Harvest Crossing Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Manteca, California.
- Location
- 469 East North Street, Manteca, California 95336
- CMS Provider Number
- 055917
- Inspections on file
- 25
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Harvest Crossing Post Acute during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including NSTEMI, DM2, Alzheimer’s disease, and dementia with behavioral disturbance, was transferred to a hospital after a fall and later moved to another hospital. The facility sent an initial Notice of Transfer to the LTC Ombudsman listing only the first hospital and did not update it when the resident was moved. When the facility decided not to readmit the resident, staff informed the hospital that a higher level of care was needed but did not complete or provide a required Notice of Discharge to the resident or representative, did not send a copy to the LTC Ombudsman, and had no physician assessment or documentation in the EHR supporting the determination that a higher level of care was required, contrary to facility policy and stated discharge procedures.
A long-term resident with multiple chronic conditions, including NSTEMI, DM2, Alzheimer’s disease, hypothyroidism, and anxiety, was transferred to a hospital after an unwitnessed fall, with documentation indicating discharge with return anticipated and a representative requesting the resident’s return. Despite available bed capacity and existing care plans that already addressed the resident’s fall risk, aggression, and wandering, the DON and marketing staff informed the hospital that the resident required a higher level of care and refused readmission, without nurse-to-nurse communication or a nursing assessment. Hospital and psychiatric records documented confusion but no current aggressive behaviors or serious mental illness, while the facility’s own policy required allowing residents to return from hospitalization if they still needed the facility’s services and remained eligible, resulting in the resident not being allowed to return home to the facility.
A resident with a history of aggressive behavior and dementia physically assaulted another resident, causing facial injuries that required stitches. Despite prior incidents and medical orders for close monitoring, staff did not consistently track or document the resident's behaviors, and behavior monitoring was not implemented until after the assault. This failure to follow care plans and provider recommendations resulted in a resident being physically abused and injured.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including the safe delivery of daily living supports and treatments for a resident.
A resident was prescribed methadone for pain management, but staff did not develop or update a comprehensive care plan to address the use of this opioid, its potential side effects, or monitoring requirements. Interviews and record reviews confirmed that the care plan should have been revised when the medication was started, in accordance with facility policy.
Three residents with complex medical conditions received pain medications without documented use of non-pharmacological interventions, as required by facility policy. The DON confirmed that pain care plans did not include alternatives such as heat therapy or repositioning before administering medications like acetaminophen, methadone, or morphine.
The facility failed to meet professional standards for diabetic care by using an expired QC solution for the glucometer on the East Unit. Two LNs confirmed the expiration, and the DON acknowledged the risk of incorrect blood sugar readings. This violated the facility's policy on blood glucose monitoring system calibration.
The facility failed to properly label, store, and dispose of medications, including expired narcotics and tuberculin PPD, leading to potential medication errors. Staff clothing was improperly stored with medical supplies, posing a cross-contamination risk. Additionally, expired blood glucose QC solutions were not discarded as per policy, highlighting lapses in medication management and infection control practices.
The facility failed to provide qualified oversight of its food and nutrition services, as the Interim Certified Dietary Manager (ICDM) was not certified and the Registered Dietician (RD) worked less than 35 hours per week. The ICDM, who was previously a cook, had only completed a ServSafe Certification and was still in school to become a Certified Dietary Manager (CDM). The regular CDM was on medical leave, and the Administrator acknowledged the lack of a qualified CDM, which is essential for ensuring the quality of nutrition services and monitoring kitchen staff.
The facility failed to maintain food safety standards, impacting 87 residents. Spoiled produce was found in the refrigerator, and staff personal items were improperly stored in the kitchen. Metal pans were stored wet, and the ice machine was not properly cleaned, posing a risk for foodborne illness. Additionally, resident freezer temperatures were not monitored due to missing thermometers.
The facility failed to implement proper infection control measures, including the absence of Enhanced Barrier Precautions signage and PPE for a resident with severe sepsis, leading to staff providing care without protection. Dirty coffee cups were placed alongside clean ones on a cart, risking cross-contamination, and a pair of pants was improperly stored in a respiratory treatment cart, violating infection control policies.
A resident with dementia and a history of fractures experienced significant pain and swelling in her left knee, but the facility failed to adequately assess and manage her pain. Despite signs of distress, the resident did not receive the prescribed Tramadol, and there was a delay in obtaining x-ray results, which revealed a fracture and dislocation. This delay potentially prolonged her suffering and led to her transfer to the hospital.
A resident with Alzheimer's and dementia was not treated with dignity during meal assistance when a CNA stood over her while feeding. The resident expressed discomfort, and the DON confirmed that staff should sit at eye level to maintain dignity, as per facility policy.
A resident with osteoarthritis, urinary retention, and stress incontinence did not have a working call light system in her room, as confirmed by staff. The facility's policies required a functional call system, but the resident was left without an alternative means of communication, such as a bell, leading to unmet needs and potential risks.
The facility failed to protect residents' privacy by improperly discarding meal tickets containing sensitive information in the garbage. A Dietary Aide was observed throwing these tickets away, and the Interim Certified Dietary Manager confirmed the practice. The Registered Dietician acknowledged the issue, noting that the tickets should have been shredded to comply with HIPAA regulations.
The facility failed to maintain a clean and safe environment for two residents, as their room vents were found full of dust and debris. The Maintenance Director confirmed the vents were dirty and in use, while the Housekeeping Supervisor admitted they were not cleaned weekly as required. Resident 340, with pleural effusion, expressed fear of inhaling particles, and staff acknowledged the potential for respiratory issues. The facility's policy emphasized a clean environment, which was not upheld.
The facility failed to complete the required PASRR evaluations for two residents. One resident's Level I PASRR did not reflect his autism diagnosis or psychotropic medication use, preventing a Level II evaluation. Another resident's Level II PASRR was not completed due to isolation precautions, despite a positive Level I screening. These oversights potentially delayed necessary specialized services for both residents.
A facility failed to notify a physician when a resident on fluid restriction exceeded the prescribed intake. The resident, with chronic health conditions, had a fluid restriction of 1 liter per day but consistently consumed more, averaging 1390 cc daily. Despite facility policies requiring notification, there was no documentation of physician contact regarding the excess intake.
A resident with multiple diagnoses, including autism and dementia, requested new dentures but was unable to tolerate dental services within the facility. Despite repeated unsuccessful attempts to take denture impressions, the facility did not refer the resident to an outside dentist for specialized care. This failure potentially delayed the resident's access to necessary dental services, impacting their dental and nutritional needs.
A facility failed to educate a resident about the Pneumococcal vaccine before administration, violating the resident's right to informed consent. The Infection Preventionist confirmed the lack of education, and the resident stated she did not understand the vaccine's risks and benefits. Interviews with the DON and DSD revealed that the facility's policy required education on vaccines, which was not followed in this case.
Two residents in the facility were found without a functioning call light system, preventing them from calling for assistance. One resident, with osteoarthritis and incontinence, and another with a leg fracture and walking difficulties, were unable to alert staff due to non-working call lights. Staff confirmed the issue, and care plans emphasized the need for a reachable call light due to their fall risks. Facility policy requires a functional call system at all times.
A resident with autism did not receive specialized care due to the facility's failure to provide staff training on autism. The resident exhibited behaviors such as yelling and crawling on the floor, which staff struggled to manage without proper training. The Speech Therapist attempted to use behavioral methods, but the lack of formal training led to reliance on medication. The Director of Staff Development was unaware of the resident's autism diagnosis and had not conducted relevant training.
The facility failed to notify the Ombudsman on the same day a resident was served with a 30-Day Notice of Transfer or Discharge, did not include the transfer location on the notice, and provided incorrect appeal rights information. These actions were not in accordance with the facility's policy and procedure for transfer or discharge documentation.
Failure to Issue Required Discharge Notice and Notify Ombudsman After Non-Readmission
Penalty
Summary
The deficiency involves the facility’s failure to complete a required Notice of Discharge (NOD) and obtain documented physician justification when it did not readmit a resident following hospitalization. The resident had been re-admitted earlier with multiple diagnoses, including non-ST elevation myocardial infarction, type 2 diabetes mellitus, cervicalgia, Alzheimer’s disease, hypothyroidism, hypertension, depression, unspecified head injury, dementia with behavioral disturbance, and anxiety disorder. On 2/18/26, the facility’s Director of Marketing informed the hospital via referral communication that the resident required a higher level of care and that the facility could not meet the resident’s needs, effectively initiating a facility-initiated discharge. Interviews and record review showed that the facility did not follow its own discharge process and regulatory requirements. The Nurse Case Manager stated that she was responsible for discharge planning and that the process required providing a written NOD to the resident, including the discharge date, discharge location, reasons for discharge, appeal rights, and sending a copy to the LTC Ombudsman. However, the Director of Nursing acknowledged that when the facility decided not to readmit the resident on 2/18/26 due to a perceived need for a higher level of care, no NOD was completed or provided to the resident or the resident’s family, and no notice was sent to the LTC Ombudsman. The DON also stated there was no documentation in the electronic health record that a physician had assessed, evaluated, or determined that the resident required a higher level of care, despite the facility’s policy requiring physician involvement and documentation to support such discharges. Additional deficiencies were identified in the facility’s handling of transfer notifications. A Notice of Transfer dated 1/31/26 indicated the resident was transferred to Hospital 1 after a fall, and a copy was sent to the LTC Ombudsman listing Hospital 1 as the transfer location. The DON reported that the resident was later transferred from Hospital 1 to Hospital 2, but the Notice of Transfer sent to the LTC Ombudsman was not updated to reflect the new location. The LTC Ombudsman confirmed receiving only the original transfer notice listing Hospital 1 and stated she did not receive an updated notice when the resident moved to Hospital 2 or a NOD when the facility chose not to readmit the resident. Facility policies on transfer/discharge notice, discharge planning, and attending physician responsibilities required timely written notice with specific content to the resident and Ombudsman, individualized discharge planning, and physician documentation to support transfers and discharges, all of which were not followed in this case.
Failure to Honor Resident’s Right to Return After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to return to the facility following a hospital transfer, despite documentation that a return was anticipated and a bed was available. The resident was a long-term resident with no discharge plan in place and considered the facility to be their home. The resident had multiple diagnoses, including non-ST elevation myocardial infarction, type 2 diabetes mellitus, Alzheimer’s disease, hypothyroidism, difficulty in walking, muscle weakness, hypertension, and anxiety disorder. The resident’s MDS Nursing Home Discharge Item Set indicated a discharge with return anticipated, and general notes documented that the resident’s representative wanted the resident to return to the facility after being sent to the hospital for an unwitnessed fall. While the resident was hospitalized, the facility’s Director of Marketing sent a referral communication to the hospital stating that the resident required a higher level of care and that the facility could not provide the needed level of care. The DON reported that the facility had a bed capacity of 99, a census of 94, and one bed hold, confirming that a bed was available. Nonetheless, the DON stated the facility would not accept the resident back due to perceived safety concerns, including aggressiveness, wandering, and fall risk. The DON also stated that a non-clinical staff member checked on the resident’s status at the hospital and that there was no nurse-to-nurse communication or nursing assessment between the hospital and the facility regarding the resident’s condition. Record review showed that the resident’s care plans, initiated prior to the hospital transfer, already identified risks for unavoidable falls related to confusion and poor safety awareness, episodes of aggressive behaviors, and wandering behaviors. The DON acknowledged that these behaviors were present before the transfer and stated that if the facility had known about them, the resident would not have been admitted, despite the resident being a long-term resident. The SSD confirmed there was no discharge plan and that the resident was considered long term with no plans for discharge. Hospital documentation, including a physician progress note and a psychiatric follow-up visit, indicated the resident remained confused due to Alzheimer’s disease but did not exhibit physical or verbal aggression, hallucinations, homicidal or suicidal ideation, and had only low to moderate anxiety managed with buspirone and non-pharmacological interventions. A PASRR notice indicated no serious mental illness requiring specialized mental health services. The facility’s own bed-hold and returns policy stated that residents must be permitted to return following hospitalization if they still require services provided by the facility and are eligible for Medicare or Medicaid services, but the resident was not allowed to return.
Failure to Protect Resident from Physical Abuse Due to Lack of Behavior Monitoring
Penalty
Summary
A deficiency occurred when a resident with a known history of aggressive behavior and dementia struck another resident in the face with a water pitcher, resulting in significant injuries. The injured resident sustained a facial contusion, lacerations to the upper lip and right eyebrow requiring stitches, and reported pain and emotional distress. Staff interviews and medical record reviews confirmed that the aggressor had previously exhibited aggressive behaviors, including yelling and striking at staff, and that these behaviors were known to the facility. Despite documented behavioral disturbances and medical provider notes recommending close monitoring and behavior tracking, the facility failed to implement consistent behavior monitoring for the resident with aggressive tendencies. Behavior monitoring was not initiated until after the incident, even though prior altercations and medical documentation indicated the need for such interventions. The Medication Administration Record (MAR) and care plans did not reflect daily behavior monitoring or tracking as ordered by the medical provider following earlier aggressive episodes. Staff and the Director of Nursing confirmed that behavior monitoring logs were not in place as required, and that the lack of monitoring prevented timely identification and intervention for escalating behaviors. The facility's policies required providing a safe environment and monitoring for aggressive behaviors, but these were not followed, directly contributing to the incident where one resident was physically abused by another.
Failure to Ensure Safe, Clean, and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided report excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Develop Care Plan for Methadone Use
Penalty
Summary
The facility failed to develop or revise a comprehensive care plan for a resident who was prescribed methadone for pain management. Despite the resident receiving methadone for approximately 25 days, there was no care plan created to address the use of this strong pain medication, its potential side effects, or to guide staff in monitoring for medication effectiveness and adverse reactions. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Director of Nursing, confirmed that the care plan should have been updated when methadone was initiated, and that it is standard practice to update care plans when new controlled medications are started, dosages are changed, or gradual dose reductions are considered. Record reviews and staff interviews further revealed that the facility's own policies require ongoing assessment and revision of care plans as residents' conditions change, and specifically call for monitoring when opioids are used. The absence of a care plan for methadone use meant that staff did not have documented guidance to monitor for side effects such as headaches, dizziness, nausea, impaired coordination, unconsciousness, or death, nor to assess the medication's effectiveness or set goals related to its use.
Failure to Implement Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to provide effective pain management for three residents by not implementing non-pharmacological interventions as part of their pain care plans. Each resident had significant medical conditions, including muscle weakness, acute kidney failure, pressure ulcers, dependence on renal dialysis, Parkinson's disease, neoplasm of the kidney, gout, obstructive and reflux uropathy, and hydronephrosis. Despite having physician orders for pain medications such as acetaminophen, methadone, and morphine, their care plans did not include non-pharmacological pain management strategies like heat therapy, cold therapy, or repositioning. During interviews and record reviews, the DON confirmed that the pain care plans for all three residents lacked non-pharmacological interventions, and acknowledged that such interventions should have been included prior to administering pain medications. The facility's own policy indicated that non-pharmacological interventions may be appropriate alone or in conjunction with medications, but these were not documented or implemented for the residents in question.
Expired QC Solution for Glucometer in Diabetic Care
Penalty
Summary
The facility failed to provide services meeting professional standards of quality for diabetic residents due to the use of an expired quality control (QC) solution for the glucometer on the East Unit. During an observation and interview, it was confirmed by two licensed nurses that the QC solution had an open date and an expiration date, indicating it was expired. The Director of Nursing (DON) acknowledged that using an expired QC solution could lead to incorrect QC testing results, potentially causing inaccurate blood sugar readings for diabetic residents. This was a violation of the facility's policy and procedure for blood glucose monitoring system calibration, which requires that test strips and control solutions not be used past their expiration date and be discarded 90 days after opening.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of medications, which led to several deficiencies. Expired medications, including a vial of tuberculin PPD and a bottle of oral Lorazepam liquid, were found in the medication storage room refrigerators. These medications were not discarded according to the facility's policy, which requires expired narcotics to be disposed of by the Director of Nursing (DON) and a pharmacist. Additionally, two vials of tuberculin PPD were opened but not labeled with an opened date, contrary to the facility's policy that mandates labeling upon opening. Further observations revealed that staff clothing was improperly stored in a treatment cart alongside medications and resident care equipment, posing a risk of cross-contamination. A pair of pants belonging to a Respiratory Therapist was found in a cart containing respiratory inhalation medications and treatment equipment. This was acknowledged by a Licensed Nurse (LN) who removed the clothing and disinfected the cart. The facility's policy on infection control was not adhered to, as personal items should not be stored with medical supplies to prevent infection risks. The facility also failed to follow its policy regarding blood glucose quality control (QC) solutions. An expired QC solution was found in a medication cart, which should have been discarded according to the policy that requires labeling with an opened date and discarding 90 days after opening. The DON confirmed that the facility's policies for medication storage, labeling, and infection control were not followed, which could lead to medication errors and affect the well-being of residents.
Deficiency in Qualified Oversight of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure qualified staff oversight of its food and nutrition services, which is a requirement under federal and state regulations. The Interim Certified Dietary Manager (ICDM) was not certified, as she was still in the process of completing her education to become a Certified Dietary Manager (CDM). The ICDM had only completed a ServSafe Certification, which provides basic food safety training, and had no additional training or certifications. The regular CDM had been on medical leave since earlier in the year, and the ICDM was assigned all duties and tasks in the interim. Additionally, the Registered Dietician (RD) worked less than 35 hours per week, specifically two days each week for six to eight hours a day. This staffing arrangement did not meet the requirements for qualified oversight of the facility's food and nutrition services. The Administrator acknowledged the absence of a qualified CDM and stated that the role of the CDM is crucial for ensuring the quality of nutrition services and monitoring kitchen staff. The facility's job description for the Food & Nutrition Services Director required qualifications that were not met by the current staffing arrangement.
Food Safety and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, impacting the 87 residents who consumed meals prepared by the facility. During an inspection, spoiled produce, specifically bell peppers with black fuzzy spots and a mushy texture, was found in the walk-in refrigerator. The Registered Dietician (RD) confirmed that the quality of the produce was unacceptable and posed a risk for foodborne illness. Additionally, staff personal items, such as an insulated cup and eyeglass cases, were improperly stored in the kitchen, which the RD stated could lead to food contamination. Further observations revealed that several metal pans were stacked and stored while still wet, sitting in a pool of water. The RD noted that this practice could lead to mildew and increase the risk of foodborne illness. The facility's ice machine was also found to be in poor condition, with black and brown substances present, indicating improper cleaning and sanitization. The Maintenance Director acknowledged the machine was not operable, and the RD confirmed that its condition was unacceptable and posed a risk to residents. Lastly, the facility failed to monitor the temperatures of resident freezers, as thermometers were missing, and no temperature logs were maintained. The RD confirmed that the freezers should have thermometers and that temperatures should be documented daily. These deficiencies collectively put residents at risk for foodborne illnesses due to improper food storage, preparation, and equipment maintenance.
Infection Control Deficiencies in PPE Use and Cross-Contamination
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for Resident 30, who was admitted with severe sepsis, chronic obstructive pulmonary disease, and gastrostomy status. Enhanced Barrier Precautions (EBP) signage and personal protective equipment (PPE) were not placed outside Resident 30's room, and staff, including a respiratory therapist, provided care without wearing PPE. Interviews with various staff members, including the Licensed Nurse, Respiratory Therapist, Infection Preventionist, Director of Nursing, and Director of Staff Development, confirmed the absence of EBP signage and PPE, acknowledging the potential risk of infection spread due to these oversights. In the resident dining room, dirty coffee cups were observed placed alongside clean cups on a coffee cart, posing a risk of cross-contamination. Certified Nursing Assistant 3 and the Activity Assistant confirmed the inappropriate placement of dirty cups next to clean ones and the coffee urn. The Director of Nursing also acknowledged the risk of infection from cross-contamination due to this practice. Additionally, on the [NAME] Unit, a pair of jean pants was found stored in a respiratory treatment cart alongside respiratory inhalation medications and percussion treatment equipment. Licensed Nurse 5 confirmed the presence of the pants, which belonged to the Respiratory Therapist, and recognized the risk of infection from cross-contamination. The Director of Nursing confirmed that storing clothing in the respiratory treatment cart violated the facility's infection control policy.
Failure to Provide Timely Pain Management and Diagnosis
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident 6, who was experiencing significant pain and swelling in her left knee. Despite exhibiting signs of pain through facial grimacing and screaming during care, the nursing staff did not adequately assess the source of Resident 6's pain or provide effective pain management. The resident, who had a history of dementia, osteoarthritis, and multiple fractures, was not given the prescribed Tramadol for moderate to severe pain, and only received acetaminophen for mild pain, which was insufficient given her condition. The delay in obtaining an x-ray result further exacerbated the situation. Although an x-ray was ordered on the evening of 11/16/24, the results were not received until the evening of 11/17/24, nearly 20 hours later. This delay in diagnosis and treatment potentially prolonged Resident 6's pain and suffering. The x-ray eventually revealed a distal femur supracondylar fracture and a dislocated left knee joint, necessitating her transfer to the hospital for further evaluation and treatment. Interviews with staff and family members highlighted a lack of prompt and effective communication and assessment. CNA 4 reported Resident 6's pain to the nursing staff, but the response was inadequate, with some staff attributing her symptoms to other causes like constipation. The DON confirmed that the x-ray results were delayed and that the resident only received two doses of acetaminophen during this period. The physician covering the facility over the weekend expressed concern over the delay in receiving x-ray results, indicating that such a delay placed the resident at risk for further complications.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during meal assistance. On the morning of November 19, 2024, a Certified Nursing Assistant (CNA) was observed assisting a resident with breakfast while standing over her at her bedside. The resident, who had been diagnosed with Alzheimer's disease and dementia, was being fed by the CNA who held a spoon with food in one hand and a carton of milk in the other. The resident expressed her discomfort by pushing the milk carton away and shouting "No!" The CNA admitted to standing while assisting the resident and acknowledged that staff should sit at the resident's bedside during meal assistance, although she was unaware of the reason for this requirement. The Director of Nursing (DON) confirmed that the facility's procedure was not followed, as the expectation is for staff to sit beside residents at eye level when assisting with meals to maintain the residents' dignity and respect. The facility's policy on Resident Rights, revised in February 2021, emphasizes treating all residents with kindness, respect, and dignity, and guarantees certain basic rights, including a dignified existence. The failure to adhere to these procedures and policies had the potential to negatively impact the resident's psychosocial well-being.
Failure to Provide Working Call Light System for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 31, by not ensuring the availability of a working call light system in her room. Resident 31, who was admitted with diagnoses including osteoarthritis of the hip, retention of urine, and stress incontinence, was observed without a functioning call light. This was confirmed by a certified nursing assistant (CNA) and the Maintenance Director. The CNA mentioned that Resident 31 could scream for help, but this was not considered an appropriate method for residents to request assistance. The Director of Staff Development and the Director of Nursing both acknowledged the importance of a working call light system to prevent risks such as unmet needs and potential falls. The resident's care plan emphasized the need for a reachable and working call light to ensure a safe environment and prompt response to requests for assistance. The facility's policy and procedure documents also highlighted the requirement for a functional resident call system at all times, with regular maintenance and testing by the maintenance department. Despite these guidelines, the call light system in Resident 31's room was not operational, and no alternative means of communication, such as a bell, was provided, leading to a deficiency in accommodating the resident's needs.
Improper Disposal of Meal Tickets Violates Resident Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information when meal tickets containing sensitive data were improperly discarded. During an observation and interview, a Dietary Aide was seen throwing residents' meal tickets into the garbage bin in the dishwashing area. The Interim Certified Dietary Manager confirmed this practice and acknowledged that multiple residents' meal tickets were returned with meal trays to the kitchen. The meal tickets contained detailed personal and medical information, including residents' names, identification numbers, room and bed numbers, diet orders, allergies, and food preferences. The Registered Dietician was aware of the improper disposal practice and stated that it did not meet her expectations. She emphasized that the meal tickets should have been shredded to comply with HIPAA regulations, which protect sensitive patient health information. Despite several meetings with the dietary and nursing departments about the proper disposal of meal tickets, the facility reverted to discarding them in the garbage bin, violating their own Confidentiality of Information and Personal Privacy Policy.
Failure to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable living environment for two residents, as observed in the condition of the floor vents in their rooms. The vents, which provide cold and warm air, were found to be full of dust and debris. This was confirmed during an observation and interview with the Maintenance Director, who acknowledged that the vents were dirty and in use, and stated that the housekeeping staff were supposed to clean them weekly. However, the Housekeeping Supervisor revealed that the vents were only cleaned if noticed during a spot check, not on a weekly basis as required. Resident 340, who was admitted with diagnoses including pleural effusion and other heart and lung symptoms, expressed fear of inhaling particles from the dirty vents. Similarly, Resident 31, with a history of cough and contracting Covid-19, was also affected by the unclean environment. Interviews with staff, including a Licensed Nurse and the Director of Nursing, confirmed awareness of the issue and its potential to trigger allergies and respiratory problems. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting, which was not upheld in this instance.
Failure to Complete PASRR Evaluations for Residents
Penalty
Summary
The facility failed to accurately complete and ensure the completion of the Pre-Admission Screening and Resident Review (PASRR) for two residents, which is a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions. For Resident 72, the Level I PASRR did not reflect his diagnosis of autism or his use of psychotropic medications, resulting in a Level II PASRR never being completed. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the PASRR Level I screening was filled out inaccurately, impacting Resident 72's ability to qualify for a Level II evaluation and subsequent specialized services. Resident 72 was admitted with multiple diagnoses, including autistic disorder, anxiety disorder, and depression. Despite these conditions, the PASRR Level I screening incorrectly marked 'no' for autism and did not list his anxiety disorder or mood disturbance. The DON stated that had the PASRR been completed accurately, Resident 72 could have qualified for programs related to his behaviors and autism diagnosis. The failure to complete the PASRR process potentially delayed necessary services for Resident 72, who exhibited behaviors such as mood lability and crawling on the floor, which were temporarily managed with medications. For Resident 60, a positive Level I PASRR screening indicated the need for a Level II evaluation, which was not completed due to the resident being in transmission-based precautions for a medical illness. The facility's Admissions Coordinator confirmed that the PASRR Level II was not completed and that nursing staff were responsible for requesting a new PASRR screen once the resident's medical condition improved. The DON confirmed that the facility policy was not followed, resulting in a failure to complete the necessary PASRR Level II evaluation for Resident 60, who was admitted with diagnoses including bipolar disorder and major depressive disorder.
Failure to Notify Physician of Excess Fluid Intake for Resident on Restriction
Penalty
Summary
The facility failed to notify the physician when a resident on fluid restriction exceeded the prescribed fluid intake. The resident, who had chronic obstructive pulmonary disease, chronic congestive heart failure, and chronic respiratory failure, was on a fluid restriction of 1 liter per 24 hours as per the physician's order. However, the resident's fluid intake consistently exceeded this limit over a seven-day period, with daily intakes ranging from 1100 cc to 1420 cc, averaging 1390 cc per day. Despite this, there was no documentation indicating that the physician was notified of the excess fluid intake. Interviews with the facility's Infection Preventionist and the Director of Nursing confirmed that the facility's policy required licensed nurses to monitor and document fluid intake and notify the physician if the intake exceeded the restriction. The Director of Nursing acknowledged that the facility policy was not followed, as there was no record of physician notification in the resident's electronic medical record. The facility's policy and procedure documents also outlined the requirement for accurate recording and reporting of fluid intake, which was not adhered to in this case.
Failure to Provide Necessary Dental Services for a Resident
Penalty
Summary
The facility failed to assist a resident, identified as Resident 72, with obtaining necessary dental services, specifically new dentures. Despite the resident's request for new dentures during a dental exam, the facility did not facilitate a referral to an outside dental service when the resident was unable to tolerate dental services provided within the facility on multiple occasions. This inaction potentially delayed the resident from receiving the required dental care and obtaining dentures, which could have impacted their dental and nutritional needs. Resident 72 was admitted to the facility with multiple diagnoses, including autistic disorder, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and dementia. The resident had a history of weight loss and was on a pureed diet due to swallowing difficulties. The resident expressed a desire for new dentures during a dental exam, but subsequent attempts to take impressions for dentures were unsuccessful due to the resident's inability to tolerate the procedure. The facility's social services director acknowledged that it would have been appropriate to refer the resident to an outside dentist for specialized care, considering the resident's multiple diagnoses. Interviews with facility staff, including a speech therapist, social services director, nurse practitioner, and registered dietician, highlighted the challenges faced by Resident 72 due to their autism and other conditions. The resident's behavior, including refusal to eat and screaming, further complicated the situation. The facility's policy on dental services indicated that residents should be referred for dental services within three days if dentures are damaged or lost, but this was not adhered to in Resident 72's case, leading to a delay in receiving necessary dental care.
Failure to Educate Resident on Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide necessary education to a resident regarding the Pneumococcal vaccine before its administration, which violated the resident's right to make an informed choice. During an interview and record review with the Infection Preventionist (IP), it was confirmed that Resident 23's Immunization Report indicated no education was provided prior to the administration of the Pneumovax vaccine. The IP acknowledged that without education, residents would not understand the vaccines they were receiving. Resident 23 also confirmed in an interview that she did not understand the risks and benefits of the Pneumococcal vaccine. Further interviews with the Director of Nursing (DON) and the Director of Staff Development (DSD) revealed that the facility's policy required residents to be educated about the vaccines they receive, including the benefits and potential side effects. Both the DON and DSD stated that education should be provided to allow residents the opportunity to refuse a vaccine if they choose. A review of the facility's Policy and Procedure on the Pneumococcal Vaccine, revised in October 2019, supported this requirement, indicating that education should be documented in the resident's medical record.
Failure to Provide Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents, Resident 31 and Resident 45, which resulted in their inability to call for assistance when needed. Resident 31, who was admitted with diagnoses including bilateral primary osteoarthritis of the hip, retention of urine, and stress incontinence, was found without a working call light system in her room. This was confirmed by a Certified Nursing Assistant (CNA) and the Maintenance Director, who acknowledged the system had been non-functional since a specific date. Resident 31's care plans emphasized the importance of having a reachable call light due to her risk of falls and self-care performance deficits. Similarly, Resident 45, who had a diagnosis of an unspecified fracture of the left lower leg and difficulty walking, also did not have a working call light system. During an observation and interview, Resident 45 confirmed the lack of any means to contact staff for assistance, which was corroborated by the Maintenance Director and a CNA. Resident 45's care plans highlighted the necessity of a working call light to anticipate and meet her needs, given her risk for falls and the need for prompt assistance. Interviews with various staff members, including the Director of Staff Development, Director of Nursing, and the Administrator, revealed a consensus that the call light system should be functional at all times to prevent risks such as unmet needs and potential falls. The facility's policy and procedure document also stipulated that each resident should have a means to call staff directly for assistance, and the call system should remain functional at all times.
Lack of Autism Training Leads to Inadequate Care
Penalty
Summary
The facility failed to provide staff education regarding autism, which affected the quality of care for a resident diagnosed with autism. The resident, identified as Resident 72, was admitted with multiple diagnoses including autistic disorder, anxiety disorder, adult failure to thrive, cognitive communication deficit, depression, and dementia. Despite these complex needs, the facility did not ensure that staff were trained to recognize and respond to the signs of autism, leading to inadequate care and potential escalation of the resident's behaviors. Observations and interviews revealed that staff were unprepared to manage the resident's behaviors, which included mood lability, yelling, screaming, and crawling on the floor. The Speech Therapist (SLP) and other staff attempted to assist the resident, but without formal training, their efforts were limited. The SLP, who did not have a background in autism, took the initiative to research and apply behavioral methods, but noted that formal training for staff would be beneficial. The lack of training led to the use of medication to manage behaviors, which the SLP believed was unnecessary if proper behavioral interventions were applied. Interviews with various staff members, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that there was no training provided for handling residents with autism. The DSD was unaware of the resident's autism diagnosis and stated that training would have been implemented if she had known. The facility's policies required staff to participate in regular in-service education, including behavioral health training, but this was not adhered to in the case of Resident 72. The absence of appropriate training and awareness resulted in the resident not receiving the specialized care needed for his condition.
Failure to Provide Timely and Accurate Discharge Notification
Penalty
Summary
The facility failed to provide timely notification to the appropriate parties regarding a facility-initiated discharge for a resident. Specifically, the facility did not inform the Office of the State Long-Term Care Ombudsman on the same day the resident was served with a 30-Day Notice of Transfer or Discharge form. The Director of Nursing (DON) acknowledged that the policy and procedure for transfer or discharge documentation was not followed, as the Ombudsman was notified five days later. This delay prevented the Ombudsman from acting as an advocate for the resident and assisting with the appeal process in a timely manner. Additionally, the 30-Day Notice of Transfer or Discharge form given to the resident did not include the location to which the resident was being transferred. The Ombudsman highlighted the importance of this information for the resident and their responsible party to have peace of mind and to alert others of the new residence. The DON confirmed that the policy and procedure requiring detailed documentation of the transfer was not adhered to in this case. Furthermore, the appeal rights information provided on the 30-Day Notice of Transfer or Discharge form was incorrect. The Administrator admitted that the appeal information was not accurate and that he should have ensured the correct information was filled out on the form. This error was identified by the state agency, and the resident and their responsible party were not given the correct information needed to file an appeal. The DON acknowledged that the policy and procedure for transfer or discharge documentation was not followed in this regard as well.
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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