27, a medicine cup containing seven tablets was left unattended on the breakfast tray. This was observed during a visit, and the resident confirmed that the nurse left the medication for him to take after breakfast. The facility's policy and interviews with staff, including the LVN and DON, indicated that medications should not be left unattended at the bedside due to the risk of other residents accessing them or the resident not taking them. Despite this, the LVN responsible for Resident 27 admitted to leaving the medication at the bedside, believing it was safe for the resident to take after eating. For Resident 44, the facility failed to follow the physician's order for padded side rails. Observations on multiple occasions revealed that the resident's bedrails were raised without padding, despite having a condition that required such safety measures. Interviews with CNAs and the DON confirmed that the resident should have had padded side rails to prevent injury, especially given the resident's medical conditions, including epilepsy. The facility's policy emphasized the importance of implementing additional safety measures for residents at higher risk of injury, which was not adhered to in this case. The deficiencies in both cases were attributed to a lack of adherence to established policies and procedures. Staff interviews revealed a general understanding of the policies, yet the practices observed did not align with these standards. The failure to ensure medication safety for Resident 27 and the lack of padded side rails for Resident 44 highlighted lapses in the facility's compliance with professional standards of care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored safely and labeled according to accepted professional principles. Specifically, medications administered via inhalers for 11 residents were not labeled with expiration or use-by dates. During observations and interviews, it was confirmed by two Licensed Vocational Nurses (LVNs) that the inhalers lacked expiration dates, which was acknowledged as a potential issue by the Director of Nursing (DON) and the Skilled Nursing Pharmacy Consultant (SN PC). The facility's policy required medication labels to include expiration dates, but this was not adhered to, raising concerns about the potential administration of expired medications. Additionally, one of the medication carts was left unattended in a hallway with keys on top, posing a risk of unauthorized access to medications. This was observed and confirmed by an LVN, the Assistant Director of Nurses (ADON), and the Administrator (ADM), all of whom acknowledged that the keys should not have been left on the cart. The facility's policy stipulated that medications should be stored in locked compartments, accessible only to authorized personnel, but this protocol was not followed, creating a risk of medication misuse or diversion.
Lack of Air Gap in Kitchen Sink Risks Resident Safety
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices for 54 out of 62 residents due to the absence of an air gap in the two-compartment prep sink in the kitchen. During an observation and interview, the Dietary Service Supervisor (DSS) acknowledged that the sink lacked an air gap, which is essential for backflow prevention. The Maintenance Supervisor (MS) was also aware of this issue. The DSS admitted that the absence of an air gap was noted in a previous survey, and although attempts were made to install one, they were unsuccessful. The Registered Dietitian (RD) explained that an air gap is necessary to prevent gases or bacteria from entering the prep sink area through the pipeline, which could contaminate food and potentially cause illness among residents. The facility's policy and procedure, as well as the FDA Food Code, require backflow prevention through an air gap to prevent contamination. Despite this requirement, the facility did not have the necessary air gap installed, posing a risk of food-borne illness to the residents.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) did not provide adequate privacy during personal hygiene care. During an observation, it was noted that the door to the resident's room was open, and the resident's buttocks were exposed and visible from the hallway. The privacy curtain was not fully drawn, leaving the resident exposed to visitors, staff, and other residents. The CNA acknowledged that the privacy curtain was stuck and admitted to not ensuring the door was closed to provide the necessary privacy. The resident involved had been admitted with diagnoses including unspecified dementia and psychosis, with a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the CNA should have ensured the resident was covered and the door was closed, especially since the privacy curtain was not functioning properly. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Resident Neglect Due to Lack of Catheter Supplies
Penalty
Summary
The facility failed to ensure that Resident 19 was free from neglect when he did not receive the necessary supplies to conduct his suprapubic catheter care. Resident 19, who was diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and depression, was admitted to the facility with the ability to change his own suprapubic catheter with staff supervision. Despite being independent and having no cognitive impairment, as indicated by a BIMS score of 15, Resident 19 was left soiled with urine after requesting supplies from three staff members, none of whom provided the necessary items. Interviews with various staff members, including an LVN, CNA, RN, ADON, and DSD, confirmed that Resident 19 was independent and capable of managing his own catheter care. The staff acknowledged that they neglected to provide the supplies when requested, which led to Resident 19 being upset and embarrassed due to his soiled condition. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and ensuring they are free from neglect, which was not upheld in this instance.
Failure to Notify LTC-Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman office of a resident's transfer to the hospital. This deficiency was identified during a review of the records for a resident who was transferred to an acute care facility for treatment of a urinary tract infection. The resident, who had severe cognitive impairment, was admitted to the facility with diagnoses including hydronephrosis, infection due to nephrostomy, and diabetes mellitus. Despite the transfer, the facility did not send a copy of the transfer notification to the local LTC-Ombudsman office, leaving them unaware of the resident's emergency transfer. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the LTC-Ombudsman of hospital transfers. A Licensed Vocational Nurse and the Director of Staff Development both stated they were unaware of this requirement. The Director of Nursing acknowledged that the LTC-Ombudsman should have been notified, as they are there to assist residents in case issues arise. A professional reference from CMS clarified that notices for emergency transfers must be sent to the Ombudsman, highlighting the facility's failure to comply with this requirement.
Failure to Transmit MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to meet the required timelines for encoding, completion, and transmission of Minimum Data Set (MDS) assessments for a resident, identified as Resident 58. The Minimum Data Set Nurse (MDSN) did not complete or transmit the discharge MDS assessment for Resident 58, who was discharged to home. During an interview and record review, it was revealed that the last assessment for Resident 58 was a quarterly assessment dated April 11, 2024, and no discharge assessment was completed or transmitted when the resident was discharged on May 1, 2024. The MDSN admitted to not having reviewed the MDS schedules and was unaware of the missing discharge assessment until the review. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the MDSN was responsible for ensuring all MDS assessments were completed and transmitted in a timely manner. The facility's policy and procedure on MDS Completion and Submission Timeframes indicated that assessments should be conducted and submitted in accordance with federal and state guidelines. The failure to complete and transmit the discharge assessment for Resident 58 resulted in the potential harm of the resident's needs upon discharge going unmet.
Failure to Re-evaluate and Document PASARR for Resident
Penalty
Summary
The facility failed to re-evaluate and document the current condition for Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is a federal requirement to ensure residents with mental disorders or intellectual disabilities are not inappropriately placed in a nursing home. The resident in question was admitted with diagnoses including unspecified dementia, psychosis, depression, and anxiety. Despite these diagnoses and the prescription of psychotropic medications, the resident's PASARR Level I indicated no diagnosis of mental disorder, highlighting a discrepancy in the documentation. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASARR assessments. The Business Office Manager, who was new and part-time, was unfamiliar with the PASARR process, and the Assistant Director of Nursing was unsure who was responsible for completing the assessments. The Director of Nursing acknowledged the absence of a designated person for PASARR completion, and the Administrator expressed the need for staff training on PASARR assessments. The facility's policy required screening for mental disorders upon admission, but this was not effectively implemented, leading to the deficiency.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for one resident, identified as Resident 59, who had moderate cognitive impairment. The resident was observed using the right side rail on multiple occasions to reposition himself and place his urinal. Despite this, there was no documented physician's order, care plan, safety evaluation, or informed consent for the use of the side rail. Interviews with staff, including CNAs and an LVN, confirmed that the necessary procedures and documentation were not completed prior to the use of the side rail. The facility's policy on bed safety and bed rails, dated August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these steps were not followed for Resident 59, as confirmed by the MDS Coordinator and the Director of Nursing. The lack of proper assessment and documentation had the potential to place the resident at risk for decreased freedom of movement, entrapment, and/or injury.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide acetylsalicylic acid 325 mg to a resident who had an order for this medication to prevent blood clots. This deficiency was identified when the medication was found to be missing during an observation and interview with a Licensed Vocational Nurse (LVN) in front of the resident's room. The LVN confirmed that the medication was not available, and the Director of Nursing (DON) indicated that the Associate Director of Nursing (ADON) was sent to a local pharmacy to obtain the medication. Interviews with the Skilled Nursing Pharmacy Consultant (SN PC) and the ADON revealed that the responsibility for re-ordering medications lies with the facility's nurses. The SN PC stated that nurses should reorder medications before they run out, and the ADON confirmed that either the ADON or RN supervisor is responsible for ordering over-the-counter medications. The ADON also stated that a full bottle of medication should always be available before the supply runs out. A review of the resident's Medication Administration Record (MAR) confirmed the order for acetylsalicylic acid 325 mg daily, and the facility's policy indicated that medications should be reordered at least three days before the last dose is administered.
Failure to Maintain LAL Mattress Cover
Penalty
Summary
The facility failed to maintain a low air loss (LAL) mattress cover sheet in good condition for one of the residents, leading to a potential malfunction of the mattress. The LAL mattress, which is designed to prevent skin breakdown by distributing the patient's body weight, had a tear where the resident rested his head. This issue was identified during an observation and interview with a certified nursing assistant (CNA), who noted the wear and tear on the mattress cover and acknowledged the importance of the LAL mattress for the resident due to past skin problems. Interviews with various staff members, including CNAs, a licensed vocational nurse (LVN), the infection preventionist (IP), the director of nursing (DON), and the director of staff development (DSD), confirmed that the LAL mattress cover should not have been torn. They emphasized that a torn cover could affect the mattress's functionality and cleanliness, potentially leading to skin breakdown for the resident. The facility's policy on bed safety also indicated that any worn or malfunctioning bed system components should be repaired or replaced, which was not adhered to in this case.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey conducted from September 9 to September 13, 2024, it was observed that eight rooms each housed more than four residents, specifically accommodating eight residents per room. This arrangement was made to cater to the residents' particular care needs and comfort. Despite the non-compliance, the facility ensured that wheelchairs and toilet facilities were accessible, and a reasonable amount of privacy and adequate storage space were provided. The staff reported no issues with providing care, and residents did not express concerns about personal space. Interviews with residents and staff revealed that the residents felt they had privacy when needed, and the staff did not encounter difficulties in delivering care. A resident expressed satisfaction with the shared room arrangement, and a CNA confirmed that each resident had personal storage space. An LVN noted that while the rooms were spacious enough for care, privacy curtains did not always close completely. An EVS staff member stated that there was ample room for cleaning. Despite these observations, the facility's room arrangements did not meet the regulatory requirements, leading to the deficiency noted in the report.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in accordance with its Abuse Prevention Program policy. A Licensed Vocational Nurse (LVN) overheard a resident alleging on the phone that staff were hitting her and reported this to the Administrator (ADM) on 5/14/24. Despite this, the facility did not notify the appropriate agencies of the abuse allegation within the required 24-hour timeframe. The Social Service Director (SSD) was also aware of the allegation and informed the ADM on the same day. However, the ADM acknowledged that the report should have been made to the California Department of Public Health (CDPH) by 5/15/24, but it was not done within the stipulated time. The resident involved had a moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. During an interview on 5/16/24, the resident reiterated that staff were hitting her. The facility's policy on abuse prevention, which mandates timely and thorough investigations and reporting of abuse allegations, was not followed. The ADM confirmed that the facility follows an All Facilities Letter (AFL) guideline requiring abuse allegations to be reported within 24 hours, which was not adhered to in this case.
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.
