Green Acres Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rosemead, California.
- Location
- 8101 E Hill Drive, Rosemead, California 91770
- CMS Provider Number
- 555755
- Inspections on file
- 37
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Green Acres Healthcare Center during CMS and state inspections, most recent first.
The facility failed to monitor and document refrigerator temperatures in the temporary food storage room, risking foodborne illness for residents. Temperature logs for one refrigerator and the freezer were left blank for several days, contrary to the facility's policy requiring daily checks. The Dietary Service Supervisor was unsure if the designated staff had performed the required checks.
A facility failed to obtain informed consent for psychotropic medications for a resident with dementia and schizophrenia, and did not ensure POLST forms for three residents were properly completed and signed. The omissions in documentation could lead to delays in care during emergencies, as POLST forms serve as physician orders. The facility's policies for informed consent and POLST completion were not followed, violating residents' rights to be informed and make decisions about their care.
The facility failed to maintain resident dignity and effective communication, as seen in two cases. A resident with a suprapubic catheter was observed without a urinary bag cover, violating privacy. Another resident, hard of hearing and speaking a foreign language, faced communication barriers due to inadequate tools and methods, leading to frustration and unmet needs. Staff acknowledged these issues, which contravened facility policies on resident rights and dignity.
The facility failed to ensure Advance Directives (AD) were offered and documented for two residents, one with bipolar disorder and schizophrenia, and another with pneumonia and schizophrenia. Despite intact cognition, neither resident had an AD or POLST in their records. Staff interviews revealed confusion about responsibility for ADs, and the medical records director admitted oversight, contrary to facility policy requiring inquiry and assistance with ADs upon admission.
The facility failed to develop comprehensive care plans for two residents, one with aggressive behavior and another with communication barriers. Despite incidents of aggression and communication difficulties, the facility did not create adequate care plans, leading to unmet needs and compromised resident rights.
A resident with hearing difficulties and language barriers did not receive necessary assistive devices or an audiology consult, despite a physician's order. Staff were aware of the resident's communication challenges but did not provide effective solutions, leading to impaired communication and delayed care. The facility's policy on accommodating communication deficits was not followed.
A resident with a suprapubic catheter was at risk for UTIs due to improper catheter care. The drainage bag was observed hanging higher than the bladder, and the tubing was wrapped around the resident's leg, both of which could cause urine backflow. Staff acknowledged these practices were inappropriate, and the facility's policies emphasize proper positioning to prevent infections.
A facility failed to refer a resident with schizophrenia for a psychiatric consultation despite documented aggressive behavior and a care plan intervention. The resident's aggressive actions were noted in assessments, but the facility overlooked the necessary referral, contrary to its behavioral health services policy.
A facility failed to maintain a medication error rate below 5%, reaching 13.79% during a medication pass. An LVN crushed and mixed four medications for a resident with bipolar disorder and schizophrenia, contrary to best practices. The DON confirmed that medications should be administered separately unless preferred otherwise. The facility's policy lacked specific guidance on administering crushed medications.
The facility failed to properly store medications by placing Hydrogen Peroxide Topical Solution, an external medication, on the same shelf as oral medications. This was observed during an inspection with an LVN, who confirmed the improper storage. The DON acknowledged the risk of misidentification and accidental ingestion due to similar container appearances. The facility's policy requires separate storage for oral and external medications.
A resident with a suprapubic catheter on Enhanced Barrier Precautions received high-contact care from an LVN and a CNA who failed to wear isolation gowns and perform hand hygiene, contrary to the facility's Infection Prevention and Control Program. The resident had a history of urinary issues and cognitive impairment, necessitating strict adherence to PPE protocols to prevent infection spread.
The facility was found to have three rooms each accommodating five residents, exceeding the regulatory limit of four residents per room. Despite a waiver request and no reported concerns from residents or staff about space, the setup did not comply with regulations. Interviews confirmed residents had intact cognitive skills and required assistance with daily activities, but the room arrangement still constituted a deficiency.
The facility failed to meet the required room size of 100 sq. ft. for four single resident rooms, with Rooms 4 and 5 measuring 76 sq. ft. and Rooms 16 and 17 measuring 99.75 sq. ft. Despite this, observations and interviews indicated that the room sizes did not affect the care provided. A resident with schizophrenia, hypertension, and anxiety disorder reported having enough space, and staff confirmed sufficient space for care delivery.
The facility failed to provide direct exit access for four resident rooms, requiring residents to pass through other rooms to reach an exit corridor. Although the residents were ambulatory and reported no issues, this arrangement potentially compromised their safety in emergencies. Interviews with staff and a resident confirmed the current setup, and a room variance indicated no adverse effects on residents' health and safety.
Failure to Monitor Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of refrigerator temperatures in the temporary food storage room, which placed residents at risk for foodborne illness. During a follow-up kitchen tour, it was observed that the temperature logs for one of the refrigerators and the freezer were not filled out for several days. Specifically, the log for Refrigerator 2 was blank from the afternoon of February 4th to February 6th, and the logs for Refrigerator 3 and the freezer were blank for the same period. The Dietary Service Supervisor (DSS) indicated that the responsibility for checking and logging the temperatures of the refrigerators and freezers fell to the cooks on both the AM and PM shifts. However, the DSS was unsure if the cooks had checked the logs, and acknowledged that the logs should not have been missed. The facility's policy requires daily temperature checks and documentation at the first opening and at closing in the evening, but this procedure was not followed, leading to the deficiency.
Failure to Obtain Informed Consent and Complete POLST Forms
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding informed consent for medications and life-sustaining treatment orders. Resident 37, who was diagnosed with dementia, psychotic disorder, and schizophrenia, was prescribed Quetiapine and Divalproex Sodium without obtaining informed consent from the resident's representative or power of attorney. The facility's policy required the prescriber's signature on the informed consent within 24 hours of admission, but this was not completed, leaving the resident's representative unaware of the medication's risks, benefits, and alternatives. Additionally, the facility did not ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 12, 69, and 14 were properly completed and signed by the responsible parties. Resident 12, with a moderately impaired cognitive status, had a POLST indicating DNR status, but it lacked the responsible party's signature, rendering it invalid. Similarly, Resident 69's POLST was missing the responsible party's signature, and Resident 14's POLST was prepared without obtaining the resident's signature. These omissions could lead to delays in care during emergencies, as the POLST forms serve as physician orders for medical professionals. The facility's policies and procedures for informed consent and POLST completion were not followed, resulting in incomplete documentation and potential delays in care. The Director of Nurses and other staff acknowledged the deficiencies, noting the importance of having valid POLST forms and informed consent to ensure residents and their representatives are aware of treatment options and preferences. The lack of proper documentation violated residents' rights to be informed and make decisions about their care, potentially affecting their quality of life and health outcomes.
Deficiencies in Resident Dignity and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by two specific incidents involving Resident 3 and Resident 226. Resident 3, who had a suprapubic catheter, was observed without a urinary catheter bag cover, which is a violation of privacy and dignity. The staff, including a CNA and an LVN, acknowledged the absence of the cover and recognized it as a breach of the resident's rights. The facility's policy mandates that urinary catheter bags should be covered to maintain resident dignity. Resident 226, who was hard of hearing and spoke a foreign language, experienced significant communication barriers with the staff. The resident expressed frustration and sadness due to the inability to communicate effectively, as the staff did not provide adequate means of communication such as a communication board or appropriate translation services. Interviews with various staff members, including CNAs and LVNs, revealed that the facility did not have effective communication tools in place, and the staff often resorted to ineffective methods like body language or phone translation, which were not suitable given the resident's hearing impairment. The facility's policies on resident rights and dignity emphasize the importance of treating residents with respect and ensuring effective communication. However, the lack of proper assessment and implementation of communication strategies for Resident 226, along with the failure to maintain privacy for Resident 3, demonstrate a disregard for these policies. The Director of Nursing acknowledged the deficiencies and the impact on resident rights, highlighting the need for comprehensive care plans and effective communication methods.
Failure to Implement Advance Directive Policy
Penalty
Summary
The facility failed to implement its policy and procedure on Advance Directives (AD) by not ensuring that the AD was offered, explained, and signed for two residents. Resident 14, admitted with diagnoses including bipolar disorder and schizophrenia, had intact cognition according to the Minimum Data Set (MDS) but did not have an AD in their medical records or the facility's database. There was no documentation indicating that the facility offered an AD during Resident 14's admission. Similarly, Resident 39, who was readmitted with pneumonia and schizophrenia, also lacked an AD or a Physician's Orders for Life-Sustaining Treatment (POLST) in their records. Although initially noted as lacking decision-making capacity, the MDS indicated intact cognition. Interviews with facility staff revealed a lack of clarity regarding responsibility for ensuring ADs and POLSTs were in place, with the medical records director admitting oversight. The facility's policy requires the social services director or designee to inquire about ADs upon admission and assist in establishing them if needed, which was not followed in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in care. Resident 9, who was diagnosed with schizophrenia and had intact cognition, exhibited aggressive behavior towards staff and other residents. Despite multiple incidents of aggression and attempts to take personal belongings from other residents, the facility did not create a care plan to address these behaviors. Interviews with staff revealed that although Change of Condition assessments were initiated, no interdisciplinary team meeting or care plan was developed to ensure the safety and dignity of all residents. Resident 226, who was admitted with Type 2 Diabetes Mellitus, dementia, and hearing difficulties, faced communication barriers due to a language difference and hearing impairment. The resident expressed frustration over the inability to communicate effectively with staff, which was exacerbated by the lack of a communication board or other aids. Staff interviews confirmed that communication methods were inadequate, and there was no documented evidence of translation services or communication aids being provided. The facility's failure to assess and address these communication needs resulted in unmet care needs and compromised resident rights. The facility's policy required the development of a comprehensive, person-centered care plan that includes measurable objectives and timeframes. However, the facility did not adhere to this policy for either resident, resulting in deficiencies that affected the residents' physical, mental, and psychosocial well-being. The Director of Nursing acknowledged the lapses in care planning and communication, emphasizing the importance of effective communication and comprehensive care planning to uphold resident rights and ensure their well-being.
Failure to Provide Hearing Assistive Devices for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper assistive devices to maintain hearing abilities, resulting in a delay of services for the resident. The resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, unspecified dementia, and abnormalities of gait and mobility, was observed having difficulty hearing and communicating with staff. Despite a physician's order for an audiology consult as needed for hearing problems, the facility did not arrange for this referral, leading to the resident's inability to hear adequately during interactions with staff. Interviews with staff revealed that they were aware of the resident's hearing difficulties and language barriers, yet no effective communication methods or assistive devices were provided. The Social Service Director stated that no hearing disability was reported upon admission, and the Director of Nursing acknowledged the failure to assess and address the resident's communication needs. The facility's policy on accommodating communication deficits was not followed, as the resident's needs for adaptive devices and modifications were not evaluated or addressed, impairing the resident's ability to communicate effectively and maintain dignity.
Improper Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for a resident with a suprapubic catheter. On two separate occasions, the resident's catheter drainage bag was improperly positioned, which could lead to backflow of urine and potential UTIs. On the first occasion, the drainage bag was observed hanging on the wheelchair's armrest, higher than the resident's bladder, contrary to the facility's policy that requires the bag to be positioned lower than the bladder. On another occasion, the resident's catheter tubing was found wrapped around their leg, which could impede urine flow and cause backflow. Both the Registered Nurse and Licensed Vocational Nurse acknowledged that these practices were inappropriate and could lead to UTIs. The facility's Infection Preventionist and Director of Nurses confirmed that the drainage bag should always be below the bladder and the tubing should not be wrapped around the leg to prevent backflow and potential infections. The resident involved had a history of urinary tract infections and was diagnosed with conditions such as benign prostatic hyperplasia and obstructive and reflux uropathy, which necessitated the use of a suprapubic catheter. The facility's policies on suprapubic catheter care and infection prevention emphasize the importance of proper catheter positioning to prevent infections, but these were not adhered to in the resident's care.
Failure to Provide Psychiatric Referral for Aggressive Resident
Penalty
Summary
The facility failed to implement its policy and procedure on behavioral health services by not providing a referral for a psychiatric consultation for a resident exhibiting aggressive behavior. The resident, who was diagnosed with schizophrenia, was readmitted to the facility and had intact cognition according to the Minimum Data Set. Despite the creation of a care plan on January 28, 2025, which included an intervention for a psychiatric consultation, the facility overlooked this intervention and did not refer the resident to a psychiatrist. The resident's aggressive behavior was documented in Change of Condition assessments on January 16 and January 28, 2025, indicating attempts to attack staff and residents and taking personal belongings from another resident. Interviews with Licensed Vocational Nurses and the Director of Nursing confirmed the oversight in referring the resident for psychiatric evaluation. The facility's policy on Behavioral Health Services, revised in February 2019, stated that residents should receive necessary behavioral services to maintain their highest practicable well-being, which was not adhered to in this case.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during a medication pass, resulting in a 13.79% error rate. This was observed during a medication administration for one of the residents, who was diagnosed with bipolar disorder and schizophrenia, and had severely impaired cognition. The resident was prescribed several medications, including Depakote Sprinkles, Docusate Sodium, Multivitamin-Minerals, and Sodium Chloride. During the medication administration, an LVN prepared and crushed four oral medications, mixing them in a single container with applesauce. The surveyor intervened before the medications were administered. The LVN acknowledged the mistake, stating that the resident would not know what medication they were taking if mixed together. The DON later confirmed that medications should ideally be administered separately unless the resident prefers otherwise. The facility's medication administration policy lacked specific instructions on administering crushed medications.
Improper Storage of Medications
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the proper and safe storage of medications and biologicals. During an inspection of the East Wing medication storage room, a bottle of Hydrogen Peroxide Topical Solution, which is an external medication, was found stored on the same shelf as oral medications, such as stool softeners and vitamins. This observation was made in the presence of an LVN, who acknowledged that external medications should not be stored with oral medications to prevent medication errors. The Director of Nursing (DON) confirmed that oral and external medications should be stored separately to avoid the risk of misidentification and accidental ingestion, especially if the containers are similar in appearance. The DON was unaware of who placed the external medication on the shelf with oral medications. A review of the facility's medication storage policy, effective since April 2008, indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program, specifically in the case of a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, it was noted that a Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) provided high-contact care to the resident without wearing the required isolation gowns as part of their Personal Protective Equipment (PPE). Additionally, both staff members did not perform hand hygiene after completing the care and proceeded to the nurses' station, which was against the facility's policy. The resident involved had a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary tract infections, and was cognitively impaired, requiring assistance with daily activities. The care plan for the resident included Enhanced Barrier Precautions due to the use of a suprapubic catheter, which required staff to use gloves, gowns, and masks during direct care and to perform hand hygiene before and after care. Despite these clear directives, the staff failed to comply with the necessary precautions. Interviews with the involved staff and facility leadership confirmed awareness of the requirements for PPE and hand hygiene. The LVN admitted to forgetting to wear a gown and perform hand hygiene, while the CNA could not provide a reason for the oversight. The Infection Preventionist and Director of Nurses reiterated the importance of following the EBP policy to prevent the spread of infections, highlighting the potential risk posed by the staff's non-compliance with established protocols.
Facility Exceeds Resident Room Capacity Limits
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as three rooms (Rooms 6, 15, and 26) each accommodated five residents, exceeding the maximum of four residents per room. This deficiency was identified through observation, interviews, and record reviews. The rooms in question had varying square footage, with Room 6 at 332.5 sq. ft, Room 15 at 441 sq. ft, and Room 26 at 496 sq. ft. Despite the facility's submission of a room waiver request, which claimed no adverse effects on residents' health, safety, or welfare, the setup did not align with the regulatory standards. Interviews with residents and staff revealed that the residents did not express concerns about the room space or sharing with others. Residents 67, 36, and 20, who were interviewed, all had intact cognitive skills and required varying levels of assistance with daily activities. They reported having enough room to perform their activities and did not mind sharing their rooms. Staff members, including a CNA and an LVN, also indicated that they had sufficient space to provide care and had not received complaints from residents regarding room space. However, the facility's arrangement still constituted a regulatory deficiency due to the number of residents per room exceeding the allowed limit.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that four single resident rooms met the required minimum size of 100 square feet per resident. Specifically, Rooms 4 and 5 measured 76 square feet each, while Rooms 16 and 17 measured 99.75 square feet each. This deficiency was identified through a review of the facility's Client Accommodation Analysis and a waiver request submitted by the Administrator. The report indicates that the room sizes did not meet the Centers for Medicare & Medicaid Services (CMS) requirements, potentially affecting the quality of care, health, and safety of the residents due to inadequate space for care, mobility, and privacy. Despite the deficiency, observations and interviews conducted on February 7, 2025, revealed that the room sizes did not negatively impact the care and services provided to the residents. Residents and staff reported having sufficient space for care delivery and daily activities. Resident 8, who has a history of schizophrenia, hypertension, and anxiety disorder, stated she had enough space in her room and did not experience any issues with her care. Similarly, a CNA and an LVN confirmed that they had enough space to perform their duties in the single rooms and had not received any complaints from residents.
Deficiency in Direct Exit Access for Resident Rooms
Penalty
Summary
The facility failed to ensure that four resident bedrooms (Rooms 4, 5, 16, and 17) had direct access to an exit corridor without passing through another resident's bedroom. This deficiency was identified during a facility tour, where it was observed that residents in these rooms had to pass through adjacent rooms to reach the nearest exit corridor. This practice potentially compromised the privacy, health, and safety of the residents, particularly in emergency situations where direct access to an exit is crucial. Despite the lack of direct access, the residents in these rooms were ambulatory and did not express any concerns about their room locations. Interviews with a resident and staff members, including a CNA and an LVN, indicated that the residents were able to move in and out of their rooms without issues. Additionally, a room variance received during the survey period suggested that the residents' needs were accommodated without adverse effects on their health, safety, and welfare. However, the facility's arrangement still posed a potential risk due to the lack of direct exit access.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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