Hampton Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 442 Hampton Street, Stockton, California 95204
- CMS Provider Number
- 056324
- Inspections on file
- 75
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 55
Citation history
Health deficiencies cited at Hampton Post Acute during CMS and state inspections, most recent first.
The facility did not submit required written notice to the State Agency when a new ADM and a new DON assumed their positions. The DON reported starting in the role recently and confirmed she had not filed the Centralized Applications Branch (CAB) application and had not been informed of CAB expectations, while the ADM believed the DON was responsible for the application. The ADM also stated he had been in his role for several months and believed the corporate office should have submitted the change-in-ADM application. State Agency database review showed no applications received for either position, delaying verification of the ADM and DON qualifications for oversight of clinical services for 109 residents.
A resident with multiple fractures and a history of suicide attempt, who was care planned as at risk for leaving without notice and monitored each shift for suicidal ideation, left the facility in a wheelchair and traveled to a nearby gas station without a day pass or appointment. Staff observed the resident leaving the parking lot and, after informal questioning among staff and searching within the building and outdoor areas, an RN walked to the gas station and found the resident inside the mini market, then escorted the resident back. The facility’s elopement policy, which required activation of an internal alert code, systematic search procedures, notifications (including to police if the resident was not found on the grounds), and documented nursing assessments post-incident, was not followed, and the nurse documented only a progress note without completing the full assessment and documentation steps outlined in the policy.
A resident with dementia, anxiety, and depression had a family-requested staffing preference that a specific CNA not provide care due to a prior skin-care concern. Although an LN, the DSD, and the DON were aware of this request, it was not documented in the resident’s care plan or on the unit’s patient preference list. As a result, staffing assignments placed the restricted CNA on the resident’s hall, and documentation showed that this CNA provided incontinent care to the resident, contrary to the expressed preference and facility policies on accommodation of needs and dignity.
A resident with a G-tube, identified as at risk for MDRO colonization and placed on Enhanced Barrier Precautions (EBP), had a care plan and posted EBP signage requiring staff to wear gown and gloves during high-contact care such as changing linens. A CNA was observed changing the resident’s bed linens while the resident was in bed without wearing a gown, despite the posted EBP instructions. The CNA acknowledged not using the required PPE, and interviews with other staff, including an LN, DSD, IP, and ADON, confirmed that facility policy and EBP signage required gown and glove use for such activities and that these infection prevention requirements were not followed.
A staff member observed one resident place his hand inside another cognitively impaired resident’s shirt sleeve and touch her chest/shoulder area in a dining room but did not report the incident to facility administration until a week later, despite prior abuse training and policies requiring immediate reporting of suspected abuse and notification of authorities within two hours for alleged abuse or serious injury.
Two residents reported that staff did not respond promptly to their call light, and observations confirmed that a room call light remained on and unanswered for an extended period while staff, including an LPN and a CNA, were nearby but did not respond. One resident, with mobility limitations and bowel and bladder incontinence, stated he had not been changed since the previous night and sometimes waited 30 minutes for his call light to be answered, while his roommate confirmed that staff said they would return to change him but did not. The resident’s care plan required staff to encourage use of the call bell, respond promptly to toileting requests, assist with cleansing after bowel movements, and maintain perineal hygiene, and facility policies required timely call light response and dignified care, but these were not followed in this incident.
A resident with dementia and blindness, who depended on a call light to request assistance, had their call light rendered nonfunctional when staff discovered a plastic item placed between the plug and the outlet. A CNA and an LN noted the obstruction and that the call light was not being used as frequently as usual, and the LN removed the plastic tube and restored function. Several days later, the LN again observed a plastic tube in the resident’s room and reported it to the supervisor. This occurred despite facility policy requiring that call lights remain plugged in, functioning at all times, and that any defective call lights be promptly reported to the nurse supervisor.
A resident with an anxiety-related adjustment disorder reported missing clothing items through her son, including multiple pairs of sweatpants, shirts, and a jacket. Although the concern was documented by social services, the facility did not promptly initiate its theft and loss process, conduct a timely search, or complete required reporting. A roommate confirmed the clothes were lost and could not be found. A social worker reported that the family said the resident was very upset and wanted to call the police, and that the facility had told the family it would reimburse $200 for the missing items but had not done so. These actions and inactions were inconsistent with facility policies requiring prompt investigation of theft/loss and respect for resident property and dignity.
A resident with type 2 DM had ordered FSBS checks and sliding-scale insulin lispro scheduled around mealtimes, but surveyors found that blood sugars were not monitored before meals and insulin doses were administered significantly later than the scheduled times. The resident reported long waits for medications and that staff sometimes appeared to forget her requests. Review of the MAR showed elevated blood sugars treated well after the scheduled administration time, despite facility policy and insulin guidelines requiring timely, meal-related dosing and medication administration within one hour of the prescribed time.
Surveyors found that three residents with documented substance use disorder (SUD) did not have individualized SUD care plans in place. The DON confirmed that, despite SUD being listed on each admission record, no care plans had been developed to monitor for withdrawal symptoms, drug-seeking or exit-seeking behavior, or psychosocial well-being. Review of facility policies on LAWN evaluation, wandering and elopement, and care plan goals showed that residents at risk for unsafe wandering or leaving without notice should have had care plans with specific, measurable interventions, but these requirements were not followed for the residents with SUD.
Two residents experienced documented changes in condition—one with loose, mucus-like stool and another with dark, foul-smelling urine and hematuria—but nursing staff did not initiate or update comprehensive care plans to address these new issues. In both cases, nurses acknowledged that a change in condition occurred and that a care plan should have been created, and the DON confirmed that no such care plans were in place despite the facility’s policy requiring documentation of changes in condition and related care plan updates.
The facility failed to ensure timely lab draws and results for four residents, including delayed C. diff stool testing after a change in bowel pattern, delayed STAT CBC/BMP/UA with C&S for a resident with UTI symptoms and hematuria, and repeated delays and communication problems around PT/INR monitoring for two residents on warfarin. Nursing staff documented multiple unanswered calls and faxes to the contracted lab, specimens that became non-viable or had to be redrawn, missing or incomplete requisitions, and PT/INR and urine culture results not returned within the facility’s stated expectations for STAT and routine testing. The DON and Administrator acknowledged that the new lab vendor was not meeting expected turnaround times and that there was no alternative lab arrangement in place, contributing to prolonged periods without needed lab information for these residents.
Two residents experienced documented changes in condition—one with loose, mucus-like stool and another with dark, bloody urine and feeling unwell—but nursing staff did not complete the required every-shift monitoring and follow-up documentation for the full 72-hour period. Despite an established process, electronic alerts for follow-up every eight hours, and staff acknowledgment that monitoring should occur each shift for three days, multiple follow-up entries were missing in both cases. This resulted in incomplete medical records that did not accurately reflect the residents’ status or changes following their conditions, contrary to the facility’s charting and documentation policy.
Two residents with pressure ulcers were found lying on low-air loss mattresses that were not set according to their actual weights, despite clear manufacturer instructions and staff responsibility to ensure proper calibration. Nursing staff and the DON confirmed the mattresses were set incorrectly, which did not align with the residents' current weights as documented in their medical records.
The facility did not ensure that the Dietary Manager held the required certification or completed necessary training before assuming full-time duties, as mandated by federal and California regulations. The DM was working full-time without having completed the Certified Dietary Manager program, and the Registered Dietitian was not managing the kitchen full-time, resulting in noncompliance with staffing requirements.
Staff did not follow the prescribed recipe for baked ziti, using unmeasured amounts of ingredients and a jarred sauce instead of the specified recipe, and failed to provide all ordered food items to two residents during lunch. These actions resulted in meals that did not meet the facility's standards for nutritional value and menu compliance.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
The facility did not implement or maintain a comprehensive QAPI program, as confirmed by the Administrator during a review of records and the QAPI binder. There was a lack of appropriate monitoring, detail, follow-up, and documentation of QAPI activities, and no evidence was provided to show ongoing quality assurance efforts or results.
The facility did not implement or document data collection, monitoring, analysis, or adverse event tracking as part of its QAPI program. The Administrator confirmed that these processes were not included in the QAPI plan or records, and the facility's policy requirements for data-driven performance measurement and feedback were not addressed.
The QAA committee did not hold a required quarterly QAPI meeting and failed to ensure attendance by all required members, including the DON and Administrator, as confirmed by interviews and record reviews. The facility also lacked proper monitoring and documentation of its QAPI plan.
Three residents did not have fluids available at bedside as required by their care plans, with staff confirming the absence of fluids and noting signs of dehydration such as chapped lips and thirst. Another resident with diabetes, anemia, and malnutrition experienced significant weight loss, with missing monthly weight records and no documentation of refusals or care plan updates, despite facility policy requiring regular monitoring and documentation.
Surveyors found that medications in pill and liquid form were disposed of in a manner that left them identifiable and retrievable by hand in pharmaceutical waste containers, contrary to facility policy. Additionally, a staff member's personal backpack was stored in the medication room, despite posted instructions prohibiting personal items, increasing the risk of drug diversion. Staff and leadership confirmed these practices did not meet required standards for medication security and disposal.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A working call system was not available in each resident's bathroom and bathing area, as required. This deficiency was observed during the survey and indicates that residents did not have access to a functioning call system in these locations.
Two residents were found without accessible call lights, with one device on the floor and another hanging behind the bed, as confirmed by CNAs and a licensed nurse. Both residents required call lights to be within reach due to their care needs, and facility policy mandated accessibility. The DON expected staff to ensure call lights were accessible during rounds.
A resident who was discharged from Medicare Part A services but remained in the facility was not given the required SNF ABN and NOMNC forms to inform them of changes in coverage and potential financial liability. The DON confirmed that these notifications were not provided, as required by facility policy.
A resident dependent on staff for ADLs was found with long, dirty fingernails and had no documented bathing for an entire month. Staff confirmed that nail care and hand hygiene were not consistently performed or documented, despite the resident's care plan and facility policy requiring such care. The DON acknowledged that the lack of hygiene and documentation did not meet expectations for resident cleanliness.
A resident did not receive IV fluids in a safe and appropriate manner when needed, as the facility failed to follow proper protocols for IV fluid administration.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within regulatory standards.
A resident's signed POLST form indicating Do-Not-Resuscitate (DNR) status was not entered into the EHR or as a physician's order, leaving the code status unavailable to staff during emergencies. Instead, the POLST was found in a binder at the nurse's station, and staff stated that in the absence of EHR documentation, the resident would be treated as full code and receive CPR. The DON confirmed the expectation for code status to be accessible in the EHR, but this was not done, despite the care plan reflecting DNR status.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. Observations and record reviews showed lapses in assessment, monitoring, and documentation of pressure ulcer care.
A resident with significant care needs did not have quarterly IDT care conferences held or documented after their comprehensive assessments, and their responsible party reported a lack of communication from the facility. Staff confirmed that required quarterly care conferences were not conducted for some long-term residents, contrary to facility policy.
A resident with diabetes did not receive required podiatry care, resulting in her family member having to trim her long and jagged toenails. Facility staff did not refer her for podiatry services as outlined in her care plan and physician orders, and she was not included on the podiatry list due to a breakdown in the referral process.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors who found lapses in confidentiality and record-keeping practices.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not submit the required 5-day follow-up investigation results to the State Survey Agency after an altercation in which two residents swung at each other. Documentation was inaccurate and undated, and both the DON and Administrator could not confirm that the report was sent as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of records showed incomplete documentation and planning, with missing interventions and unclear goals for the resident's care.
A resident with aphasia sustained a head injury during an altercation with another resident and developed new facial bruising. Facility policy required immediate and frequent neurochecks by a licensed nurse after such incidents, but documentation and staff interviews confirmed that neurochecks were not initiated until about four hours later. The DON verified that neurochecks should have started immediately, indicating a failure to follow professional standards and facility policy.
A resident with dementia and a history of wandering left the facility unsupervised on two occasions. Despite documentation of elopement risk and a prior incident, staff did not implement immediate interventions such as a wander guard device or 1:1 supervision until after a second elopement occurred. The DON confirmed that no preventative measures were in place following the initial event, in contrast to facility policy.
A resident with dysphagia and a physician-ordered pureed diet was served mashed potatoes containing large chunks, contrary to dietary orders and care plan requirements. Staff identified the error during meal service, intervened to prevent choking, and confirmed that the meal did not meet the prescribed texture modification. The incident was attributed to a breakdown in communication and failure to follow facility policy regarding therapeutic diets.
A resident with left-sided weakness and frequent incontinence waited approximately 20 to 30 minutes for staff to respond to a call light, despite multiple staff members passing by and the alert being active at the nurse's station. The delay resulted in the resident remaining in need of a brief change and expressing distress over the lack of timely assistance, with staff acknowledging the response time was not in accordance with facility expectations.
A resident with multiple medical conditions and intact cognition did not receive scheduled showers as required, with staff interviews and records revealing missed showers, inconsistent documentation, and no evidence of refusals or alternative bathing options being offered or recorded, contrary to facility policy.
A resident colonized with CRE was not provided with proper Enhanced Barrier Precautions, as there was no signage or PPE cart outside the room despite physician orders and facility policy requiring these measures. The absence of these precautions was confirmed by the Infection Preventionist during an observation when multiple individuals were present in the room.
A CNA provided direct resident care for over a month with an expired certification due to a lack of communication and oversight among the DSD, staffing coordinator, and administrator. Facility policy and job descriptions require current certification, but the lapse was not identified or addressed until after the CNA had worked multiple shifts.
A resident with a history of cerebral infarction reported significant left thigh pain, prompting a stat x-ray order that was not fulfilled by the contracted x-ray service. The x-ray was not performed at the facility, and there was no documented follow-up or escalation. The resident was later transferred to a hospital, where an x-ray revealed a femoral fracture and the resident was admitted for further care.
A resident with unsteadiness on his feet was transported by a CNA in a shower chair with a toilet seat opening, leaving his genitals exposed from the side due to inadequate covering. Staff, including the Infection Preventionist and Director of Staff Development, confirmed that the resident's privacy and dignity were not maintained, despite existing training and facility policy requiring protection of bodily privacy during personal care.
A resident with Alzheimer's and a history of confusion and exit-seeking behaviors was not re-evaluated for elopement risk or provided with updated interventions, despite multiple incidents of attempting to leave. The resident was able to exit the facility unsupervised, resulting in a fall and head injury. Staff interviews and record reviews confirmed that required assessments and interventions were not completed prior to the incident, and the resident was not wearing a monitoring bracelet at the time.
A resident with a history of cerebral infarction submitted multiple grievances regarding care concerns, including requests for specialist consultations and x-rays. Despite meetings with staff and submission of grievance forms, the facility failed to document or investigate these grievances as required by policy, and no records were found in the Grievance Binder.
Two residents with chronic conditions did not have documented quarterly IDT care plan conferences after admission, and both reported not being invited to or attending such meetings. Review of their EMRs confirmed the absence of required care conferences, and staff acknowledged that facility policy was not followed.
Failure to Notify State Agency of Changes in ADM and DON
Penalty
Summary
The facility failed to provide required written notice to the State Agency (SA) regarding changes in key administrative personnel, specifically the Administrator (ADM) and the Director of Nursing (DON). The current DON began working in the DON position on 4/21/26, but the facility did not submit the necessary application to the Centralized Applications Branch (CAB), the SA unit responsible for reviewing licensure and certification-related transactions. In an interview, the ADM stated he did not think the CAB application for the new DON had been completed and indicated that the DON was responsible for completing it. In a separate interview, the DON confirmed she had started working at the facility eight days prior, had not filed the CAB application, and stated she was not informed about CAB expectations, indicating a lack of clarity about responsibility for regulatory notification. The facility also failed to notify the SA of the change in the ADM position. During an interview, the ADM reported he had been working at the facility since August 2025 and stated that the change-in-ADM application should have been completed and sent to CAB by the facility’s corporate office at that time. A review of the SA database showed no record of receiving an application for either the DON or the ADM from the facility. These failures delayed the SA from verifying that the ADM and DON were qualified to lead clinical services for a census of 109 residents and from confirming compliance with federal and state regulations.
Failure to Prevent and Properly Respond to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision to prevent an elopement for one resident. The resident was admitted in 2026 with multiple serious diagnoses, including closed fractures of the left radius and left tibia, a basilar skull fracture, and a suicide attempt. Physician orders included 1:1 staff assistance for 72 hours due to suicidal ideation and ongoing orders to notify the provider immediately if suicidal ideation or attempts recurred, with monitoring for suicidal ideation every shift. The resident’s care plan identified a focus of risk for leaving the facility without notice related to the prior suicide attempt, with a goal that the resident would remain safe within the facility and demonstrate reduced exit-seeking behavior. Interventions included allowing time for expression of feelings and redirecting the resident if near exits or doorways. A separate care plan focus allowed the resident to smoke with supervision per a smoking assessment, with interventions to educate on the smoking policy, inform and remind of smoking areas and times, and monitor the resident. On the date of the incident, progress notes documented that around 10:19 a.m. the resident told staff that he wanted to sit in front of the facility in his wheelchair. Subsequently, staff observed the resident going toward a nearby gas station. A nurse, who was in the process of medication administration and could see the front of the facility through the windows, saw the resident in his wheelchair leaving the facility parking lot. Another staff member asked the nurse if the resident had a day pass and reported that the resident was headed toward the gas station. The nurse knew the resident did not have a day pass and walked on foot to the gas station, where the resident was found inside the mini market. The nurse asked if the resident was hurt, and the resident stated he was not and that he just wanted snacks or donuts from the gas station. The nurse then accompanied the resident back to the facility. Interviews and record reviews showed that the facility did not follow its own policy and procedure titled "Leave of Absence without Notice." The policy defined elopement as leaving the premises or a safe area without notice or authorization and/or necessary supervision, and outlined steps for locating a missing resident, including alerting personnel using an internal alert code, searching the building and grounds, notifying the Administrator and DON, contacting police if the resident was not located, notifying the physician and family, and documenting assessments and notifications. The Administrator acknowledged that, based on the facility’s definition, the resident’s departure to the gas station without a day pass or appointment met the definition of elopement and that the policy was not followed. A CNA reported that staff wondered where the resident was, asked other staff, and searched the facility, smoking area, and front patio for about an hour without finding the resident, but there is no indication that the facility’s formal elopement protocol, including activation of the internal alert code or notification of police, was implemented. The nurse involved stated she did not know all the forms required for an elopement, and besides a progress note and a call to the physician as directed by the DON and ADON, she did not complete or document a physical or mental assessment as required by the post–leave-of-absence procedure.
Failure to Honor Resident Staffing Preference for CNA Assignment
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s known staffing preference regarding which CNA should provide care. Resident 1, who had dementia, anxiety, and depression, had a family request made in December 2025 that CNA 1 not provide care to the resident due to concerns related to a prior care encounter involving a skin issue. During interviews and record reviews, LN 1 stated that CNA 1 was not to care for this resident per the family’s request. However, the facility’s [nurses’ station] Patient Preferences document, updated as of 3/11/26, only indicated that the resident preferred CNA 2 when she was present and did not indicate that CNA 1 was restricted from providing care. Further review showed that Resident 1’s comprehensive care plan, last reviewed on 4/22/26, did not reflect the family’s staffing request and lacked interventions to communicate this preference to direct care staff. The Nursing Staffing Assignment and Sign-in Sheet for 4/12/26 showed CNA 1 was assigned to the unit including the resident’s room, and incontinent care documentation for that date showed CNA 1 provided care to the resident. The DSD confirmed the family’s request via text message that CNA 1 not provide care, acknowledged it was not documented in the Patient Preferences list or care plan, and confirmed CNA 1 did provide care on 4/12/26. The DON also confirmed that the request was not reflected in the care plan or preference list and that CNA 1 provided care, despite facility policies on Accommodation of Needs and Dignity stating that resident needs, choices, and preferences are to be respected and honored to the extent possible.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident identified as being at risk for multidrug-resistant organism (MDRO) colonization or infection. The resident was admitted with gastrostomy status, requiring ongoing care of a surgically created opening in the stomach wall for a feeding tube. The resident’s care plan documented that the presence of a G-tube placed the resident at risk for MDRO colonization/infection and required the use of PPE, including gown and gloves, during high-contact resident care activities such as dressing and changing linens. Surveyors observed that an EBP sign was posted at the doorway of the resident’s room, indicating the need for specific PPE when providing direct care. During an observation, CNA 2 was seen inside the resident’s room changing the resident’s bed linens while the resident was in bed, but CNA 2 was not wearing a gown as required by the EBP sign and the resident’s care plan. Upon exiting the room, CNA 2 confirmed that she had not worn the appropriate PPE and acknowledged that she should have donned a gown before entering the room to change the linens for a resident on EBP. Multiple staff interviews confirmed that the facility’s policy and expectations required staff to wear appropriate PPE, including gown and gloves, when providing high-contact care to residents on EBP. CNA 1, LN 1, the Director of Staff Development, the Infection Preventionist, and the Assistant Director of Nursing each stated that EBP signs were posted to guide staff on required PPE and that high-contact activities such as changing linens required gown and glove use for residents on EBP. Review of the facility’s Enhanced Standard/Barrier Precautions policy, revised 2/21/25, specified that EBP is used to prevent MDRO transmission and that high-contact activities, including changing linens, require gown and glove use for the duration of the resident’s stay or until the risk factor (such as an indwelling device) is discontinued. The ADON acknowledged that the policy and procedure were not followed and that nursing staff did not meet the expected infection prevention requirements in this instance.
Failure to Timely Report Allegation of Potential Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of an allegation of potential sexual abuse to the state survey agency within the required two-hour timeframe. A housekeeper observed an interaction between two residents in the dining room in which one resident placed his right hand inside the left sleeve of another resident’s shirt and put his hand on her chest/near her shoulder and underarm. The resident who was touched had a history of sequelae of cerebral infarction and dementia and, per a recent MDS, had severe cognitive impairment with a Brief Interview for Mental Status score of 7 out of 15. Despite having received prior abuse training and knowing that any kind of abuse must be reported, the housekeeper did not report the incident to anyone on the day it occurred or during the following workdays. The housekeeper only reported the incident to the administrator seven days later, after attending another scheduled abuse training. The administrator then reported the allegation to the state agency, law enforcement, and the ombudsman that same afternoon. The DON and administrator both confirmed that the incident had occurred on the earlier date and that it was not reported to facility administration until a week later, contrary to facility policy. Facility policies titled “Abuse Prohibition” and “Abuse Investigation and Reporting” require that anyone who witnesses suspected abuse immediately report the incident to a supervisor and that alleged violations involving abuse or serious bodily injury be reported immediately, but no later than two hours. The delay in reporting by the housekeeper constituted a failure to follow these policies and to meet the regulatory requirement for timely reporting of alleged abuse.
Failure to Timely Respond to Call Light and Provide Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not responding to a call light in a timely manner. Resident 1, who had spinal stenosis, difficulty walking, generalized muscle weakness, ADL self-care performance deficits, and was at risk for bowel and urinary incontinence, relied on staff assistance for toileting and hygiene. On the survey date, the call light for the shared room of Resident 1 and Resident 2 was observed to be on at 11:37 AM and remained unanswered through multiple observations at 11:40 AM and 11:44 AM, despite staff, including a licensed nurse, being present at the nurses’ station and not responding. During a joint observation and interview in the room at 11:46 AM, the call light for Resident 1 was still unanswered. Resident 2 reported that staff did not come to answer the call light and that both residents did not get the attention they needed. Resident 2 stated that Resident 1 wore incontinent briefs that would get wet and needed changing, and that when Resident 1 asked staff to change him, they would say they would come back but did not. Resident 1 stated he had not been changed since the previous night and sometimes waited 30 minutes for his call light to be answered. Resident 2 confirmed that staff had not come to change Resident 1’s brief since the previous night and that he did not know the name of the CNA assigned to their care. Further observation at 11:54 AM showed a CNA passing by the hallway in front of the room without responding to the call light. The call light was finally answered at 12:01 PM by the Administrator, who then sought assistance from staff and contacted the licensed nurse. Interviews with the Director of Staff Development and the Administrator confirmed that the facility’s expectation and policy were for call lights to be answered within a few minutes and for any staff member to respond, and that residents, including Resident 1, were to be checked and assisted with toileting and incontinence care regularly and as needed. Resident 1’s care plans directed staff to encourage use of the call bell for assistance, respond promptly to toileting requests, assist with cleansing after bowel movements, and maintain proper perineal hygiene, as well as to promote dignity by promptly responding to toileting assistance requests. These documented expectations contrasted with the observed prolonged, 24-minute delay in answering the call light and the reported lack of timely incontinence care for Resident 1.
Tampered Call Light Not Maintained in Functional State for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences when the resident’s call light was tampered with and rendered nonfunctional. The resident had dementia and blindness and relied on the call light to communicate needs. On one evening shift, a CNA delivering snacks observed a plastic item placed between the call light plug and the outlet, which interfered with the device. A licensed nurse on the same shift had noticed that the resident’s call light was not being activated as frequently as usual and, upon checking, also found a plastic tube between the call light plug and the outlet. The nurse removed the plastic tube, confirmed the resident was okay, and reinserted the call light plug directly into the outlet, restoring its function. The licensed nurse later reported that she again saw a plastic tube in the resident’s room several days after the initial incident and brought this to the attention of her supervisor. The DON stated that the nurse reported the call light concern after observing another plastic tube on the resident’s bedside table. The facility’s policy on answering call lights required that call lights be plugged in and functioning at all times and that all defective call lights be promptly reported to the nurse supervisor. Despite this policy, the resident’s call light had been tampered with, and the device was not maintained in a continuously functional state as required.
Failure to Promptly Investigate and Compensate for Resident’s Missing Belongings
Penalty
Summary
The facility failed to protect a resident from the wrongful use or loss of personal belongings by not promptly investigating and addressing reported missing items. A resident with an admission diagnosis that included adjustment disorder with anxiety was reported by her son on 12/19/25 to have missing clothing items, including five pairs of sweatpants, some shirts, and a blue jacket. A social services progress note documented the son's call and indicated that the Social Services Director would follow up with the resident. However, no theft and loss investigation was initiated at that time, and the facility did not conduct a timely search or complete required theft and loss reporting. On 2/11/26, during an interview, the Administrator in Training acknowledged that when the missing items were reported, staff should have searched the facility and, if the items were not found, completed a theft and loss report to begin the investigation process, but confirmed this process was not initiated until that date. A roommate stated that the resident's clothes were lost and the facility could not find them. The Dialysis Social Worker reported that the resident's family said the resident was so upset about her missing clothes that she wanted to call the police, and that the facility had told the family they would reimburse the resident $200, but reimbursement had not been provided. Facility policies on investigating incidents of theft and loss and on dignity required prompt and thorough investigation of theft or misappropriation of resident property, protection from theft and loss, and respect for residents' property and private space at all times, which were not followed in this case.
Untimely Blood Glucose Monitoring and Insulin Administration for Diabetic Resident
Penalty
Summary
The facility failed to ensure professional standards of quality care were met for a resident with type 2 diabetes mellitus when ordered blood sugar monitoring and insulin administration were not performed in a timely manner. The resident’s care plan identified a risk for hyperglycemia related to diabetes and included interventions such as education on medications, performing finger stick blood sugars (FSBS) as ordered with regular insulin, and following MD orders for a new insulin regimen/sliding scale. The MAR for the month showed that the resident’s blood sugar levels and insulin administration were scheduled for 7:30 AM and 5:00 PM daily, with a sliding scale order for insulin lispro based on blood sugar readings. However, documentation revealed that on multiple dates the resident’s elevated blood sugars were treated with insulin significantly later than the scheduled time, including administration at 9:37 AM and 9:18 AM instead of at the scheduled 7:30 AM time. During interview, the resident reported having to wait a long time to receive medications and stated that when she requested medication, staff would acknowledge the request but then appeared to forget once they left the room. The DON confirmed that it was her expectation that medications be administered within one hour before or after their scheduled time and acknowledged that breakfast was provided to the resident at 7:30 AM daily. Facility policy on administering medications required that medications be given in a safe and timely manner, within one hour of the prescribed time, and based on resident need and benefit rather than staff convenience. The facility’s insulin administration policy and manufacturer information for insulin lispro specified that rapid-acting insulin should be administered within 15 minutes before or immediately after a meal, underscoring that the late administration times documented on the MAR did not align with these standards or the resident’s ordered regimen.
Failure to Develop and Implement SUD Care Plans for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement individualized care plans for residents with diagnosed substance use disorder (SUD). Record review showed that three sampled residents, each with SUD documented on their admission records, did not have SUD care plans in place prior to a specified date. For each of these residents, the DON confirmed during concurrent interviews and record reviews that no SUD care plan had been developed, despite the presence of SUD as an active diagnosis. The DON stated that SUD care plans were important to monitor for potential withdrawal symptoms and drug-seeking behavior, and acknowledged that the absence of such care plans meant the residents’ psychosocial well-being was not being monitored in relation to their SUD. During a phone interview and policy review, surveyors examined the facility’s policies on LAWN Evaluation & Management – Leave of Absence without Notice, Wandering and Elopements, and Goals and Objectives, Care Plans. These policies required that residents at risk for leaving without notice be evaluated upon admission, that at-risk residents have care plans including strategies and interventions to maintain safety, and that care plans incorporate measurable, behaviorally stated goals and objectives derived from comprehensive assessments. The DON confirmed that these policies were not followed for the three residents with SUD, as their SUD-related risks, including potential exit-seeking behavior and withdrawal, were not addressed in their care plans.
Failure to Develop Care Plans After Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans following documented changes in condition for two residents. For the first resident, who had diagnoses including mild chronic kidney disease, Parkinson’s disease, and dementia, an eINTERACT Change in Condition Evaluation dated 12/20/25 documented that the resident was noted with loose, mucus-like stool. During interview and concurrent record review, a licensed nurse stated that when a resident has a change in condition, the nurse is required to complete reports and update the resident’s care plans to include the new issue. Upon review of this resident’s care plans, the nurse confirmed that no care plan had been initiated to address the mucus in the stool following the documented change in condition. For the second resident, who had diagnoses including type 2 diabetes mellitus and benign prostatic hyperplasia, an eINTERACT Change in Condition Evaluation dated 1/2/26 documented that the resident complained of not feeling well and that a CNA had reported dark-colored urine in the urinal and hematuria. In a subsequent interview and record review, a licensed nurse stated that this constituted a change in condition and that a care plan should have been created. Review of the resident’s care plans confirmed that no care plan was created to address the hematuria and associated symptoms. In a later interview, the DON confirmed that neither resident had a care plan created for their respective changes in condition and stated that her expectation was that a care plan be created for every change in condition. The facility’s Charting and Documentation policy required documentation of changes in condition and progress toward or changes in care plan goals and objectives in the medical record.
Delayed Lab Draws and Results for Stool, STAT Infection Workups, and PT/INR Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely laboratory services and results for four residents after physician orders were obtained. For one resident with chronic kidney disease, Parkinson’s disease, and dementia, a change in condition was documented when loose, mucus-like stool with odor was noted. A stool sample for C. difficile testing was ordered and picked up by the contracted lab, but the result was not returned within the expected timeframe. Nursing notes show repeated calls to the lab with no answer, eventual notification that the specimen was no longer viable, and a lack of prior notification to the facility about this issue. A subsequent STAT C. difficile order was placed, the specimen was picked up, and staff again made multiple calls to the lab before the result was finally received, creating a prolonged delay between the initial change in condition and receipt of the test result. Another resident with type 2 diabetes and benign prostatic hyperplasia experienced a change in condition with complaints of not feeling well, dark urine, and hematuria. The physician ordered STAT CBC, BMP, and UA with C&S, and also ordered staff to follow up with the lab if the blood draw was not completed or to call for STAT results. Progress notes document that staff called the lab, faxed the STAT order, and that no one came initially to draw the blood. The urine sample was not collected and picked up until the following day, and by several days later the UA C&S results were still pending. The physician, finding no lab results available during assessment, ordered the resident to be sent to the ED, where a UTI was diagnosed and antibiotic therapy initiated. A third resident with spastic quadriplegic cerebral palsy and communication disorders was on warfarin and required regular PT/INR monitoring. Orders and progress notes show multiple scheduled and STAT PT/INR tests in December, but there were gaps in documentation of draws, delays in obtaining results, and repeated unsuccessful attempts to contact the lab. Staff documented that PT/INR was drawn but results were still “awaiting,” that phlebotomists came at night to draw STAT labs, that calls to the lab went unanswered or the phone line cut out, and that additional STAT PT/INR orders had to be placed due to missing or delayed results. Nurses and the DON reported that since switching to a new lab company, results were faxed rather than integrated into the electronic chart and were taking longer, with no backup lab available other than sending residents to the ED. A fourth resident with atrial fibrillation and congestive heart failure, also on warfarin, had weekly PT/INR testing and dosing managed through a coumadin clinic. Progress notes show a change in condition related to missed warfarin doses and a STAT PT/INR ordered and called to the lab. A phlebotomist drew the STAT PT/INR in the early morning, but nurses documented multiple follow-up calls to the lab without results, confusion over requisitions that did not include PT/INR, and the need to create a new requisition and redraw blood. Hospital anticoagulation communication records later reflected missed warfarin doses on several days, which the DON attributed to the lab’s failure to complete the PT/INR draw and the resulting lack of current dosing orders. Throughout these events, the DON and Administrator confirmed that the lab was expected, per contract and facility practice, to prioritize STAT orders and return results promptly, but that there were repeated delays in draws and reporting for these four residents. The facility’s own policy stated that the lab or testing source would report test results to the facility and that concerns about handling or reporting of results should be communicated to the DON or Medical Director, without delaying clinically appropriate management. Interviews with multiple nurses and the DON confirmed that staff repeatedly attempted to follow up with the lab by phone and fax, that results were not received within the expected 4–8 hours for STAT draws and 24–72 hours for routine tests, and that there was no alternative contracted lab at the time. The contracted lab’s representative described a process in which orders are received by email or fax, confirmed with the facility, and prioritized for STAT processing, but the documented experiences for these four residents show that orders, draws, and results were not consistently handled within those expectations, leading to the cited deficiency in timely laboratory services and test results.
Failure to Document Shift-by-Shift Monitoring After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ medical records accurately reflected their progress or decline following a documented change in condition. For one resident with mild chronic kidney disease, Parkinson’s disease, and dementia, a change in condition was recorded when loose, mucus-like stool was noted on 12/20/25 at 1240 using an eINTERACT Change in Condition Evaluation. Facility practice, as described by nursing staff, required monitoring and documentation every shift for 72 hours after such a change, using follow-up documentation and/or progress notes. However, only three follow-up documentation entries were completed over that 72-hour period, and only one progress note referenced monitoring for mucus in the stool, leaving six required follow-up documentation entries missing. A second resident, admitted with type 2 diabetes mellitus and benign prostatic hyperplasia, experienced a change in condition when he complained of not feeling well and staff observed dark-colored urine and hematuria, documented on 1/2/26 at 2201 on an eINTERACT Change in Condition Evaluation. As with the first resident, the facility’s process called for monitoring and documentation every shift for three days following the change in condition. Review of the record showed only three follow-up documentation entries over the 72-hour period and one progress note describing difficulty obtaining a urine sample and low urine output, with six follow-up documentation entries missing for the required monitoring timeframe. Interviews with licensed nurses and the DON confirmed that the facility’s expectation and practice were to complete follow-up documentation or progress notes every shift for 72 hours after a change in condition, and that the electronic record system displayed alerts indicating follow-up documentation was due every eight hours. Staff acknowledged that multiple shifts of required monitoring documentation were missing for both residents. The facility’s Charting and Documentation policy required that all changes in a resident’s medical, physical, functional, or psychosocial condition be documented in the medical record to facilitate communication among the interdisciplinary team. The missing shift-by-shift monitoring entries for both residents after their changes in condition constituted a failure to maintain medical records in accordance with this policy and accepted professional standards.
Failure to Properly Calibrate Low-Air Loss Mattresses for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent pressure ulcers for two residents who were observed lying on low-air loss (LAL) mattresses that were not calibrated according to their individual weights. For one resident with multiple diagnoses, including Alzheimer's disease and a history of skin breakdown, the LAL mattress was set for a person weighing 355 pounds, while the resident's actual weight was 137.2 pounds. Nursing staff confirmed the incorrect setting and acknowledged that it was their responsibility to ensure the mattress was adjusted to the resident's current weight. The manufacturer's user manual specified that the mattress pressure should be set according to the patient's weight. Another resident, admitted with multiple wounds including pressure ulcers and weighing less than 100 pounds, was found to have an LAL mattress set for someone weighing 160 pounds. The treatment nurse verified the incorrect setting and confirmed that the mattress should have been adjusted to the resident's actual weight of 93.4 pounds. The resident's medical record included orders for pressure ulcer precautions and the use of a pressure-relieving mattress, but the settings were not properly adjusted as required. Interviews with nursing staff and the Director of Nursing (DON) confirmed that nurses were responsible for adjusting LAL mattress settings according to each resident's current weight. The DON acknowledged that staff did not follow the manufacturer's guidelines for the LAL mattresses and that her expectations for proper adjustment were not met. The failure to set the mattresses correctly was confirmed through observation, interview, and record review, and was identified as a deficient practice that could contribute to the worsening of wound conditions for the affected residents.
Dietary Manager Lacked Required Certification and Training
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met federal, California, and facility standards for the position. The DM had not completed the Certified Dietary Manager (CDM) program, despite having started work in December 2024 and the program being purchased in January 2025. The DM was working full-time in the role without the required certification. The facility's job description for the DM position required a bachelor's degree in nutrition or dietary management and certification as a Dietary Manager or comparable credential in the state. Additionally, the Registered Dietitian (RD) at the facility was primarily responsible for clinical nutrition tasks, such as assessments and care planning, and only performed monthly inspections and meal observations in the kitchen. California Health and Safety Code 1265.4 requires that if a facility does not employ a full-time registered dietitian to manage the kitchen, a full-time Dietary Manager with specific qualifications must be employed. The DM had not met these qualifications, including completion of an approved training program and maintaining certification, as well as receiving required in-service training prior to assuming full-time duties.
Failure to Follow Menu Recipes and Meal Tickets Results in Incomplete and Improperly Prepared Meals
Penalty
Summary
The facility failed to maintain the nutritive value of food by not following the prescribed menu recipe for baked ziti with meat sauce and by not ensuring that residents received all items ordered on their lunch trays. During observation, a dietary staff member prepared baked ziti without measuring the required amounts of sauce, cottage cheese, and shredded cheese as specified in the facility's recipe. The staff member was unsure of the container measurements and used a jarred sauce product instead of preparing the sauce according to the recipe, which could affect the nutritional content, especially for residents on salt-free diets. Additionally, two residents did not receive all the food items listed on their meal tickets; specifically, pureed garlic bread was missing, and a pureed brownie was served instead of a moist iced brownie. The registered dietitian confirmed that not following meal tickets and recipes could impact the quality, taste, nutritional value, and caloric intake of the meals provided. The facility's policy required menus to be served as written unless substitutions were necessary, but this was not adhered to during the observed meal service.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Implement and Document Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance and Performance Improvement (QAPI) program and plan. During an interview and record review, the Administrator acknowledged that the facility did not have appropriate monitoring and documentation for the QAPI program. The QAPI program binder was reviewed and found to lack detail, follow-up, and documentation. Although the QAPI team reportedly performed work behind the scenes, there was no documentation available to show the results of their monitoring activities. The Administrator confirmed that the absence of a well-documented QAPI program and plan meant that quality of care issues may not have been reviewed and correction plans may not have been developed or implemented. A review of the facility's undated policy and procedure for the QAPI program indicated that the Administrator is ultimately responsible for the program and for interpreting its results to the governing body, and that the governing body is responsible for ensuring the program is implemented, maintained, and sustained. However, the facility was unable to provide evidence of ongoing QAPI activities or documentation to support that the program was being followed as required.
Failure to Implement QAPI Data Collection and Monitoring
Penalty
Summary
The facility failed to utilize its Quality Assurance Performance Improvement (QAPI) program to develop and implement policies and procedures for data collection systems, feedback, monitoring, analysis, and action, including adverse event monitoring. During an interview and record review, the Administrator confirmed that the QAPI program did not include measures for monitoring and documentation, and that these components were not compiled or input into facility records. The facility's QAPI policy indicated that the program should be based on data, resident and staff input, and other information that measures performance, but these processes were not addressed or implemented. As a result, the facility did not collect data or identify corrective measures for any issues affecting the facility.
QAA Committee Failed to Meet Quarterly and Lacked Required Member Attendance
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to meet the regulatory requirement of convening at least quarterly with all required members present. Specifically, the committee did not hold a required quarterly Quality Assurance Performance Improvement (QAPI) meeting in April 2025. Additionally, attendance records and interviews confirmed that the Director of Nursing (DON) was absent from the January 2025 meeting, and the Administrator did not attend the June 2025 meeting. The facility's policy requires the Administrator, DON, Medical Director, and Infection Preventionist to serve on the committee and attend these meetings. During interviews and record reviews, the Administrator acknowledged the lapses in both meeting frequency and required attendance, confirming that the QAA committee did not meet in April and that key members missed other meetings. The Administrator also stated that the monitoring and documentation portion of the QAPI plan was not compiled or maintained in the facility's records, and recognized that these practices were not up to standard. No information about specific residents or their conditions was provided in the report.
Failure to Provide Adequate Hydration and Monitor Weight Loss
Penalty
Summary
The facility failed to ensure proper hydration for three residents and did not maintain the usual body weight for another resident, as required by facility policy and each resident's care plan. Multiple observations revealed that three residents did not have fluids available at their bedside on several occasions, despite care plans specifying the need for monitoring and encouraging fluid intake. Staff interviews confirmed the absence of fluids and acknowledged the importance of having fluids accessible to prevent dehydration, with some residents displaying signs such as chapped lips and expressing thirst. One resident with a history of urinary tract infection and an indwelling catheter was observed without fluids at bedside, and staff noted dark urine in the collection bag. Another resident, who was on diuretics and required assistance with fluid intake, reported waiting for hours for a water refill and feeling frustrated by unmet needs. Staff confirmed the lack of fluids and recognized the associated risks, as outlined in the residents' care plans and the facility's hydration policy. Additionally, the facility did not consistently monitor and document the weight of a resident with multiple diagnoses, including diabetes, anemia, and mild malnutrition, who experienced significant weight loss over several months. Weight records were missing for three months, and there was no documentation of refusal to be weighed or care plan updates reflecting such refusals. Staff interviews confirmed that weights should have been taken and documented monthly, and that refusals should have been recorded and communicated to the interdisciplinary team, but these actions were not completed as required by facility policy.
Improper Medication Disposal and Unauthorized Storage in Medication Room
Penalty
Summary
The facility failed to ensure the safe disposal of medications and to reduce the risk of drug diversion. During observations in two medication rooms, pharmaceutical waste containers were found to contain medications in both pill and liquid forms that were still identifiable and could be retrieved by hand. Pills were left in their original packaging and liquid medications remained in their bottles, rather than being removed and mixed with an undesirable substance as required by facility policy. Multiple staff, including a licensed nurse and the Director of Staff Development, confirmed that the medications should not have been recognizable or retrievable once discarded, and that the observed disposal practices did not comply with established procedures. Additionally, a staff member's personal backpack was found stored under the sink in a medication room, despite a posted sign prohibiting personal items in that area. Both the licensed nurse and the Director of Nursing acknowledged that personal items should not be present in the medication room due to the risk of theft, misuse of medications, or drug diversion. Facility policy requires that medications and biologicals be stored safely and securely, accessible only to authorized personnel, and that the medication room remain free of unauthorized personal belongings.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The report does not provide additional details about specific residents affected or the circumstances under which the deficiency was discovered.
Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring their call lights were within reach and functioning. For one resident, the call light was found on the floor and not accessible, as confirmed by both a CNA and a licensed nurse during observation and interview. The resident's care plan indicated a moderate risk for falls due to confusion and unawareness of safety needs, and specifically required the call light to be within reach and prompt responses to requests for assistance. For another resident, the call light was observed hanging on the wall behind the bed, also out of reach. A CNA confirmed this during observation and interview, stating the importance of call light accessibility for timely assistance. The DON stated her expectation that all residents have working call lights within reach and that CNAs should check on this during rounds. Facility policy required call lights to be accessible to residents when in bed.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required beneficiary protection notifications to a resident who was discharged from Medicare Part A services but continued to reside at the facility. Specifically, the resident was not issued a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: CMS 10055) or a Notice of Medicare Non-Coverage (NOMNC: CMS 10123) when their Medicare Part A coverage ended, despite having remaining skilled benefit days. This was confirmed through review of facility records and an interview with the DON, who acknowledged that the necessary forms were not provided to the resident at the time of the change in coverage. Facility policy states that a SNF ABN should be issued prior to providing care that Medicare may not pay for, and a NOMNC should be given at least two days before Medicare-covered services end. The DON verified that these notifications were not given to the resident, and there was no documentation to show that the resident or their representative was informed of the change in coverage or potential financial liability. The deficiency was identified through review of the resident's records and staff interviews.
Failure to Provide ADL Assistance and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs) was not provided with adequate hygiene care. Observations revealed that the resident's fingernails were long, sharp, and had a brown substance caked underneath. The resident had not received a documented bath or shower for the entire month of July, despite being scheduled for bathing twice weekly. Staff interviews confirmed that nail care and hand hygiene were not consistently performed, and there was no documentation of these tasks in the electronic health record (EHR). The resident expressed a desire to be cleaned and have his nails cut, and staff acknowledged the importance of maintaining hygiene to prevent infection and injury. The care plan for the resident indicated a self-care deficit related to cognitive impairment and poor judgment, with goals to maintain personal hygiene with staff assistance. The care plan also emphasized the importance of keeping the skin clean and dry to prevent skin tears and infection. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain good grooming and hygiene. However, the lack of documented bathing, nail care, and hand hygiene for this resident demonstrated a failure to follow the care plan and facility policy, resulting in the resident not receiving essential hygiene care.
Failure to Safely Administer IV Fluids
Penalty
Summary
A deficiency was identified regarding the administration of IV fluids to a resident. The facility failed to ensure that IV fluids were provided in a safe and appropriate manner when needed for a resident. This indicates that the necessary protocols or procedures for IV fluid administration were not followed at the time care was required.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices.
Failure to Maintain Accessible DNR Status in EHR
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for one resident when the resident's Physician Orders for Life-Sustaining Treatment (POLST), which indicated a Do-Not-Resuscitate (DNR) status, was not readily accessible in the resident's electronic health record (EHR). The resident reported having signed a POLST at admission, but during a review, a licensed nurse was unable to locate any code status in the EHR and stated that, in the absence of this information, the resident would be treated as a full code and receive cardiopulmonary resuscitation (CPR) if needed. The POLST form was later found in a binder at the nurse's station, but it had not been entered into the EHR or as a physician's order at the time of admission. The Director of Nursing confirmed that it was expected for a resident's code status to be readily available in the EHR and that, if not listed, the default assumption was full code status. The resident's care plan did indicate DNR status, but this information was not reflected in the EHR or physician orders, contrary to facility policy. The facility's policy stated that CPR and related emergency measures would not be used when a DNR order is in effect, but the lack of documentation in the EHR could have resulted in actions contrary to the resident's wishes.
Failure to Provide and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the necessary interventions to prevent further skin breakdown were not consistently provided, and documentation of care was incomplete or missing in some cases.
Failure to Hold and Document Quarterly IDT Care Conferences
Penalty
Summary
The facility failed to conduct and document quarterly Interdisciplinary Team (IDT) care conferences for a resident who was admitted with diagnoses including cerebral infarction and quadriplegia, and who was dependent on staff for all activities of daily living. Review of the resident's records showed that no IDT care conferences were held or documented after quarterly assessments were completed for the first and second quarters of the year. The responsible party for the resident reported not receiving any communication from the facility regarding the resident's care, and expressed concern that it seemed no one cared about the resident. Interviews with facility staff, including the MDS Coordinator and the Administrator, confirmed that the expectation was for quarterly IDT care conferences to be held for long-term residents, but acknowledged that these meetings did not occur for some residents, including the one in question. Facility policy indicated that the IDT is responsible for developing and revising individualized care plans with input from the resident and their family or representative, but this process was not followed as required for the resident during the specified time period.
Failure to Provide Podiatry Care for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus did not receive proper foot care and podiatry services as required by her care plan and physician orders. Upon observation, the resident was found with long and jagged toenails, and she reported that facility staff did not trim her toenails due to her diabetes diagnosis. Instead, her family member was providing this care, despite being uncomfortable with the task. The resident stated she had not been offered podiatry care since her admission. Multiple staff interviews confirmed that the process for referring residents to podiatry services was not followed, and the resident was not included on the podiatry list because CNAs and licensed nurses did not make the necessary referral to social services. Record review showed that the resident's care plan included diabetic foot checks and monitoring for signs of infection, and her admission orders specified podiatry evaluation and treatment as needed. However, there was no documentation that podiatry care had been provided since her admission. The facility's policy required residents with medical conditions associated with foot complications, such as diabetes, to be referred to qualified professionals for foot care. The failure to follow these procedures resulted in the resident not receiving appropriate podiatry care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and incomplete or improperly maintained medical records. The report specifically notes noncompliance with standards related to the handling and documentation of resident medical information. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Investigation Results of Resident Altercation
Penalty
Summary
The facility failed to submit the results of its investigation into a resident-to-resident altercation to the State Survey Agency within the required five working days. The incident involved two residents who swung at each other, and the initial documentation provided by the facility was undated and inaccurately stated that there was no physical contact. During interviews, both the DON and the Administrator were unable to confirm whether the 5-day follow-up investigation report had been sent to the appropriate authorities. The facility's own policy requires that findings of all completed investigations be reported within five working days, but this was not followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
Failure to Perform Timely Neurochecks After Resident Head Injury
Penalty
Summary
A deficiency occurred when a resident, admitted with a diagnosis including aphasia, was involved in a resident-to-resident altercation resulting in a blow to the head and new facial bruising. According to the facility's policy, neurological checks (neurochecks) were required to be performed by a licensed nurse immediately after any head injury, with specific intervals for monitoring and documentation. However, the clinical record and interviews revealed that neurochecks were not initiated until approximately four hours after the incident, rather than immediately as required. The licensed nurse involved could not recall if neurochecks were performed, and documentation showed the first set of vital signs and assessments were recorded significantly later than policy dictated. The Director of Nursing confirmed that neurochecks should have been completed immediately following the head injury, and the facility's policy outlined a clear protocol for the frequency and documentation of these assessments. The failure to perform timely neurochecks meant that the resident did not receive care in accordance with professional standards and facility policy following a head injury.
Failure to Implement Timely Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement preventative measures to reduce the risk of elopement for a resident with dementia and a history of falls. The resident was admitted with diagnoses including dementia and had previously attempted to leave the facility. On one occasion, the resident left the facility without notifying staff and was later found at a hospital. Documentation showed that the care plan identified the risk of elopement and set a goal for the resident not to leave without an escort, but interventions listed were limited to encouraging participation in activities and personalizing the resident's room. Despite the resident's known risk and a documented incident of elopement, there were no immediate interventions such as a wander guard device or 1:1 supervision implemented after the first elopement. Staff interviews confirmed that a wander guard device was not ordered or placed until after a second elopement occurred. The DON acknowledged that no interventions were in place to prevent the resident from leaving unattended following the initial incident, contrary to facility policy requiring systematic monitoring and management of residents at risk for elopement.
Failure to Provide Prescribed Pureed Diet Results in Dietary Deficiency
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and a history of traumatic subdural hemorrhage, who was prescribed a regular pureed diet with nectar/mildly thick liquids due to dysphagia, was served mashed potatoes containing large chunks of potato during a dinner meal. The resident's care plan and physician orders specified a pureed diet to mitigate the risk of aspiration and choking, and these requirements were documented in the resident's records. Despite these clear dietary orders, the meal provided did not meet the prescribed texture modification, resulting in a potential risk for aspiration. Staff interviews revealed that licensed nurses were responsible for checking meal trays for correct diets before distribution by CNAs. On the day of the incident, a licensed nurse identified the presence of potato chunks in the resident's mashed potatoes and intervened to remove the food from the resident's mouth to prevent choking. The nurse reported the incident to the Dietary Manager and the Assistant Director of Nursing, and a correct meal tray was subsequently provided. The Dietary Manager confirmed that the cook responsible for preparing the meal was unaware of the resident's dietary requirements and did not follow facility policy, as the meal ticket was missing. The facility's policy on therapeutic diets, which requires adherence to physician-ordered texture modifications, was not followed in this instance. The Registered Dietitian and Dietary Manager both confirmed that the resident should have received a pureed meal and that the risk of serving food with chunks was choking. The incident was corroborated by multiple staff interviews and a review of the facility's menus and dietary orders, all of which indicated that the resident did not receive the prescribed diet consistency.
Delayed Call Light Response Compromises Resident Dignity
Penalty
Summary
Staff failed to answer a resident's call light in a timely manner, resulting in the resident waiting approximately 20 to 30 minutes for assistance. During this period, multiple staff members, including CNAs, PTAs, LNs, and other staff, walked past the call light without responding, despite the system visibly blinking and making an auditory alert at the nurse's station. Four staff members were observed sitting at the nurse's station while the call light was active. The Activity Director eventually responded and found that the resident needed a brief change, notifying the CNA for further assistance. Interviews with staff confirmed that all staff are responsible for answering call lights and that the expected response time is within 5-10 minutes. The resident involved had a history of hemiplegia and hemiparesis following a stroke, resulting in left-sided weakness and frequent incontinence. The resident was dependent on staff for ADL care, including toileting, and was able to use the call light to request assistance. The resident reported feeling upset and expressed dissatisfaction with the delay, stating that she sometimes had to yell for help. Staff interviews acknowledged that the wait time was excessive and not in line with facility policy, which requires prompt response to call lights to maintain resident dignity.
Failure to Provide and Document Scheduled Showers for a Resident
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, convulsions, and generalized muscle weakness did not receive scheduled showers as required by the facility's policy. The resident was cognitively intact, as indicated by a BIMS score of 15, and was able to communicate his needs. Despite being scheduled for showers twice a week, documentation and interviews revealed that the resident did not receive showers according to the established schedule, and there was no evidence of refusals or alternative bathing options being offered or documented. Multiple staff interviews confirmed that the resident's showers were not provided as scheduled, and that documentation was inconsistent or missing for several dates. Certified Nurse Assistants (CNAs) and Licensed Nurses (LNs) acknowledged that showers were important for hygiene, skin assessment, and resident dignity, but records showed only a few bed baths and showers were documented, with several scheduled showers lacking any documentation. The facility's own monitoring reports and shower sheets further indicated gaps in both the provision and documentation of bathing care. The facility's policy required thorough documentation of all showers, refusals, and skin assessments, but this was not consistently followed. The Director of Nursing and Director of Staff Development both confirmed that the expected documentation was incomplete and that the resident missed scheduled showers without proper record of refusals or alternative care. This failure to provide and document scheduled showers had the potential to negatively impact the resident's personal hygiene and psychosocial well-being.
Failure to Implement Enhanced Barrier Precautions for Resident with CRE
Penalty
Summary
The facility failed to follow its infection control policy and procedures regarding Enhanced Barrier Precautions (EBP) for a resident colonized with Carbapenem-resistant Enterobacteriaceae (CRE), a multidrug-resistant organism. Specifically, there was no sign indicating EBP and no cart with the required personal protective equipment (PPE) such as gowns, gloves, eye protection, or facemasks outside or near the resident's room. This was observed during a time when the resident was in her room with a visitor, and a maintenance worker was present, indicating that multiple individuals could have entered the room without proper precautions. Record review showed that the resident had a history of chronic obstructive pulmonary disease and heart failure, and was identified as colonized with CRE following an acute care stay. Physician orders and the care plan both specified the need for EBP to prevent transmission, and facility policy required PPE to be available near or outside the room for residents with MDROs. The Infection Preventionist confirmed the absence of both the EBP sign and PPE cart, acknowledging that this could result in staff not knowing the proper PPE to use during direct care.
CNA Worked with Expired Certification
Penalty
Summary
Certified Nurse Assistant (CNA) 1 was allowed to work and provide direct resident care for a period of thirty-two days with an expired CNA certificate. Interviews with facility staff, including a Licensed Nurse, the Staffing Coordinator, the Director of Staff Development (DSD), and the Administrator, confirmed that CNA 1's certificate had expired and that she continued to be scheduled and worked during this time. The DSD acknowledged that there was a lack of communication regarding the certificate expiration and that CNA 1 should not have been scheduled to work without a valid certificate. The Staffing Coordinator was not made aware of the expiration, and the Administrator confirmed that CNA 1 worked while waiting for her renewed certificate. A review of facility policies and CNA 1's job description indicated that maintaining current certification is required for employment as a CNA. Despite this, CNA 1 was scheduled and worked for over a month without a valid certificate, providing direct care to residents. There is no mention in the report of any specific residents being harmed or of any particular medical conditions affected by this deficiency.
Delay in Urgent X-ray Services Resulting in Delayed Diagnosis of Fracture
Penalty
Summary
The facility failed to ensure that contracted radiological (x-ray) services were available and provided in a timely manner for a resident who required an urgent x-ray. The resident, who had a history of cerebral infarction, reported significant pain in the left thigh, which was documented as a change in condition. A stat x-ray was ordered by the primary care provider to assess the cause of the pain, but the x-ray was not performed as required. Progress notes indicated that the x-ray technician from the contracted service did not arrive to perform the x-ray, and the order remained unfulfilled in the resident's medical record. Despite the stat order, there was no documentation of follow-up with the x-ray provider or escalation to the physician regarding the delay. The resident continued to experience pain, and the x-ray was not completed at the facility. Subsequently, the resident was transferred to an acute care hospital, where an x-ray revealed an oblique fracture of the proximal left femoral shaft. The resident was admitted to the hospital with a diagnosis of femur fracture. Facility staff, including a licensed nurse and the assistant director of nursing, confirmed that the delay in obtaining the x-ray resulted in a delay in care and that facility policy was not followed.
Resident Exposed During Transfer to Shower Room
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) transported a male resident, who had been admitted with unsteadiness on his feet, from his bedroom to the shower room in a shower chair with a toilet seat opening. The resident was unclothed, with only a blanket covering the front of his legs, leaving the sides exposed. During this transfer, the resident's penis and scrotum were visible from the side of the chair, as they hung below the seat opening. This exposure was observed by staff, including the Infection Preventionist, who confirmed that the resident was not adequately covered to maintain privacy and dignity. Interviews with facility staff revealed that the CNA had received training on maintaining resident privacy and dignity but was unaware that the resident was exposed during the transfer. The Director of Staff Development also confirmed that staff were educated on the importance of privacy and that the resident's privacy was not maintained in this instance. A review of the facility's policy on dignity emphasized the need to promote and protect resident privacy, including bodily privacy during personal care, which was not upheld in this situation.
Failure to Reassess and Intervene for Resident with Exit-Seeking Behaviors Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease, who had a documented history of confusion, agitation, and exit-seeking behaviors, was not re-evaluated for elopement risk nor provided with updated interventions despite multiple documented incidents of attempting to leave the facility. The resident had repeatedly verbalized a desire to go home, attempted to exit the building, and sought assistance from others to leave, as noted in progress notes and staff interviews. Despite these behaviors, staff did not complete an elopement risk assessment or update the care plan to include interventions such as a monitoring bracelet or increased supervision prior to the incident. On the evening of the incident, the resident was observed following staff in a wheelchair and expressing a strong desire to leave. Staff lost track of the resident during a medication pass, and the resident was later found outside the facility after falling from her wheelchair and sustaining a head laceration requiring stitches, as well as abrasions to her elbow and knee. The front door alarm had sounded for several minutes before staff responded, and the resident was not wearing a monitoring bracelet at the time of the event. Interviews with nursing staff and review of facility policy confirmed that the resident's behaviors should have triggered a new elopement risk assessment and additional interventions, but these were not implemented until after the resident's injury. The facility's own policy required systematic monitoring and management of residents at risk for elopement, including timely assessment and individualized care planning, which was not followed in this case.
Failure to Document and Investigate Resident Grievances
Penalty
Summary
The facility failed to document and investigate grievances submitted by one of three sampled residents regarding his care concerns. The resident, who had a history of cerebral infarction, reported multiple care issues, including requests for consultations with a podiatrist and ophthalmologist, as well as x-rays for various body parts. Progress notes indicated that the resident had meetings with staff to discuss these concerns and had submitted grievance forms, keeping personal copies before handing the originals to the Social Services department. Despite the resident's efforts to file grievances, a review of the facility's Grievance Binder revealed that there were no copies of the resident's grievance forms on file. The Social Services Director confirmed that the facility's policy required completed grievance forms to be tracked, investigated, and stored in the binder for three years, but acknowledged that this process was not followed for the resident in question. The Assistant Director of Nursing also confirmed that, according to nursing progress notes, the resident had discussed grievances with the Director of Nursing and had grievance forms in hand, yet no documentation of these grievances was found in the binder. Facility policy stipulated that all grievances concerning resident care should be considered, investigated, and responded to in writing, with findings communicated to the resident both verbally and in writing. The policy also required that a written summary of the investigation be provided to the resident and maintained on file. In this case, the facility did not follow its own grievance policy, resulting in the resident's care concerns not being addressed or documented in a timely manner.
Failure to Conduct and Document Quarterly IDT Care Plan Conferences
Penalty
Summary
The facility failed to consistently conduct and document Interdisciplinary Team (IDT) care plan conferences for two residents. Both residents, one with diabetes mellitus and hypertension and the other with chronic kidney disease and prostate cancer, reported not being invited to or attending any care conferences after their initial admission meeting. Review of their electronic medical records confirmed that no quarterly IDT care plan conferences were documented since their admission. The Social Services Director and Assistant Director of Nursing both verified the absence of these required quarterly meetings and acknowledged that facility policy was not followed. Facility policy requires that the IDT, including Social Services, Physical Therapy, Director of Nursing, Dietary, Activities, the resident, and/or the resident's responsible party, participate in care plan conferences upon admission, quarterly, and annually. The lack of documentation and resident participation in these conferences was confirmed through interviews and record reviews. The Social Services Director stated that the risk of not holding these meetings is that residents' concerns may not be addressed and there may be no plan of care.
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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