Kern Valley Healthcare District Dp Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Isabella, California.
- Location
- 6412 Laurel Ave, Lake Isabella, California 93240
- CMS Provider Number
- 555517
- Inspections on file
- 37
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Kern Valley Healthcare District Dp Snf during CMS and state inspections, most recent first.
The facility failed to follow its staffing policy when no RN was present for the required 8 consecutive hours in a 24-hour period. Review of TSNH records showed multiple days with 0 RN hours despite resident census levels of 52 to 55, and the DON and ADON confirmed the RN was not covering the floor on those dates.
Staff failed to provide hand hygiene to three residents before lunch, including two residents who stated they were not offered hand hygiene and a third resident with a BIMS score of 4 who was eating with her fingers after receiving her tray. In a separate event, housekeeping entered a resident’s room marked for EBP due to a urinary catheter and cleaned the room wearing gloves only, despite the IP stating a gown was also required.
Unlocked Medication Cart During Pass: An LVN left a med cart unlocked in the hallway during med pass, with unattended blood sugar supplies on top of the cart, including lancets, diabetic test strips, testing solutions, and a glucometer. The issue was observed twice, and another LPN confirmed the cart was left unlocked and the supplies needed to be locked on top of the cart. The facility policy stated that medications shall be locked and attended by persons with authorized access.
Housekeeping carts were observed unsecured with open buckets of clear cleaning solution, measuring containers, mop heads, and chemical containers labeled Super Sani Cloth and Sani Cloth Bleach accessible on the carts. HKs stated the buckets contained cleaning chemicals used for resident room cleaning and that the carts could be left unattended while they cleaned resident rooms. The DON stated housekeeping chemicals were to be locked and secured at all times because confused residents wandered the halls and could pick items up and be injured.
A cook with a full beard was observed cutting strawberries in the kitchen without a beard cover. The cook stated he should have been wearing one, and the CDM also stated he should have been. The facility policy required staff entering and working in the kitchen to wear hair and beard restraints.
Failure to Follow O2 Sat Order: A resident was observed without O2 and later was not using the nasal cannula despite an order to verify O2 saturation was at or above 92% twice daily and notify the RN if outside parameters. The MAR showed multiple low O2 Sat readings, including 91%, 90%, 83%, and 89%, with no documentation that the RN was notified or that O2 was administered. The ADON stated the LVNs did not follow the PO for O2 management.
No Designated Refrigerator for Food Brought in by Family or Visitors: The facility failed to follow its policy when it did not have a designated refrigerator for residents’ food brought in by family or visitors. CNAs were unsure where such food should be stored, the AA was unaware it could be stored in the activities refrigerator, and the DON confirmed the facility did not have a designated refrigerator despite the policy stating perishable outside food may be stored in designated unit refrigerators.
Lack of Smoking Policy and Unsafe Resident Smoking Practices: A resident who was allowed to smoke was observed using a lighter without staff present, with her procedure mask pulled down around her chin, and using a cup on her wheelchair to extinguish cigarettes instead of facility ashtrays. Staff stated the resident sometimes kept the lighter and that the facility had no policy outlining smoking expectations for residents allowed to smoke; the DON said the resident was expected to smoke in the designated area, use facility ashtrays, and return the lighter to the charge nurse.
A cognitively intact resident with a history of pneumonia had physician orders for a NAS pureed diet with nectar‑thick liquids following a video swallow evaluation that recommended minced & moist texture and thin liquids by cup in a chin‑tuck position or nectar‑thick liquids. The care plan noted non‑compliance with diet recommendations and directed staff to educate on risks and benefits, monitor for aspiration, and respect the resident’s right to refuse. IDT documentation showed the NP explained that non‑compliance with the ordered diet could lead to aspiration and that the resident stated she did not care if this was what killed her. Despite the resident’s clear refusal of pureed foods and thickened liquids, staff continued to enforce the ordered diet, including restricting participation in an activity to items that met texture requirements, while the resident left pureed meals untouched and reported only eating desserts. The DON stated the facility had no waivers for refusal of therapeutic diets and did not offer a minced & moist texture, even though facility policy affirmed patients’ rights to make decisions about care and to refuse treatment.
A resident with severely impaired cognition experienced a fall and was found on the bathroom floor, with documentation showing that the NP and DON were notified. Review of nursing notes and the facility’s fall TRIPS form showed no documentation that the resident’s family was notified, and the family notification section was marked “NA,” which the DON could not explain. This failure occurred despite a facility policy requiring licensed staff to promptly notify the resident’s physician and family/representative of any accident involving the resident.
A resident with moderately impaired cognition, extremity impairments, and total dependence for transfers was found sitting naked on the floor by staff, yet the Charge Nurse did not treat the event as a fall, did not perform or document timely vital signs or neuro checks, and did not immediately report the incident to a supervisor. Multiple CNAs reported that the resident could not have gotten to the floor independently, that they assisted in lifting the resident into a Geri-chair, and that the Charge Nurse did not assess the resident and told them not to say anything about the incident. A later assessment by an LVN, prompted by reports to social services, identified a new bruise on the resident’s forearm and led to completion of unwitnessed fall documentation hours after the event, while the Charge Nurse’s own late entry note, written days later, acknowledged that she chose not to report or document the incident as a fall at the time.
A resident with a documented history of a fall had a care plan intervention requiring fall mats on both sides of the bed when in bed. During observation and concurrent interview and record review, the resident was found in bed with only one fall mat in place. An LVN confirmed that the care plan called for fall mats on both sides but that only one was provided, despite a facility fall prevention policy stating that residents at risk for falls must have care plans incorporating appropriate safety interventions.
A resident was found unclothed and sitting on the floor next to the bed, confused and hallucinating, and was placed in a Geri-chair near the nurses’ station without documented vital signs, neuro checks, or a full assessment at the time of the incident. CNAs later reported seeing the charge nurse lifting the resident from the floor and being told not to say anything, and the event was not initially reported as a fall or documented on a fall form. An LVN learned of the incident hours later, completed unwitnessed fall documentation, vitals, and skin assessment, and noted a new bruise on the resident’s forearm; the first neuro checks were not started until several hours after the fall. The charge nurse acknowledged in interview that she did not complete neuro checks, vital signs, or a full assessment at the time and documented her nursing note as a late entry days later, contrary to the facility’s Neurological Evaluation policy requiring immediate assessment and scheduled neuro evaluations after witnessed or unwitnessed falls.
A resident with a history of stroke and intact cognition experienced sudden right-sided weakness and slurred speech, indicating a possible stroke. Despite reporting these symptoms and requesting help, staff only contacted the NP, who instructed them to monitor the resident and did not assess her in person, citing her DNR status. No escalation to the MD occurred, and the resident's POLST allowed for selective treatment. The resident was eventually transferred to the hospital after significant decline and was diagnosed with an intracranial hemorrhage, resulting in a marked loss of functional abilities.
The facility did not ensure that residents were seen face-to-face by an MD or NP at the required intervals, as confirmed by interviews and record reviews. Multiple residents reported not seeing their MD or NP for extended periods, and staff acknowledged ongoing complaints about missed visits. Documentation showed delays and inconsistencies in assessment records, failing to meet the facility's policy for regular physician visits and timely progress note entries.
The facility did not report an allegation of sexual abuse involving two residents to CDPH, the Ombudsman, and LLE within the required 24-hour period, and failed to complete a follow-up investigative report within five working days, as confirmed by the DON and facility records.
The facility did not provide pharmaceutical services to meet the needs of each resident and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not ensure an RN was on duty for at least eight hours each day, as required, with multiple days showing insufficient or no RN coverage according to staffing records. The Staffing Coordinator confirmed ongoing challenges in recruiting qualified RNs and reliance on registries when applications were lacking.
Surveyors found that food items in the dry storage room were not properly sealed or labeled with received by dates, including an open bag of powdered cocoa and multiple bottles of chocolate syrup and cans of tuna. Staff confirmed that these practices did not follow facility policy for food storage and labeling.
Two residents were found to have tab alarms in use without proper physician orders, informed consent, or care plan documentation. Staff confirmed the absence of required documentation and stated there was no facility policy or process for alarm use.
The facility did not document an unwitnessed fall or update the care plan for a resident with a history of falls and multiple health conditions, and failed to include blood sugar monitoring indicators in the care plan for another resident receiving insulin for diabetes. These actions did not follow facility policy for care planning and monitoring.
A resident with depression and intact cognition did not receive timely follow-up for dentures after admission, resulting in embarrassment, difficulty speaking, and withdrawal from social activities. Despite dental appointments and x-rays, staff failed to ensure consistent follow-up or documentation, and the resident remained without dentures, affecting her participation and well-being.
A resident reported distressing interactions with an Activities Supervisor, including exclusion from activities and uncomfortable comments. The facility did not investigate or resolve the grievance within the required timeframe, failing to follow its own grievance policy.
Two residents who were cognitively intact and had no upper extremity impairments were not allowed to fully participate in activities, such as rolling dice during games, due to the actions of the Activities Supervisor. This restriction limited their ability to make choices and discouraged their involvement in the activity program, contrary to facility policy.
A resident with a history of anxiety and bipolar disorder, and moderately impaired cognition, repeatedly attempted to leave the facility. Despite these attempts, the facility failed to complete an elopement risk evaluation or notify the physician, as required by policy. The resident eventually eloped, sustaining a hip fracture that required surgery. Interviews revealed staff did not follow the facility's elopement policy, leading to the resident's injury.
The facility failed to provide sufficient CNAs and RNAs to meet the needs of 20 residents, leading to long wait times for call lights and missed restorative nursing exercises. Interviews and records confirmed that staffing shortages, particularly during the night shift, resulted in inadequate care and unmet physician orders for RNA services.
The facility failed to monitor the temperatures of a refrigerator and freezer in the Day room, which contained drinks and ice cream, potentially leading to foodborne illnesses. The absence of thermometers was confirmed by the DON and AD, and a work order for temperature monitoring had not been addressed until the day of the survey.
The facility failed to update a resident's PASRR after a new diagnosis of Schizophrenia was made, resulting in the resident not receiving recommendations for specialized services. The Social Worker confirmed that a new PASRR Level 1 screening should have been completed.
The facility failed to communicate a resident's weightbearing status to the interdisciplinary team, resulting in a delay of rehabilitative and restorative care. The resident, who had a brace on her right leg, had not received therapy since breaking her leg six weeks prior. The PT discontinued services due to unknown weightbearing status, and the LVN confirmed no follow-up documentation was received from the orthopedic doctor. A letter from the clinic indicated weightbearing was allowed with specific conditions, but this was not communicated to the staff.
The facility failed to provide proper care for a Foley catheter for a resident, leading to potential risks of infection and injury. The catheter tubing was found on the floor under the wheelchair, despite the resident being treated for a urinary tract infection. Both the LVN and Infection Preventionist confirmed that the tubing should not have been on the floor, as per the facility's policy.
The facility failed to update and communicate a change in dietary orders for a resident, resulting in the resident receiving thickened liquids instead of the preferred thin liquids. The CNA, LVN, RD, and DON all acknowledged lapses in updating the physician's order and notifying the kitchen.
The facility failed to store oxygen tubing per policy for two residents. Observations revealed that the oxygen tubing was laying on the handrail of the bed instead of being placed in a plastic bag, as required by the facility's policy to avoid contamination and decrease the risk of infection.
RN Not Present for Required Daily Coverage
Penalty
Summary
The facility failed to follow its policy and procedure titled, Staffing, Sufficient and Competent Nursing, when a Registered Nurse (RN) was not present in the facility for eight working hours. During interview and record review, the facility's Total Skilled Nursing Hours for October 2025 and December 2025 showed that on 10/26/25 and 10/30/25 with a census of 52 residents, there were 0 RN hours, and on 12/29/25 and 12/30/25 with a census of 55 residents, there were 0 RN hours. The DON stated the facility did not have an RN covering the floor on those dates, and the ADON confirmed there was no RN on 10/26/25 or 10/30/25. The facility policy dated 7/28/25 stated that a registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week.
Hand Hygiene and EBP Not Followed
Penalty
Summary
Facility staff failed to provide hand hygiene to three sampled residents before meals. During observations, a CNA delivered a lunch tray to one resident, another CNA delivered and set up a lunch tray for a second resident by cutting up meat on the plate, and a third resident was observed eating pudding with her fingers after receiving her lunch tray. The two residents observed eating stated they had not been given anything to clean their hands before lunch, and the CNA caring for the third resident stated she did not provide hand hygiene and should have. RN and LVN staff stated the process was to provide hand hygiene to residents prior to meals. A review of the third resident’s BIMS dated 4/3/26 showed a score of 4. Housekeeping staff also failed to follow EBP for a resident with a urinary catheter. A sign outside the room indicated the resident was on EBP, but the housekeeper entered the room wearing only gloves and cleaned the overbed table, dresser top, drawer handles, shutters, and mopped the floor without a gown. The IP stated the resident was on EBP because of the urinary catheter and that the housekeeper needed to wear a gown in addition to gloves. The housekeeper stated the sign indicated she was to wear a gown and gloves when entering the room, but she was not sure which resident was on EBP or why, and acknowledged she did not wear a gown while cleaning the room.
Unlocked Medication Cart During Pass
Penalty
Summary
The facility failed to follow its Medication Storage policy when an LVN left a medication cart unlocked in the hallway during medication pass. During observation, unattended blood sugar supplies, including lancets, diabetic test strips, testing solutions, and a glucometer, were seen on top of the unlocked cart while the LVN was away from the cart. The same issue was observed again a short time later outside a resident's room, with the blood sugar supplies still unattended and the cart still unlocked. When interviewed, the LVN stated that he normally locks the medication cart when he walks away, and another LVN confirmed seeing him leave the cart unlocked twice and stated that the blood sugar supplies needed to be locked on top of the cart. The facility policy stated that medications shall be locked and attended by persons with authorized access.
Housekeeping carts left unsecured with accessible cleaning chemicals
Penalty
Summary
The facility failed to ensure two housekeeping carts were secured and that cleaning chemicals were not accessible by residents. During a concurrent observation and interview on 4/22/26 at 9:43 a.m. with Housekeeper (HK) 1 by Cart 1, the cart had an open bucket on the outside that was half full of clear liquid. HK 1 used a measuring container to dip liquid from the bucket and pour it into the mop handle, then returned the container to the bucket. A small bucket on top of the cart was half full of clear liquid, and a pocket on the side of the cart contained two containers labeled Super Sani Cloth and Sani Cloth Bleach. HK 1 stated the smaller bucket contained a cleaning chemical used to wipe down resident rooms. During a concurrent observation and interview on 4/22/26 at 10:03 a.m. with HK 2 by Cart 2, the cart also had an open bucket on the outside that was half full of clear liquid, with mop heads and a measuring container, and a small bucket on top of the cart contained clear liquid. A pocket on the side of the cart contained two containers labeled Super Sani Cloth and Sani Cloth Bleach. HK 2 stated the mop bucket and small bucket contained microkill 3 and that the container in the mop bucket was used to pour cleaning chemical into the mop handle. HK 2 stated the cart was not to be left unattended because confused residents could take things off the cart, but also stated she was unable to stay with the cart at all times while cleaning resident rooms. The DON stated housekeeping staff were to keep cleaning chemicals locked and secured at all times because confused residents wandered the hallways and could pick something up and be injured. The facility policy stated housekeeping personnel were to keep the cleaning cart in view at all times and that no dangerous items were to be kept on the cart.
Kitchen Staff Failed to Wear Required Beard Cover
Penalty
Summary
The facility failed to ensure that one of two cooks followed the Hair and Beard Restraint policy and procedures when Cook 2, who had a full beard, was observed cutting up strawberries in the kitchen without wearing a beard cover. During an interview, Cook 2 stated he should use a beard cover while in the kitchen. The Certified Dietary Manager stated she did not know why Cook 2 was not wearing a beard cover and stated he should have been. Review of the facility policy titled Hair and Beard Restraint dated 2020 stated that hair and beard restraints are designed and worn to effectively keep hair from contacting food, clean equipment, and utensils, and that staff entering and working in the kitchen must wear a hair and beard restraint.
Failure to Follow Oxygen Saturation Monitoring Order
Penalty
Summary
The facility failed to ensure a physician order to monitor oxygen saturation was followed for one resident. During an observation, the resident was found lying in bed without oxygen. Later, an oxygen concentrator was present in the room, but the resident was not using the nasal cannula and stated she did not need the oxygen machine in her room. The resident’s BIMS score was 9, and the order summary dated 2/24/26 directed staff to verify oxygen saturation was at or above 92% and, if outside parameters, notify the RN to titrate as indicated to achieve at least 92% twice a day. Review of the April 2026 MAR showed multiple oxygen saturation readings below the ordered parameter, including 91%, 90%, 90%, 91%, 83%, and 89%. The ADON stated there was no documentation that an RN was notified and no oxygen was administered for those low readings. During interview, the ADON stated the LVNs did not follow the physician order for oxygen management and said they should have. The facility policy titled Oxygen Delivery stated oxygen therapy shall be initiated with an appropriate physician order and that staff should check the physician order for indications, contraindications, and hazards of the ordered therapy.
No Designated Refrigerator for Food Brought in by Family or Visitors
Penalty
Summary
The facility failed to follow its policy and procedure titled "Foods Brought in by Family or Visitors" when it did not have a designated refrigerator for residents’ food brought in by family or visitors. During interviews, CNA 1 stated she believed residents could receive food from visitors or family but was not aware of the process or where to store that food. CNA 2 stated she believed residents’ food brought in from family could be kept in the activities refrigerator, but also said she did not know where residents would put their food. The Activities Assistant stated she was not aware that residents’ food could be stored in the activities refrigerator. The DON stated the facility did not have a designated refrigerator for residents’ food brought in from the outside. During record review, the policy dated 4/10/2026 stated that perishable food brought in from outside sources may be stored in designated unit refrigerators, but the DON stated the facility no longer had a designated refrigerator for food brought in for residents from the outside.
Lack of Smoking Policy and Unsafe Resident Smoking Practices
Penalty
Summary
The facility failed to develop and implement a policy and procedure for smoking for one resident who was allowed to smoke. During an observation on 4/21/26 at 11:06 a.m. in the courtyard outside the activities room, the resident used a lighter to light a cigarette while her procedure mask was pulled down around her chin, and no facility staff were present. No ashtrays were within reach, and there was a no smoking sign on the activities room door. During another observation at 11:20 a.m. the same day, the resident extinguished her cigarette on the side of a cup hanging on her wheelchair and placed the cigarette butt in the cup, then lit another cigarette while still wearing the mask pulled down around her chin, again with no staff present. On 4/23/26 at 9:25 a.m., the resident was observed lying in bed with eyes closed and not responding when greeted. Her wheelchair had a cup attached to the side containing a cigarette case, and the case contained a lighter. During a concurrent observation and interview, a CNA stated the resident was not allowed to keep the lighter and was supposed to give it back to staff after smoking. An RN stated the resident sometimes did not return the lighter and staff had to look for it, and that the resident sometimes used the cup on the wheelchair for cigarette butts instead of the facility-provided ashtrays. The RN also stated the facility had multiple confused residents who liked to wander and were at risk of injury due to access to the lighter. The DON stated there was no policy outlining expectations for residents who were allowed to smoke, and that the resident was expected to smoke in the designated smoking area, use facility-provided ashtrays, and return the lighter to the charge nurse to be locked up until needed again.
Failure to Honor Cognitively Intact Resident’s Refusal of Therapeutic Diet Consistency
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact resident could exercise the right to refuse a physician‑ordered therapeutic diet and meal consistency. The resident had an order for a NAS pureed diet with nectar/mildly thick liquids and no straws, based on a video swallow evaluation that recommended minced & moist food texture and thin liquids by cup in a chin‑tuck position or nectar‑thick liquids. The resident’s care plan for non‑compliance with diet and fluid recommendations included interventions to educate on risks and benefits, observe for signs and symptoms of aspiration, and respect the resident’s right to refuse recommendations. The MDS showed a BIMS score of 15, indicating the resident was cognitively intact. IDT notes documented that the NP discussed the risks of non‑compliance with the ordered pureed diet and thickened liquids, including that the resident’s pneumonia was likely caused by aspiration and that continued non‑compliance made aspiration very probable. The NP documented that the resident stated, “I don’t care if this is what kills me.” Despite this, the facility continued to enforce the ordered pureed/nectar‑thick diet without honoring the resident’s expressed refusal of the prescribed meal consistency. Nursing notes described that when the resident wanted to participate in a Christmas hot chocolate bar and treats, the DON confirmed with the provider that participation was allowed only if items met the ordered texture requirements; when this was explained, the resident declined and returned to her room. Observation showed an untouched lunch tray with multiple pureed items at the bedside, and the resident reported she did not eat the pureed foods, only desserts, and that she had told the NP she frequently had pneumonia but the diet was not changed. She stated she wanted food “the way I want it,” acknowledged she was “stubborn,” and said the facility must bring the food but knew she would not eat it. The DON stated the facility did not have waivers for residents who refuse therapeutic diets and did not offer a minced & moist texture, despite the VSE recommendation. The facility’s own Patient Rights and Responsibilities policy stated that patients have the right to make decisions regarding medical care, receive information needed to give informed consent or refuse treatment, and are responsible for their actions if they refuse treatment or do not follow physician instructions.
Failure to Notify Family of Resident Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member after the resident experienced a fall. The resident’s admission record listed the daughter as the first emergency contact and the son as the second emergency contact. The resident’s MDS dated 10/21/25 documented a BIMS score of 4, indicating severely impaired cognition. A nursing note dated 12/1/25 at 6:04 a.m. recorded that the resident was found on the bathroom floor and that the nurse practitioner and DON were notified. However, there was no documentation in the progress notes that the resident’s family was notified of the fall. During review of the facility’s TRIPS form for the fall dated 12/1/25, the section for family notification was marked “NA,” and the DON stated she did not know what “NA” meant in that context. The facility’s policy titled “Change in a Resident’s Condition or Status,” approved 9/2/15, requires licensed staff to promptly notify the resident, attending physician, and family/representative of changes in the resident’s condition or status, including when the resident is involved in any accident. Despite this policy, there was no evidence that the resident’s family or representative was notified following the fall incident, resulting in the cited deficiency.
Failure to Report and Assess Unwitnessed Fall Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect when a Charge Nurse intentionally did not report, document, or properly assess an unwitnessed fall. The resident had moderately impaired cognition with a BIMS score of 11 and was documented as having upper and lower extremity impairments, requiring total assistance for bed-to-chair transfers. On the day of the incident, a behavior note documented that the Charge Nurse found the resident attempting to get out of bed, talking about playing a game with her boys and getting a dog, and then later documented that the resident was found sitting naked on the floor, confused, hallucinating, and talking about playing a game with her boys and eating toes. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation, but the contemporaneous documentation did not show that a fall assessment, vital signs, or neuro checks were completed at that time. A later nursing note by another LVN, entered that evening as a late entry, indicated that CNAs had informed her that the resident had been found on the floor naked and hallucinating earlier in the day, and that she then notified the DON, the physician, and the resident’s son, completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. Neuro/vital sign flow sheets showed that the first neuro checks were not initiated until the early evening, several hours after the initial fall event. Another late entry nursing note, authored by the Charge Nurse days later, stated that the Charge Nurse had found the resident calmly sitting on the floor next to the bed, unclothed and playing a game with her boys, that the resident denied falling twice, was assessed with no injury noted, denied pain or discomfort, and was lifted into a Geri-chair and placed by the nursing station. This late entry note also stated that the Charge Nurse did not report the event as a fall to a supervisor and did not complete a fall form at the time because she did not believe the resident had actually fallen. Multiple CNAs reported that they observed the resident on the floor and assisted in moving the resident without seeing the Charge Nurse perform an assessment or ask the resident questions. One CNA stated that the Charge Nurse instructed them to help lift the resident into the Geri-chair and did not assess the resident before or after moving her, and that the resident was totally dependent for care and could not have gotten to the floor and sat there on her own. This CNA reported that the Charge Nurse told the CNAs not to say anything, and she felt this was neglect. Another CNA stated that the Charge Nurse said this was the second time the resident had been found on the ground, did not perform an assessment or take vital signs, and told the CNAs not to say a word about the incident; this CNA had given the resident a shower earlier and noted no skin issues at that time. A third CNA, who initially found the resident on the floor without a gown, reported the fall to the Charge Nurse, helped dress the resident and transfer her to the Geri-chair, and also stated that the Charge Nurse did not ask questions or take vital signs and told the CNAs not to say anything about the fall. The Charge Nurse later acknowledged that she did not complete vital signs or neuro checks at the time of the incident, did not document the late entry note until a couple of days later, and stated that she told the CNAs she was not reporting it as a fall. The facility’s abuse prevention policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and the resident’s care plan later identified a focus on potential for neglect related to unwitnessed falls, including interventions that all necessary documents would be completed and staff would report any unwitnessed falls.
Failure to Implement Ordered Fall Mat Interventions per Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of an actual fall. The resident’s comprehensive care plan, initiated on 12/13/25 with a focus on a prior fall, specified the intervention of placing fall mats on both sides of the bed when the resident was in bed. During an observation and concurrent interview and record review on 12/17/25 at 1:52 p.m., the resident was observed in bed with only one fall mat at the bedside. The LVN present confirmed that the care plan required fall mats on both sides of the bed but acknowledged that only one mat was in place. Review of the facility’s Fall Prevention policy, approved 11/4/09, indicated that all residents are considered at risk for falls and that the care plan should incorporate goals and interventions to provide an optimal safe environment, but the specific fall mat intervention in this resident’s care plan was not fully implemented. This failure to follow the resident’s individualized fall prevention care plan constituted the deficiency identified by the surveyors.
Failure to Perform Timely Neuro Checks and Assessment After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its Neurological Evaluation policy after an unwitnessed fall for one resident. A behavior note documented that on 12/2/25 at 3:11 p.m., the charge nurse found the resident sitting naked on the floor next to the bed, described as playing a game with "my boys," very confused, hallucinating people and objects, and making unusual statements. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation. The behavior note did not document that a neurological assessment, vital signs, or a full assessment were completed at that time. A later nursing note, entered at 7:08 p.m. as a late entry, stated that CNAs had informed an LVN that the resident had been found on the floor earlier in the day, naked and hallucinating, and that the resident was dressed and assisted into a Geri-chair. The LVN documented that she then completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. The Neuro/Vital Sign Flow Sheet showed that the first set of neuro checks was not completed until 6:30 p.m., approximately 3 hours and 15 minutes after the initial unwitnessed fall. In an interview, the LVN stated she was informed of the fall around 5:30 p.m. and that she was instructed to treat the fall as if it had just occurred. Additional documentation and interviews showed that the charge nurse did not initially report the incident as a fall, did not notify a supervisor, and did not complete a fall form at the time of the event because she did not believe the resident had actually fallen, based on the resident twice denying a fall. CNAs reported seeing the charge nurse picking the resident up from the floor and helping to put the resident back in bed, and reported that the charge nurse told them not to say anything and that it was the second time it had happened. The charge nurse confirmed in interview that she did not complete vital signs, neurological checks, or a full assessment at the time of the incident, and that her late-entry nursing note describing the fall was written a couple of days after the event. These actions and omissions did not comply with the facility’s Neurological Evaluation policy, which required immediate safety assessment, full assessment, vital signs, timely neuro checks, and documentation after any witnessed or unwitnessed fall where a head bump was suspected or the fall was unwitnessed.
Failure to Respond to Resident's Acute Change in Condition Due to Misinterpretation of DNR Status
Penalty
Summary
The facility failed to assess, recognize, escalate, and properly respond to a significant change in condition for a resident who experienced symptoms consistent with a stroke. The resident, who had a history of stroke and was cognitively intact, reported new onset slurred speech and right-sided weakness to staff, explicitly stating she believed she was having a stroke. Despite these acute symptoms and her direct communication, staff only contacted the Nurse Practitioner (NP), who instructed them to place the resident back in bed and monitor her, citing her DNR status as a reason for not pursuing further intervention. The NP did not assess the resident in person, and no further escalation to the Medical Doctor (MD) occurred, even though the resident was not in need of resuscitation but required a higher level of care. Staff interviews revealed that both the LVN and CNA observed clear signs of neurological decline, including facial droop, drooling, and loss of mobility, which were significant changes from the resident's baseline. The CNA noted that the resident, previously able to move independently, now required assistance from three staff members to return to bed. Documentation in the resident's records confirmed these changes, and progress notes indicated low oxygen saturation and elevated blood pressure. Despite these findings, the only action taken was to monitor the resident, and the NP did not visit or reassess the resident during the night. The MD later stated he was not contacted and would have reviewed the resident's POLST and wishes had he been notified. The resident's POLST indicated she did not want resuscitation but did want selective treatment for medical conditions, including IV antibiotics, fluids, and non-invasive airway support. Facility policy required prompt notification of the physician and family for significant changes in condition, but this did not occur. The resident was eventually transferred to the hospital after further decline, where she was diagnosed with a left thalamic intracranial hemorrhage and experienced a marked decline in functional abilities. The failure to escalate care and provide timely intervention resulted in a delay in treatment for a critical medical emergency.
Failure to Ensure Timely Physician and NP Assessments
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a Medical Doctor (MD) or Nurse Practitioner (NP) at all required intervals, as outlined in the facility's policy and procedure. Record reviews and resident interviews revealed that seven residents had not consistently received timely assessments by an MD or NP. Several residents reported not having seen their MD or NP for extended periods, ranging from several months to over a year. Documentation in progress notes showed that while NPs had entered assessments, there were significant delays between the actual assessment dates and the dates the notes were electronically signed, and residents' recollections did not align with the documented visits. Interviews with staff, including the Assistant Director of Nursing (ADON) and a Licensed Vocational Nurse (LVN), confirmed that there had been ongoing complaints from both residents and staff regarding the lack of regular visits by the MD or NP. Some residents stated they had never met their MD or NP, while others recalled only sporadic visits since their admission. The Director of Nursing (DON) stated she was not aware of these concerns but expected residents to be seen for their assessments as required. A review of the facility's policy indicated that residents should be visited by their physician at least every 30 days, with each visit documented in a progress note. The failure to adhere to this policy resulted in incomplete and potentially outdated medical records, as events were not always recorded in chronological order or within the required timeframes. This deficiency was identified for all seven residents reviewed, indicating a systemic issue with compliance to required physician and NP visits and documentation.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Program - Reporting policy for two residents when an allegation of sexual abuse was not reported to the California Department of Public Health (CDPH), the Ombudsman, and local law enforcement (LLE) within 24 hours as required. Documentation showed that the initial report (SOC-341) was submitted to CDPH two days after the incident, and there was no evidence that the report was sent to the Ombudsman or LLE. The Director of Nursing (DON) confirmed the lack of timely reporting and missing documentation for the required agencies. Additionally, the facility did not complete and submit a follow-up investigative report (FIR) within five working days of the allegation, as mandated by facility policy. The DON acknowledged that the FIR had not been completed or sent to CDPH within the required timeframe. These actions were in direct violation of the facility's written procedures for reporting and investigating allegations of abuse.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process and indicates that the required pharmaceutical oversight and services were not in place for residents at the time of the survey. 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 Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight hours a day, seven days a week, as required. Review of the Payroll Staffing Data Report (PBJ) and the facility's Staffing Log from September to December 2024 revealed multiple days where no RN hours were recorded or the hours worked were less than the required eight hours. Specific dates were identified where either no RN was present or the RN coverage was insufficient, as documented in both the PBJ and staffing logs. During an interview and record review with the Staffing Coordinator, it was confirmed that the facility experienced ongoing difficulties in securing adequate RN staffing. The Staffing Coordinator stated that the facility was not receiving enough applications and that a requirement for previous skilled nursing facility experience further limited the applicant pool. When applications were lacking, the facility attempted to reach out to registries to fill the RN shifts, but gaps in coverage persisted.
Improper Food Storage and Labeling in Dry Storage Room
Penalty
Summary
Surveyors observed that food items in the facility's dry storage room were not stored and labeled according to professional standards and facility policy. Specifically, a bag of powdered cocoa was found open and not properly sealed, exposing it to room air. Additionally, five bottles of chocolate syrup and eleven cans of tuna did not have received by date labels. During interviews, staff confirmed that all food items should be closed, sealed, and labeled with a received by date, as required by the facility's policy and procedure for food storage, labeling, and dating. These actions and inactions resulted in a failure to maintain food in a sanitary manner.
Failure to Obtain Orders and Informed Consent for Tab Alarms
Penalty
Summary
The facility failed to ensure that tab alarm orders and informed consents were obtained for two residents. For one resident, a tab alarm was observed attached to the resident's wheelchair and T-shirt, but there was no physician order for the alarm, and the informed consent form was unsigned by the resident's representative. The resident's care plan referenced the use of a bed alarm and tab alarm, but the Minimum Data Set (MDS) did not indicate the use of a chair alarm. The Assistant Director of Nursing (ADON) confirmed the absence of both the required order and signed consent. For another resident, a tab alarm was also observed in use while the resident was in a wheelchair. The MDS indicated daily use of a chair alarm, and the medical orders included a tab alarm while in the chair. However, there was no informed consent for the tab alarm in the medical record, and no care plan had been initiated for its use. The ADON and a Licensed Vocational Nurse (LVN) confirmed the lack of consent and care plan documentation. Additionally, the ADON stated that there was no alarm policy or process in place at the facility.
Failure to Document Fall and Monitor Diabetes Management in Two Residents
Penalty
Summary
The facility failed to document and monitor changes in condition for two residents. For one resident with Alzheimer's disease, a history of falls, and multiple comorbidities including a left femur fracture and impaired mobility, an unwitnessed fall occurred. The nursing note indicated the fall, but the nurse did not initiate the fall protocol or update the care plan as required. The facility's policy states that all falls, including those prior to or during admission, must be documented in the care plan, but this was not done for this resident. For another resident with diabetes who was receiving insulin therapy, the comprehensive care plan did not include indicators for identifying or preventing hypo- or hyperglycemia, despite physician orders for insulin administration and specific blood sugar monitoring protocols. The Assistant Director of Nursing confirmed that the care plan should have included these indicators. The facility's policy requires that acute or temporary problems be incorporated into the comprehensive plan of care, but this was not followed in this case.
Failure to Provide Timely Dental Care and Denture Follow-Up
Penalty
Summary
The facility failed to ensure that a resident's dental needs were met and that appropriate follow-up was conducted regarding the provision of dentures. The resident, who was admitted with a diagnosis of depression and had intact cognitive function, reported having dentures prior to admission but did not have them upon arrival. The resident expressed that her dentures were uncomfortable and did not fit properly, and she was interested in obtaining new ones. Despite an initial dental appointment being scheduled and rescheduled due to pain, and x-rays being completed for dentures, there was a significant delay in follow-up regarding the status of the dentures. Observations and interviews revealed that the resident was without teeth, had difficulty speaking, and felt embarrassed, leading her to avoid social activities. The Activities Assistant confirmed that the resident refused to participate in group activities due to the lack of dentures, resulting in increased isolation and potential worsening of her depression. Documentation showed repeated statements from the resident about her desire to obtain dentures before rejoining activities, and staff noted her ongoing discomfort and social withdrawal. The Social Services Designee acknowledged that follow-up with the dental office was infrequent and not consistently documented in the medical record. The delay was attributed to waiting for insurance authorization, but no proactive steps, such as contacting the ombudsman as done for another resident, were taken for this resident. The facility's policy required annual and as-needed dental care, but the lack of timely follow-up and documentation resulted in the resident not receiving necessary dental services, impacting her quality of life.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
A resident submitted a Concern/Comment Form (CCF) detailing upsetting interactions with the Activities Supervisor, including being told to leave an activity if they did not want to participate, feeling unwelcome, and being prevented from fully participating in a game. The resident also reported feeling uncomfortable after the Activities Supervisor referenced buying them food in a manner that made the resident feel awkward. These concerns were formally documented on the CCF. Upon review, it was found that the facility failed to investigate or resolve the resident's grievance in accordance with its own policy and procedure. The policy required that concerns be routed to Social Services within 24 hours and that the appropriate department manager respond within 48 hours. However, ten days after the CCF was filed, the Social Worker confirmed that the grievance had not been investigated or resolved, and acknowledged that this was not acceptable and did not follow the facility's established procedures.
Failure to Promote Resident Choice and Participation in Activities
Penalty
Summary
The facility failed to promote the physical and emotional well-being of two residents by not allowing them to fully participate in activities and make their own choices. Both residents were assessed as cognitively intact with no upper extremity impairments, as indicated by their MDS assessments and BIMS scores of 15. Despite this, one resident reported that the Activities Supervisor did not allow him or other residents to roll dice during Yahtzee, treating them as if they were handicapped. This led the resident to avoid participating in activities when the Activities Supervisor was present. Another resident confirmed that some activities staff, particularly the Activities Supervisor, did not allow residents to handle dice, attributing this to staff being overly cautious. An Activity Assistant stated that she allowed residents to play games and respected their wishes, but noted that the Activities Supervisor tended to make decisions for the residents, which discouraged participation. The facility's policy on activity programs requires that activities promote physical, cognitive, and emotional well-being, encourage self-expression and choice, and reflect individual resident evaluations. The actions of the Activities Supervisor were inconsistent with these policy requirements, resulting in residents not being able to fully engage in activities or exercise their autonomy.
Failure to Implement Elopement Policy Leads to Resident Injury
Penalty
Summary
The facility failed to implement its policy and procedure on elopement and wandering for a resident who expressed and attempted to leave the facility. The resident, who was admitted with diagnoses including muscle weakness, anxiety, and bipolar disorder, had a moderately impaired cognition score. Despite multiple documented attempts to leave the facility, the resident's elopement risk evaluation was not completed, and no care plan was initiated. The staff did not notify the physician after the resident's initial elopement attempt, which was a requirement according to the facility's policy. The resident made several attempts to leave the facility, expressing a desire to go home and displaying aggressive behavior towards staff. On one occasion, the resident managed to elope and was found outside the facility, having sustained a fall that resulted in a left hip fracture. The resident required surgical intervention for the fracture. The facility's failure to reassess the resident's risk for elopement and implement appropriate interventions, such as a wander guard, contributed to the resident's successful elopement and subsequent injury. Interviews with the Director of Nursing and Assistant Director of Nursing revealed that the staff did not follow the facility's policy, which required an elopement risk assessment upon admission, quarterly, and after any elopement attempts. The policy also mandated that care plan interventions be initiated based on the results of the Wandering Risk Scale. The lack of adherence to these procedures resulted in the resident's elopement and injury, highlighting a significant deficiency in the facility's supervision and safety measures.
Insufficient Staffing and Inconsistent RNA Services
Penalty
Summary
The facility failed to provide sufficient Certified Nursing Assistants (CNA) and Restorative Nursing Assistants (RNA) to meet the needs of 20 out of 31 sampled residents. Interviews with residents and staff revealed that the facility was consistently short-staffed, particularly during the night shift. Residents reported long wait times for call lights to be answered, with one resident stating it took up to 45 minutes, and another reporting a wait time of five hours. Additionally, several residents indicated they had not received their prescribed restorative nursing exercises for several days or weeks, which are crucial for maintaining their range of motion and mobility. The staffing coordinator confirmed that on a specific night, only one CNA was available to cover a census of 43 residents, as two CNAs from the Emergency Department who were supposed to assist left after a few minutes. This left the lone CNA to handle all responsibilities, including answering call lights and changing residents. The facility's staffing schedule typically included four CNAs for the day shift and three for the night shift, but they were not always able to meet the required Direct Care Service Hours per Patient Day (DHPPD). Record reviews showed that multiple residents had physician orders for RNA services, such as range of motion exercises and ambulation, which were not provided for an entire week. Interviews with CNAs and residents confirmed that RNA services were inconsistent, with CNAs often being pulled to cover other duties due to staffing shortages. The facility's policy on Activities of Daily Living (ADLs) emphasized the importance of following daily work assignments and providing necessary care, including answering call lights promptly and performing daily range of motion exercises, which were not adhered to due to the staffing issues.
Failure to Monitor Refrigerator and Freezer Temperatures
Penalty
Summary
The facility failed to ensure that one refrigerator and one freezer in the Day room were monitored for temperature control, which had the potential for foodborne illnesses to be spread to residents. During an observation and interview, it was noted that the Day room refrigerator and freezer did not have thermometers inside, despite containing drinks and ice cream. The Director of Nursing (DON) and Activities Director (AD) confirmed the absence of thermometers. Further review with the Plant Operations Manager (POM) revealed that the temperature sensor had only been installed on the same day, and food should not have been placed in the units until the sensor was in place. Additionally, a work order dated two months prior indicated the need for temperature monitoring in the Day room fridge/freezer, which had not been addressed until the day of the survey.
Failure to Update PASRR After Change in Psychological Status
Penalty
Summary
The facility failed to ensure that a resident was referred for a Preadmission and Resident Review (PASRR) after a change in psychological status. During an interview and record review, it was found that the resident's PASRR, dated 11/26/19, indicated a diagnosis of Generalized Anxiety Disorder. However, a Psychiatric Mental Health Progress Note dated 8/22/23 indicated a new diagnosis of Schizophrenia. The Social Worker confirmed that the PASRR did not include the new diagnosis and acknowledged that a new PASRR Level 1 screening should have been completed at the time of the new diagnosis in August 2023. This oversight resulted in the resident not receiving recommendations for specialized services to best meet her needs.
Failure to Communicate Weightbearing Status Delays Resident's Care
Penalty
Summary
The facility failed to communicate the weightbearing status of a resident to the interdisciplinary team, resulting in a delay of rehabilitative and restorative care. The resident, who had a brace on her right leg after breaking it six weeks prior, expressed a desire for therapy but had not received any. The Physical Therapist discontinued the resident's Restorative Nursing Assistant services because the weightbearing status was unknown. The Licensed Vocational Nurse confirmed that no orders or follow-up documentation were received from the orthopedic doctor after the resident's visit. A letter from the orthopedic clinic, dated the day after the visit, indicated that weightbearing was allowed with specific conditions, but this information was not communicated to the staff. The Director of Nursing acknowledged that the weightbearing status should have been documented and communicated to all involved staff.
Failure to Maintain Foley Catheter Care
Penalty
Summary
The facility failed to provide proper care for a Foley catheter for one resident, leading to potential risks of infection and injury. During an observation, the resident's Foley catheter tubing was found on the floor under the wheelchair. The Licensed Vocational Nurse confirmed that the resident was being treated for a urinary tract infection and acknowledged that the catheter tubing should not have been on the floor due to the risk of infection or it being pulled out. The Infection Preventionist also confirmed that the catheter tubing should not have been touching the floor, especially since the resident was already at high risk for infection. The facility's policy and procedure for Indwelling Foley Catheter Care indicated that drainage bags should be kept off the floor, which was not adhered to in this case.
Failure to Update and Communicate Dietary Orders
Penalty
Summary
The facility failed to change a physician order and communicate the change in the dietary order for one resident. During an observation, it was noted that the resident's meal tray contained both thickened and non-thickened milk, contrary to the resident's preference for thin liquids. The CNA acknowledged that the resident's preference for whole milk was not honored. The LVN admitted that the physician's order for thin liquids was not updated, despite being informed of the change during a report. The PA confirmed that the order for thin liquids was made based on the resident's request during a discussion about comfort care options. The RD stated that the kitchen was not notified of the change in the dietary order, resulting in the continued provision of thickened liquids. The RD received an email about the resident's preference for whole food but noted that the nursing staff failed to submit a dietary service request to update the kitchen. The DON confirmed that the change in the resident's diet order was neither entered into the computer system nor communicated to the dietary staff, leading to the deficiency.
Failure to Properly Store Oxygen Tubing
Penalty
Summary
The facility failed to store oxygen tubing per policy for two residents, Resident 13 and Resident 31. During an observation and interview with a Certified Nursing Assistant (CNA) in Resident 13's room, it was noted that Resident 13's oxygen tubing was laying on the handrail of the bed instead of being placed in a plastic bag as required by the facility's policy. Similarly, during an observation and interview with a Registered Nurse (RN) in Resident 31's room, Resident 31's oxygen tubing was also found on the handrail of the bed. The RN confirmed that the tubing should have been placed in a plastic bag to avoid contamination. The facility's policy, dated 12/1/10, indicated that all oxygen tubing should be placed in a plastic bag to ensure clean equipment and decrease the risk of infection.
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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