Lodi Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lodi, California.
- Location
- 1334 S. Ham Lane, Lodi, California 95242
- CMS Provider Number
- 555049
- Inspections on file
- 25
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Lodi Nursing & Rehabilitation during CMS and state inspections, most recent first.
Medication Refrigerator Not Maintained Within Required Range A medication refrigerator at Nurse Station 1 used to store insulins, tuberculin tests, eye drops, and an emergency kit had heavy frost buildup and a temperature of 24 degrees Fahrenheit, below the facility’s required range. LN staff, the IP Nurse, the PC, and the DON stated that refrigerated meds must be kept between 36 and 46 degrees Fahrenheit and that staff were expected to monitor temperature and frost buildup. The DON acknowledged the facility had no log or tracking system for routine cleaning and defrosting, and the policy did not identify who was responsible for maintaining and defrosting the refrigerator.
Improper Food Storage and Covered Transport of Meal Trays: Kitchen staff stored multiple utensils, pitchers, a blender, baking sheets, and plates while wet, and a bag of uncooked pasta was kept in a clear bag without a use by date. During meal delivery, a CNA transported lunch trays on an uncovered cart, and two meal plates were not fully covered. The DM, RD, DSD, and ADM confirmed the items and trays were not stored or transported in accordance with facility food safety standards.
Multiple infection control lapses were observed, including perishable food left at a resident’s bedside for an extended period, a single-use skin ointment packet left on an overbed table after incontinent care, a CNA entering a room on contact precautions without PPE, a nurse obtaining VS for a resident on EBP with ungloved hands and equipment placed on the bed, bloody linens left in use after Foley care, and a nurse using a resident’s tissue on a fingerstick puncture site instead of approved supplies.
A resident with major depressive disorder and anxiety disorder was observed in bed with a meal tray while wearing a clothing protector during meals despite stating she did not want to wear one. CNA confirmed the protector was used routinely to keep clothing clean and said a towel or cloth napkin could be used instead, while the DSD and DON stated residents should be asked their preference and their choice honored. The facility policy also stated to avoid using bibs or clothing protectors unless requested by the resident.
Two residents did not have their call lights within reach. One resident with breast cancer, dementia, and palliative care was seated in a wheelchair and could not locate or use the call light because it was placed on the opposite side of the bed. Another resident with difficulty walking, muscle weakness, pain, and kidney cancer had a call light stuck between the bed rail and bed frame and said staff had previously had to free it. The DON stated call lights must be within residents’ reach, and facility policy required call lights to be accessible while residents were in bed.
Failure to Provide Written Bed-Hold Notice: A resident with breast cancer, lung cancer, and palliative care was transferred to the hospital and later returned to the facility, but the RP did not receive a written Bed-Hold Notice. LN and the DON stated that the bed-hold option must be offered in writing to the resident or RP before transfer, and the facility policy required written notice of the bed-hold and return policy.
Failure to care plan and communicate an ordered q2h repositioning intervention for a resident with an existing pressure injury. The resident had impaired mobility, severe cognitive impairment, and was at risk for further skin breakdown; the LPN and CNA confirmed the order was not in the care plan or Kardex used for daily care, and the resident later developed a facility-acquired right heel DTI.
Incomplete Pharmacy Delivery Receipt Documentation: Pharmacy delivery manifests were not consistently signed and dated by licensed staff when medications were received at Nurse Station 1. LN staff confirmed that deliveries occurred on all shifts and included psychotropic meds and antibiotics, but multiple manifests were missing required signatures and dates. The receiving nurse was expected to verify the delivery, confirm the residents were still in the facility, and document receipt, but unsigned and undated manifests left the facility unable to verify whether meds were received, misplaced, or not delivered.
Medication administration errors exceeded the acceptable rate when surveyors observed 6 errors in 26 opportunities, resulting in a 23.08% error rate. A nurse administered a resident’s morning medications more than 3 hours late, including several time-sensitive orders such as a diuretic, antihypertensive, seizure medication, and psychotropic medications. The nurse, another RN, the pharmacy consultant, and the DON all confirmed medications were expected to be given within the ordered time window, and the facility policy required administration within 60 minutes of the scheduled time.
Failure to Continue Ordered PT and Restorative Services: A resident admitted with a femur fracture, left hip periprosthetic fracture, weakness, and difficulty walking had PT ordered to continue 5x/week for 8 weeks, but the therapy was discontinued and the resident reported no one was assisting with exercises. The DOR confirmed the extended PT order was not followed, the resident remained in the facility, and the resident was not enrolled in RNA/restorative services.
QAPI Committee Failed to Include Required Members at Quarterly Meetings: The facility's QAPI Committee did not meet quarterly with all required members present. The ADM confirmed the previous ADM missed the Q3 meeting and the MD did not attend any of the scheduled quarterly meetings. The DON stated the MD's attendance was needed to provide medical input, review trends, and support resident safety and quality of care, and the ADM stated all required committee members were expected to attend.
A facility failed to ensure a working call light system for two residents whose care plans required the call light to be within reach and answered promptly. One resident with mobility impairment, incontinence, and respiratory issues had a call light that only illuminated briefly before turning off, and staff said it had not worked properly for quite a while; the resident also reported the backup call bell was faint and hard for staff to hear. Another resident with mobility deficit, incontinence, and a history of PE and DVT pressed the call light and it did not turn on, with no alternative device in the room, and she said she had to yell for staff assistance.
A resident was not given the required SNF ABN notification after their Medicare Part A skilled services ended and they remained in the facility as an LTC resident. Staff confirmed that the notice, which should inform the resident of changes in coverage and potential financial liability, was not provided as required by facility policy.
A resident with severe mobility impairments and high fall risk was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat, as recommended by therapy. The care plan was not updated with these critical rehabilitation instructions, and staff relied on verbal communication rather than documented interventions. This led to the resident falling from the wheelchair and sustaining a head injury.
The facility failed to maintain food safety and sanitation standards, with issues including an unclean ice machine, improper food handling without gloves, expired coffee machine water filter, damaged utensils, and unclean equipment. These deficiencies posed a risk of foodborne illness to residents.
The facility failed to ensure functional and accessible call lights for residents, affecting their ability to contact staff for assistance. Residents with various medical conditions were given ineffective alternatives like hand bells, leading to longer wait times. Observations revealed nonfunctional call lights and inadequate systems for notifying staff, with issues escalated but not resolved due to cost. Staff confirmed the importance of call lights being within reach, but this was not consistently practiced, resulting in deficiencies in resident care.
The facility failed to ensure proper food safety practices, as staff were observed handling food without gloves, posing a cross-contamination risk. Additionally, weekly thermometer calibrations were not completed as required, potentially affecting food safety. These deficiencies could expose residents to bacterial contamination and foodborne illnesses.
The facility failed to ensure pureed food was of acceptable texture and palatability for residents on a pureed diet. Observations revealed that the cook did not follow the recipe for dilled zucchini and carrots, resulting in discoloration due to overcooking. Additionally, a puree beef entree was too thin, posing a choking hazard. These issues affected six residents, potentially impacting their nutritional status.
The facility failed to provide snacks that met residents' preferences, as revealed by resident council meetings and interviews. Two residents reported not receiving preferred snacks, such as cheese and meat sandwiches, due to shortages. Staff interviews highlighted inconsistencies in snack availability, and the facility's policies on food preferences were not followed, potentially impacting residents' nutrition and health.
The facility failed to implement proper infection control measures, as a used urinal in a shared bathroom was not labeled, and shared medical devices like glucometers and blood pressure devices were not adequately cleaned between uses. Staff confirmed these lapses, which contradicted facility policies and CDC guidelines.
The facility failed to maintain the low-temperature dishwashing machine at the required 120 degrees Fahrenheit, operating instead at 90-100 degrees. The booster equipment was non-functional for a week, and staff confirmed the temperature should be higher to ensure sanitation. This failure posed a potential health risk to residents.
A resident with dysphagia and muscle weakness was not treated with dignity during meal assistance. A CNA stood over the resident while feeding him, contrary to policy requiring staff to be at eye level. The CNA also referred to residents needing meal assistance as 'feeders,' which violates the facility's dignity policy. The DON confirmed these actions were dignity issues.
A resident experienced a lack of privacy due to a non-functioning curtain in their room, which staff were unaware of. The resident, admitted with muscle weakness, expressed concerns about privacy, and interviews with a CNA and the Director of Maintenance confirmed the issue. The DON highlighted the importance of functioning curtains for resident dignity.
A resident with a history of neoplasm, anxiety, and heart failure was not provided with adequate nail care, resulting in long, thick, and discolored toenails causing discomfort. Despite being on a podiatry list, staff failed to trim the resident's nails, citing a lack of appropriate tools and misunderstanding of policy. Facility policies emphasize the importance of grooming and foot care, yet staff did not address the issue, impacting the resident's quality of life.
A resident with a history of femur fracture and mobility issues did not receive restorative nursing services after physical therapy was discontinued due to insurance limitations. Despite recommendations for a restorative nursing program to maintain the resident's functional status, these services were not provided, as confirmed by facility staff. The facility's policies indicate that such care should be provided to promote safety and independence.
A resident with an indwelling catheter was observed multiple times with their urinary collection bag positioned above bladder level, contrary to facility policy and professional standards. Staff confirmed the bag should be below the bladder to prevent infection. The resident's care plan highlighted the risk of complications, including UTIs, due to catheter use, yet the deficiency persisted.
The facility failed to ensure safe medication storage practices, as staff's personal belongings were found in a medication storage room, and loose pills were discovered on the floor and in a cabinet. The DON acknowledged these practices were unacceptable due to risks of cross-contamination and drug diversion.
A resident with dysphagia and no teeth was not provided with the recommended mechanical soft texture diet, receiving instead a regular texture meal that was difficult to chew. Despite the Registered Dietitian's recommendation, the facility failed to implement the appropriate diet, potentially impacting the resident's nutrition and leading to weight loss.
The facility failed to provide adequate hydration for two residents, as observed when one resident's water pitcher was empty and another resident had no water pitcher available, despite expressing thirst. A CNA confirmed the risk of dehydration due to the lack of water availability. Interviews with the RD and DON indicated that water should be readily available unless there are fluid restrictions, aligning with the facility's hydration policy.
Medication Refrigerator Not Maintained Within Required Temperature Range
Penalty
Summary
The facility failed to ensure safe medication storage in the medication refrigerator at Nurse Station 1. During observation, the refrigerator used to store insulins, tuberculin tests, eye drops, and the emergency kit had heavy frost buildup on the top section, and the temperature was observed at 24 degrees Fahrenheit, which was outside the facility’s required range. LN 2 acknowledged the findings and stated she was unsure who was responsible for defrosting the refrigerator. She also stated that refrigerated medications must be kept within a specific temperature range because improper temperatures could damage the medications and affect their effectiveness. LN 7 stated that nursing staff were required to check the medication refrigerator twice daily, during the morning and night shifts, to ensure the temperature remained within the acceptable range and to monitor for cleanliness and frost buildup. The Pharmacy Consultant stated that nursing staff should check refrigerator temperatures as required by facility policy, take corrective action when temperatures were outside the acceptable range, notify responsible personnel, and monitor for excessive frost buildup. The Infection Prevention Nurse stated that nursing staff were required to check the refrigerator temperature during the morning and night shifts, clean the refrigerator weekly, and visually monitor it for frost buildup that might require defrosting. The DON stated that medication refrigerator temperature should be maintained within the proper range and addressed immediately if found outside that range. The DON also stated that the refrigerator should be kept clean, routinely monitored for frost buildup, and defrosted monthly, but acknowledged that the facility had not implemented a log or tracking system for routine cleaning and defrosting. Review of the facility policy indicated that refrigerated medications should be kept between 36 and 46 degrees Fahrenheit, but the policy did not address who was responsible for maintaining and defrosting the refrigerator.
Improper Food Storage and Covered Transport of Meal Trays
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observation in the kitchen, two water pitchers were found stored wet on a shelf next to the hot water dispenser, and the Assistant Dietary Manager confirmed they should have been dried completely before storage. In the same kitchen area, multiple spoons and spatulas were stored wet in a dry utensil drawer, a blender was stored wet on the food preparation counter, two metal baking sheets were stacked wet in the dry pan storage area, and plates were stacked wet on the food preparation counter. The Assistant Dietary Manager confirmed these items were stored wet and stated they should have been dried completely before being stored. In the dry food storage area, a bag of uncooked pasta had been removed from its original package and placed in a clear plastic bag without a use by date. The Assistant Dietary Manager confirmed the pasta did not have a use by date and stated it should have been labeled once removed from its original package. The Assistant Dietary Manager also stated the food could have been expired and that food without expiration dates should not be used. During lunch delivery, a CNA was observed taking an uncovered lunch cart from the dining room and leaving it in the hallway outside a resident's room, and two lunch meal plates were not fully covered with plate covers. Another CNA was observed delivering lunch trays from the uncovered cart to residents' rooms. The Registered Dietitian, Director of Staff Development, and Administrator each stated the cart and plates should have been fully covered, and the Administrator stated the uncovered plates should have been discarded while the fully covered plates should have been served to residents.
Infection Control Failures During Resident Care and Isolation Precautions
Penalty
Summary
The facility failed to maintain infection prevention and control practices in multiple resident care situations. During observation, perishable food was found at a resident’s bedside with a date showing it had been in the room for two days, despite staff stating that perishable food left at room temperature should be discarded within two hours. The Infection Prevention Nurse and DON both stated that food left in the room beyond that time could allow bacterial growth, and the facility policy stated that perishable foods left at bedside for extended periods shall be discarded. An open, half-filled single-use skin guard ointment packet was observed on another resident’s overbed table after it had been used during incontinent care. The resident stated staff left it there after use, and a nurse confirmed it should have been discarded after use. The Infection Prevention Nurse and DON stated the packet was intended for single use and should be discarded immediately after use, and that leaving it on the overbed table created an infection control concern because it could contaminate surfaces used for eating. Additional infection control failures were observed with resident care and isolation precautions. A CNA entered a room under contact precautions for ESBL urinary infection without wearing the required PPE, despite the posted isolation sign and the resident’s orders for gloves and gown on room entry. A nurse obtained vital signs for a resident on enhanced barrier precautions while using ungloved hands and placing equipment directly on the bed linens, and the nurse acknowledged she should have worn PPE. Another nurse used the resident’s tissue to wipe and apply pressure to a fingerstick puncture site after blood glucose testing, rather than using alcohol prep pads or sterile gauze. In a separate event, a resident’s bed sheets and linens were observed with blood on them after a Foley catheter change, and staff confirmed the linens needed to be cleaned right away but had not been changed at the time of observation.
Clothing Protector Applied Against Resident’s Wishes
Penalty
Summary
The facility failed to ensure Resident 19 was treated with dignity and respect when a clothing protector was applied during mealtime against her wishes. Resident 19’s admission record showed diagnoses of major depressive disorder and anxiety disorder. During a concurrent observation and interview, Resident 19 was found in bed in a sitting position with a meal tray on the overbed table, and she stated that she did not want to wear a clothing protector. CNA 1 confirmed that Resident 19 was wearing a clothing protector during each mealtime to prevent her clothing from getting dirty and stated that if one was not available, a towel or cloth napkin would be used instead. CNA 1 acknowledged there was a potential risk that Resident 19 could feel left out or singled out when she was the only resident wearing a clothing protector during meals in her room. The DSD and DON both stated that residents should be asked their preference before a clothing protector is applied and that staff should honor a resident’s choice. The facility policy on Assistance with Meals stated residents should receive assistance in a manner that meets individual needs and should avoid the use of bibs or clothing protectors instead of napkins unless requested by the resident.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents when their call lights were not within reach. Resident 10 had diagnoses including breast cancer with palliative care, metastatic lung cancer, dementia, metabolic encephalopathy, anxiety disorder, and pain. During observation, Resident 10 was seated in a wheelchair next to the bed and stated she did not know where the call light was and could not use it if she needed help. The call light cord was observed wrapped around the opposite bed rail, and the Activity Director stated it was not within the resident’s reach because it was placed on the other side of the bed. Resident 83 had diagnoses including difficulty walking, muscle weakness, pain, and kidney cancer. During observation, Resident 83 was sitting upright in bed and tried to pull the call light out after it was stuck between the left bed rail and bed frame, but could not remove it. Resident 83 stated it had also been stuck during the previous shift and staff had to free it, and that she would ask her roommate to press the roommate’s call light to get staff assistance. A CNA confirmed the call light was not within Resident 83’s reach and stated it was a safety concern. The DON stated call lights must be within residents’ reach and answered promptly, and the facility policy stated staff should place call lights within reach and keep them accessible while residents are in bed.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that Resident 10 and her resident representative were fully informed in writing of the bed-hold process when the resident was transferred to the hospital on [DATE]. Resident 10’s admission record showed diagnoses including breast cancer, lung cancer, and palliative care, and identified a resident representative. Progress notes dated 12/1/25 indicated that Resident 10 transferred to [hospital] from a PCP appointment, and progress notes dated 12/8/25 indicated that Resident 10 returned to the facility via gurney. During a concurrent interview and record review on 3/5/26, LN 8 reviewed Resident 10’s admission record and electronic health record and stated that the resident’s RP had not received a written Bed-Hold Notice when the resident was transferred to the hospital. LN 9 stated that a bed hold must be offered to the resident or RP when a resident is transferred to the hospital and return is anticipated, and the DON stated that a written Bed-Hold Notice must be offered to the resident or RP to allow the option to hold the bed for up to seven days during hospitalization. The facility policy titled Bed-Holds and Returns stated that prior to transfers, residents or resident representatives will be informed in writing of the bed-hold and return policy.
Failure to Care Plan Ordered Repositioning for Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure that a physician-ordered intervention to prevent pressure injuries was included in the care plan and communicated to staff for one resident with an existing left buttock stage II pressure injury present on admission. The resident was admitted with multiple diagnoses including generalized muscle weakness, difficulty walking, bilateral shoulder osteoarthritis, right ankle contracture, major depressive disorder, dizziness, and severely impaired cognition, and the physician ordered turning and repositioning every 2 hours with wedges and pillows on 2/12/26. During record review and interviews, the licensed nurse stated the repositioning order needed to be in the care plan so it would trigger the Kardex used by CNAs, but the resident’s care plan did not include repositioning every 2 hours. A CNA stated the Kardex did not include the intervention and that, if it was not listed, the resident might not be repositioned every 2 hours. Additional records showed the resident was bed bound, confused, required dependent to moderate assistance with bed mobility, had a Braden score of 16 indicating pressure injury risk, and later developed a facility-acquired right heel suspected deep tissue injury that was documented as a right heel deep tissue pressure injury.
Incomplete Pharmacy Delivery Receipt Documentation
Penalty
Summary
The facility failed to ensure safe pharmaceutical services were provided with accountability for delivered medications because pharmacy delivery slips and manifests were not consistently signed and dated by licensed staff when medications were received from the delivery courier. Review of the pharmacy delivery receipt binder at Nurse Station 1 for the period from 2/3/26 to 3/3/26 showed that the consolidated delivery sheets were incomplete and did not consistently contain the required licensed nursing staff signatures and dates. The facility’s documents stated that authorized signatures only were required and that stamped signatures and dates were not acceptable. During a concurrent interview and record review on 3/3/26, LN 3 reviewed the binder and confirmed that multiple pharmacy delivery manifests dated 2/24/26, multiple manifests dated 2/25/26, and one manifest dated 3/1/26 were missing the required signatures and dates. LN 3 stated that pharmacy deliveries could occur on any shift, that the deliveries included medications such as psychotropic medications and antibiotics, and that the receiving nurse was responsible for verifying the residents listed on the manifest and signing and dating the delivery manifest. LN 3 also stated that a signed copy should be maintained in the binder and that when manifests were left unsigned and undated, the facility could not verify whether the medications were received, misplaced, or not delivered. LN 7 stated during interview on 3/4/26 that pharmacy deliveries occurred during all shifts and that the nurse at Nurse Station 1 typically received the medications, signed and dated the manifest, and printed their name to acknowledge receipt before a copy was placed in the binder. LN 7 stated that when delivery manifests were not signed and dated consistently, there was a possibility that medication could be diverted or lost. The Pharmacy Consultant stated that the receiving nurse should verify the medications listed on the manifest, confirm that the residents were still in the facility, and return medications for residents no longer in the facility at the time of delivery. The DON stated that licensed nursing staff were expected to reconcile medications with the delivery manifests and sign and date the receipts at the time of delivery, and that when this did not occur, there was a risk that received medications might not be appropriately reviewed.
Medication Administration Errors Exceeded Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices when its medication error rate exceeded 5 percent. Surveyors observed medication administration over multiple days and found 6 errors out of 26 opportunities, resulting in a facility-wide medication error rate of 23.08% in 1 of 9 residents observed during medication administration. For one resident with diagnoses including hypertension, seizure disorder, schizophrenia, anxiety disorder, and depression, a nurse prepared 12 medications during a morning medication pass but administered them more than three hours after the scheduled 8:00 a.m. time. The resident’s medication list included several time-sensitive medications ordered for 8:00 a.m., including furosemide, gabapentin, amlodipine, olanzapine, levetiracetam, and quetiapine. The nurse stated she was giving the morning medications late because she was running behind. During interviews, the nurse confirmed the medications were due at 8:00 a.m. and were given outside the acceptable window. Another nurse stated medications should be given at the prescribed time to prevent adverse reactions and maintain the resident’s condition. The pharmacy consultant stated medications were expected to be administered within the established time window, and the DON stated the five rights of medication administration included the right time and that delayed medications outside the acceptable timeframe should prompt physician notification. The facility policy stated medications are to be administered within 60 minutes of the scheduled time.
Failure to Continue Ordered PT and Restorative Services
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were continued for Resident 31 after a physician ordered skilled PT to be extended 5 times per week for 8 weeks for difficulty walking. Resident 31 was admitted with diagnoses including a left femur fracture, periprosthetic fracture around the left hip prosthesis, difficulty walking, muscle weakness, acute kidney failure, major depressive disorder, bone density and structure disorders, pain, and a history of falls. The PT evaluation described decline in overall mobility related to recent acute hospitalization, deconditioning, pain, generalized weakness, and decreased activity tolerance, and stated the resident required skilled PT to minimize falls and increase lower-extremity ROM and strength. The PT discharge summary indicated the resident was not medically safe and would need significant help at home, with discharge recommendations for home health PT and a wheelchair. However, during observation, the resident stated PT had been discontinued a couple of weeks earlier and that no one was assisting with exercises, leaving the resident sitting in a wheelchair and hoping to walk again. The DOR confirmed the physician’s order to extend PT was not followed, verified the resident did not receive PT services for the ordered 8-week extension, and stated the resident remained in the facility and could have been transitioned to the RNA program. RNA staff also confirmed the resident was not enrolled in the RNA program and was not receiving restorative nursing services.
QAPI Committee Failed to Include Required Members at Quarterly Meetings
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to meet quarterly with all required members present. During a concurrent interview and record review on 3/6/26, the Administrator confirmed that the previous Administrator did not attend the quarter 3 meeting on 11/7/25, and the Medical Director did not attend any of the scheduled quarterly meetings held on 4/10/25, 7/28/25, or 11/7/25. The report identified this as a failure of the facility's Quality Assurance Committee to include the required members and meet at least quarterly for a census of 69. During interviews, the DON stated that the Medical Director's attendance was important so he could provide medical input for resident safety and quality of care, discuss trends occurring in the facility, and help the committee develop plans for improvement. The DON also stated the Administrator played a vital role in conducting the quarterly QAPI meetings and following through to make sure the meetings occurred, and that both the Administrator and the Medical Director should have attended all regularly scheduled QAPI meetings. The Administrator similarly stated it was his expectation that all required committee members, including the Medical Director and Administrator, attend the QAPI meetings. The facility policy titled Quality Assurance and Performance Improvement (QAPI) Committee stated the committee would include the Administrator and Medical Director and would meet at minimum quarterly at an appointed time.
Call Light System Not Functioning for Two Residents
Penalty
Summary
The facility failed to ensure a functioning call light system was available for two residents, both of whom had care plans that included keeping the call light within reach and answering the light promptly. Resident 61 was admitted with diagnoses including difficulty walking, muscle weakness, and acute respiratory failure with hypoxia, and his care plan addressed altered bladder elimination due to incontinence and high risk for falls and injury. During observation, he pressed his call light and it illuminated for only about two seconds before turning off automatically. He stated the system had been functioning this way for a long time, that the call bell provided was annoying to use, and that staff could not hear it well because his room was at the end of the hall. CNA 7 stated the call light system in his room had not been functioning properly for quite a while, and the DSD and DON stated the call light system should function properly and be audible to alert staff when assistance was needed. Resident 62 was admitted with diagnoses including difficulty walking, muscle weakness, chronic pulmonary embolism, and thrombosis of the deep veins of the right lower extremity. Her care plan addressed mobility deficit and altered bladder elimination due to incontinence, with interventions to keep the call light within reach and answer promptly. During observation, she pressed the call light and it did not turn on, and no call bell or whistle was present as an alternative method of notifying staff. She stated she had to yell and scream for staff to come assist her. CNA 2 stated she became upset when the call light was not answered in a timely manner, especially when she needed to use the restroom, and the DOM stated there was a visual screening system but not an auditory alert system at each nurses' station.
Failure to Provide SNF ABN Notification After End of Medicare Coverage
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident after the end of their Medicare Part A skilled services coverage. According to interviews and record reviews, the resident's Medicare Part A coverage ended, but the resident continued to stay in the facility as a long-term care resident. The Admissions Coordinator confirmed that the SNF ABN notice, which informs residents of changes to their Medicare coverage and potential financial liability, was not issued when the skilled services ended. The Social Services Director and Director of Nursing also confirmed that there was no documentation in the resident's medical record indicating that the SNF ABN was provided. Facility policy requires that Medicare beneficiaries be informed of their potential liability for payment and that the SNF ABN (Form CMS-10055) be issued before providing items or services not covered by Medicare. Staff interviews revealed that the SNF ABN should have been given three days before the last covered day to ensure the resident was aware of their rights and had the opportunity to appeal. The failure to provide this notice was acknowledged by facility staff, and it was confirmed that the resident did not receive the required notification.
Failure to Update Care Plan and Ensure Safe Wheelchair Use Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure an accident-free environment and provide adequate supervision to prevent accidents for a resident with significant mobility impairments. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, paraplegia, and contractures, was assessed as having a high risk for falls and was totally dependent on staff for transfers and mobility. The care plan did not include updated or specific instructions from the rehabilitation department regarding the use of a recliner wheelchair and a non-slip mat (Dycem), which were necessary to safely position the resident and prevent falls. On the day of the incident, nursing staff placed the resident in a regular upright wheelchair instead of the recommended recliner wheelchair with a Dycem. The staff relied on verbal communication and did not have access to therapy notes or updated care plan interventions. The resident was left in a 90-degree upright position in the wheelchair, became agitated, and attempted to push himself forward, resulting in a fall and a minor head laceration. Interviews with staff revealed that the specific rehabilitation instructions were not documented in the care plan, and staff were unaware of the need for a recliner wheelchair and Dycem for this resident. The facility's policies required that care plans be updated as residents' conditions changed and that interventions be clearly documented to prevent accidents. However, the care plan for this resident lacked the necessary details about the type of wheelchair, positioning, and supervision required, leading to a breakdown in communication between the rehabilitation and nursing departments. This omission directly contributed to the resident being placed in an unsafe position, resulting in a fall and injury.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards and facility policy for food service, resulting in multiple deficiencies. The ice machine was not cleaned according to the manufacturer's guidelines and facility policy, with visible black and brown substances and debris found inside the machine. The Maintenance Director and Dietary Services Manager acknowledged the internal areas with debris, and the Registered Dietitian emphasized the risk of food-borne illnesses from dirty ice. The facility's policy required monthly cleaning of the ice machine, which was not followed. During a trayline observation, food handling practices were found to be unsanitary. Cooks and dietary aides were observed preparing and serving food without wearing gloves, and one cook placed a bare thumb inside a disposable dish. The Dietary Services Manager and Registered Dietitian both stated that gloves should be worn to prevent cross-contamination, aligning with the FDA Food Code that prohibits bare hand contact with ready-to-eat food. Additional deficiencies included an expired coffee machine water filter, damaged serving utensils, and unclean equipment. The coffee machine's water filter was expired by 18 months, contrary to the manufacturer's recommendation for annual replacement. Serving ladles and scoops had melted handles with grime, posing a risk of contamination. A griddle top collection tray was found with grime and food residue, and expired curry powder and discolored parsley were noted in storage. These issues collectively had the potential to cause widespread foodborne illness among the 61 residents consuming facility-prepared meals.
Deficiency in Call Light Functionality and Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of eight residents by not ensuring that their call lights were functional or within reach. Residents with various medical conditions, including ataxic gait, acute respiratory failure, epilepsy, and muscle weakness, were affected. The call lights for several residents were nonfunctional, and alternative means such as hand bells were provided, which were not effective in alerting staff promptly. This led to longer wait times for assistance, particularly for residents experiencing pain or needing to use the restroom. During observations, it was noted that call lights in multiple rooms were not working, and only one resident per room was given a hand bell to notify staff on behalf of others. This system was inadequate, especially when the resident with the hand bell had no visibility of their roommates. Staff confirmed that the call system had been down for 6-12 months, and the issue had been escalated to corporate, but repairs were denied due to costs. The facility's policies emphasized the importance of maintaining adaptive devices for residents, but these were not adhered to. Additionally, a resident's call light was found underneath the bed and out of reach, preventing them from contacting staff when needed. Staff interviews confirmed that call lights should be within reach to ensure residents can ask for help, and failure to do so increases the risk of unmet needs and falls. The facility's policy required call lights to be placed within reach before staff left the room, but this was not consistently practiced, leading to deficiencies in resident care.
Food Safety and Thermometer Calibration Deficiencies
Penalty
Summary
The facility failed to ensure that the kitchen staff adhered to proper food safety and sanitation practices, as observed during a tray line inspection. Two cooks and two dietary aides were seen handling food without wearing gloves, which is against the facility's policy and the FDA Food Code 2022. One cook was observed placing her bare thumb inside a foam container while serving meatloaf, and another was preparing dessert plates without washing her hands or wearing gloves. The dietary aides were also seen placing food trays onto carts without gloves. Interviews with the Dietary Services Manager and a Registered Dietitian confirmed that these practices posed a cross-contamination risk. Additionally, the facility did not complete weekly thermometer calibrations as required by their policy. A review of the WEEKLY THERMOMETER CALIBRATION CHART showed that calibrations were not performed weekly, with gaps of several weeks between calibrations. This was confirmed during an interview with a cook, who stated that calibrations depended on the cooks' schedules. The Dietary Services Manager acknowledged the failure to adhere to the weekly calibration schedule, which could result in food items not being at the correct temperatures. The facility's failure to follow proper food handling and thermometer calibration procedures had the potential to expose residents to bacterial contamination and foodborne illnesses. The facility's policies and the FDA Food Code emphasize the importance of wearing gloves during food preparation and maintaining accurate thermometer readings to ensure food safety. The census at the time of the survey was 61 residents, all of whom could be affected by these deficiencies.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that food served to residents on a pureed diet was of acceptable texture and palatability. During an observation, it was noted that the cook did not follow the pureed recipe as written for the preparation of dilled zucchini and carrots. The puree mixture was observed to have a dark brownish color, which was attributed to being kept in the oven for too long. The Dietary Services Manager (DSM) and Registered Dietitian (RD) confirmed that the oven's high temperature led to discoloration and potential loss of nutritional value. The facility's recipe for dilled carrots and zucchini specified simmering and steaming the vegetables until tender, which was not adhered to. Additionally, during a test tray observation, the puree of a beef entree was found to be too thin and not of the desired mashed potato consistency. The DSM confirmed that extra gravy was added, making the puree too watery, which could pose a choking hazard and aspiration risk. The facility's policy on food preparation emphasized using approved recipes and preparing foods close to serving time to preserve nutrition and prevent overcooking. These failures affected six residents on a pureed diet, potentially impacting their meal intake and nutritional status.
Failure to Meet Residents' Snack Preferences
Penalty
Summary
The facility failed to ensure that residents received snacks that met their preferences, as evidenced by observations, interviews, and record reviews. The resident council meeting minutes from April 2024 to October 2024 revealed ongoing concerns about the lack of regular snacks and nourishments. During a resident council meeting, residents expressed dissatisfaction with the availability and variety of snacks, noting that dietary preferences were not being met. This issue was further highlighted by the experiences of two unsampled residents, who reported not receiving snacks or alternative meals that aligned with their preferences. Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation, reported not receiving alternative meals and foods she liked, such as cottage cheese, oatmeal, and yogurt. Despite having an intact cognitive status, she had not communicated her food preferences to the Registered Dietitian. Similarly, Resident 63, with diagnoses including cellulitis, hyperlipidemia, hypertension, and constipation, expressed a preference for cheese and meat sandwiches and crisp rice cereal treats, but noted that the facility consistently ran out of these items. Interviews with staff members revealed inconsistencies in the availability and distribution of snacks, with some staff unaware of the residents' unmet needs. The facility's policies on food preferences and nourishment indicated that residents' food preferences should be adhered to and that suitable, nourishing alternative meals and snacks should be provided. However, interviews with the Administrator, Director of Nursing, Dietary Services Manager, and Registered Dietitian revealed a lack of awareness and communication regarding the residents' snack preferences and the facility's failure to consistently offer a variety of snacks. This deficiency had the potential to impact the residents' nutrition and health status, as the facility did not adhere to its policies and procedures regarding food preferences and nourishment.
Infection Control Lapses in Shared Equipment and Facilities
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, as observed during a survey. In one instance, a used urinal in a shared bathroom was not labeled with a resident identifier, which was confirmed by a Certified Nursing Assistant (CNA). The CNA acknowledged that the urinal should have been cleaned after use and labeled with a resident identifier to prevent cross-contamination among the three residents sharing the bathroom. The Infection Preventionist and the Director of Nursing also confirmed that the urinal should have been labeled to prevent potential cross-contamination. Additionally, the facility did not adhere to proper cleaning protocols for shared medical devices. Observations revealed that a Licensed Nurse (LN) used a glucometer and blood pressure device on multiple residents without adequately cleaning and disinfecting them between uses. The LN used a single wipe to quickly clean the glucometer's outer surface, contrary to the facility's policy and manufacturer's instructions, which require thorough cleaning and disinfection. The Director of Staff Development confirmed that the glucometer should be cleaned with a specific type of wipe and allowed to remain wet for a specified time to ensure proper disinfection. The facility's policies and procedures, as well as CDC guidelines, were not followed, leading to potential risks of infection spread among residents. The facility's policy required cleaning and disinfecting reusable items between residents, and the CDC guidelines emphasized the importance of cleaning and disinfecting glucometers between uses to prevent the spread of infectious agents. The failure to adhere to these protocols was acknowledged by the facility staff during interviews.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the kitchen equipment in a safe and operable manner, specifically the low-temperature dishwashing machine, which was not reaching the required wash temperature of 120 degrees Fahrenheit. During an observation, the dishwashing machine was found to be operating at temperatures between 90-100 degrees Fahrenheit. Dietary Aide 1 confirmed that the booster equipment, which is responsible for heating the water to the correct temperature, had been non-functional for a week. This issue was corroborated by the Maintenance Director and the Dish Machine Vendor Technician, both of whom stated that the wash temperature should be at least 120 degrees Fahrenheit. The Dietary Services Manager initially misunderstood the temperature requirements but later acknowledged the mistake, recognizing the potential health risks to residents if proper temperatures were not maintained. The Registered Dietitian also confirmed that the inadequate temperature could result in bacteria not being killed, posing a risk of illness to residents. The facility's policy and the FDA Food Code both specify the necessity of maintaining the dishwashing machine at the correct temperature to ensure sanitation and safety, which was not adhered to in this instance.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically in the case of Resident 10. Resident 10, who was admitted with diagnoses including dysphagia and muscle weakness, required supervision and assistance with eating. During an observation, CNA 1 was seen standing over Resident 10 while assisting him with his meal, which is contrary to the facility's policy that requires staff to be at eye level with residents during meal assistance. CNA 1 acknowledged that standing over a resident could make them feel uncomfortable and confirmed that she should have been sitting while assisting Resident 10. Additionally, CNA 1 referred to residents who needed assistance with meals as 'feeders,' which is against the facility's policy of addressing residents by their name of choice and not labeling them by their care needs. This was confirmed during an interview with the Director of Nursing, who stated that such terminology and actions were dignity issues. The facility's policies on assistance with meals and quality of life emphasize the importance of treating residents with dignity and respect, which was not adhered to in this instance.
Privacy Curtain Deficiency for Resident
Penalty
Summary
The facility failed to protect the privacy of a resident, identified as Resident 45, due to the absence of functioning privacy curtains in their room. Resident 45, who was admitted in the fall of 2023 with a diagnosis of muscle weakness, pointed out that the curtain in their room was unable to close completely, resulting in a lack of privacy since their admission. This issue was confirmed during an observation and interview with the resident, who expressed concerns about the lack of privacy. Further interviews with facility staff, including a CNA and the Director of Maintenance, revealed that the staff was unaware of the missing curtain. The CNA acknowledged that without the curtain, providing privacy during care would be challenging. The Director of Maintenance stated that residents could request curtain replacements, but was not aware of the issue in Resident 45's room. The Director of Nursing emphasized the expectation for complete and functioning curtains to maintain resident dignity and prevent embarrassment. The facility's policy on dignity and privacy was reviewed, indicating staff should promote and protect resident privacy during personal care and treatment procedures.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident 43, who was admitted with diagnoses including neoplasm of the bladder, anxiety, and heart failure. The resident's Minimum Data Set indicated the need for supervision or assistance with personal hygiene. Despite this, the resident's toenails were observed to be long, thick, curved, and discolored, causing discomfort and pain. The resident reported that staff had not trimmed his toenails for months, despite multiple requests and being informed that he was on a podiatry list. Interviews with facility staff, including the Social Services Director, Licensed Nurse, and Director of Nursing, confirmed the resident's toenails were not trimmed and that he was not diabetic or suffering from vascular disease, which would necessitate podiatric intervention. The facility's policies on foot care and quality of life emphasize the importance of maintaining residents' mobility and dignity through proper grooming, including nail care. However, the staff acknowledged that the resident's toenails were not trimmed due to the lack of appropriate tools and the assumption that only a podiatrist could perform the task, despite the facility's policy allowing trained staff to provide routine foot care.
Failure to Provide Restorative Services Post-Physical Therapy
Penalty
Summary
The facility failed to provide restorative services to a resident, identified as Resident 35, after the discontinuation of physical therapy. Resident 35 was admitted to the facility with diagnoses including a fracture of the lower end of the right femur, abnormalities of gait and mobility, and muscle weakness. The resident's care plan indicated a self-care deficit requiring extensive assistance with bed mobility, toileting, and personal hygiene. Despite recommendations for continued restorative nursing services following the end of physical therapy, these services were not provided. Resident 35's physical therapy was discontinued on December 21, 2023, due to insurance limitations, although the resident still required moderate assistance for mobility and self-care activities. The physical therapy discharge summary recommended a restorative nursing program to maintain the resident's current level of performance and prevent decline. However, the resident did not receive these services, as confirmed by interviews with the Restorative Nursing Assistant and the Director of Nursing. The facility's policies on restorative nursing and rehabilitation services indicate that residents should receive restorative care as needed to promote safety and independence, especially after discharge from rehabilitative care. Despite these policies, Resident 35 did not receive the recommended restorative nursing services, which could have helped maintain or improve her functional status. This oversight was acknowledged by the facility's Director of Nursing during the investigation.
Improper Positioning of Urinary Collection Bag for Resident with Catheter
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling catheter, as the urinary collection bag was repeatedly observed positioned above the resident's bladder level. This improper positioning was confirmed by multiple staff members, including CNAs and LNs, who acknowledged that the urinary collection bag should be kept below the bladder to ensure proper urine drainage and prevent infection. Despite the facility's policy and professional standards indicating the necessity of keeping the collection bag below the bladder, observations on multiple occasions showed the bag placed on the upper bed rail, above the bladder level. The resident involved had a history of obstructive uropathy and was at high risk for complications, including urinary tract infections, due to the use of a Foley catheter. The resident's care plan specifically noted the need to keep the drainage bag below the bladder level to mitigate these risks. Interviews with the Infection Preventionist and the Director of Nursing further confirmed the potential risks associated with improper catheter bag positioning, such as urinary retention and infection. Despite these guidelines and the resident's care plan, the deficiency persisted, as evidenced by repeated observations of the improper placement of the urinary collection bag.
Unsafe Medication Storage Practices Identified
Penalty
Summary
The facility failed to ensure safe medication storage practices for its residents, as observed during a survey. In one instance, staff's personal belongings, including a personal bag and an insulated water bottle, were found stored in the Station 2 medication storage room. The Licensed Nurse (LN) confirmed these items belonged to her and acknowledged that personal items should not be stored in the medication room. The Director of Nursing (DON) also confirmed that storing personal items in the medication storage room was unacceptable due to the risk of cross-contamination and drug diversion. In another instance, loose pills were found on the floor and at the bottom of the base cabinet in the Station 1 medication storage room. A total of five loose pills and one capsule were observed, and the LN confirmed their presence, stating they needed to be disposed of. The DON acknowledged that loose pills should not be on the floor or in the cabinet and should have been destroyed properly. The facility's policy on medication storage, revised in April 2007, indicates that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Provide Correct Diet Texture for Resident
Penalty
Summary
The facility failed to provide a diet in the correct texture to meet the needs of Resident 19, who was admitted with diagnoses including essential hypertension, GERD, and constipation. The resident's Nutrition Care Plan indicated impaired nutrition and hydration status related to osteoporosis and dysphagia, with a goal to maintain safe swallowing. Despite this, the active Physician Diet Order prescribed a regular consistency diet with thin liquids, which was inconsistent with the Registered Dietitian's recommendation for a dysphagia mechanical soft texture diet. Observations and interviews revealed that Resident 19, who is edentulous and rarely wears dentures, received a regular texture lunch meal that was difficult to chew. The resident expressed difficulty eating the hard noodles and vegetables and preferred soft and semi-soft foods. The Licensed Nurse confirmed that the resident was on a regular diet but preferred softer foods, and the Registered Dietitian acknowledged that the recommended diet texture was not implemented. The facility's policy required diet orders to be provided as prescribed by the physician, with any discrepancies clarified by the Food & Nutrition Services Director. However, the Registered Dietitian and Dietary Services Manager were unaware that the resident was not receiving the recommended mechanical soft texture diet. This oversight had the potential to negatively impact the resident's food intake, nutrition status, and lead to weight loss, as the resident had already lost weight over a short period.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, Resident 3 and Resident 36, as observed during a survey. On one occasion, Resident 36's water pitcher was found empty on the bedside table, and on another occasion, Resident 3 was observed without a water pitcher and expressed thirst. These observations were confirmed by a Certified Nursing Assistant (CNA), who acknowledged that the absence of water pitchers could put residents at risk for dehydration. Interviews with facility staff, including a Registered Dietitian (RD) and the Director of Nursing (DON), revealed that it was the facility's expectation for water to be readily available to residents unless there were fluid restrictions. The facility's policy on Resident Hydration and Prevention of Dehydration, revised in October 2017, indicated that nurses' aides should provide and encourage fluid intake as part of daily care. The lack of water availability for Resident 3 and Resident 36 was contrary to these expectations and policies, potentially leading to health issues such as dehydration and urinary tract infections.
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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