Loma Linda Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Loma Linda, California.
- Location
- 25383 Cole Street, Loma Linda, California 92354
- CMS Provider Number
- 055299
- Inspections on file
- 28
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Loma Linda Post Acute during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including dish drying racks with black substance build-up, cracks, and corrosion, as well as scoops with dry food residue stored among clean utensils. Additionally, expired wheat tortillas were found in the refrigerator, and facility policies regarding sanitation and food storage were not followed, as confirmed by the kitchen director.
A resident was admitted with major depressive disorder, anxiety disorder, and PTSD, but the PASARR assessment did not reflect these mental health diagnoses and incorrectly indicated no serious mental illness. The MDS nurse, responsible for reviewing PASARR accuracy, acknowledged the oversight, and the facility did not identify or correct the discrepancy as required by policy.
A resident with a history of mental health conditions was newly diagnosed with Paranoid Schizophrenia, but the facility did not notify the State Mental Health or Intellectual Disability authorities or complete a required PASARR. Staff interviews confirmed that the MDS Coordinator was responsible for these actions, but they were not carried out, and facility policy was not followed.
A resident with complex medical needs did not receive the physician-ordered frequency of physical therapy sessions, missing one session in a week without any documentation or explanation in the clinical record. Facility staff failed to follow policy requiring documentation of missed or refused treatments.
A resident with chronic kidney disease and dependent on dialysis was not consistently provided with a sack lunch to take to dialysis appointments, as required by physician orders and facility policy. Facility records and interviews confirmed multiple missed meals, and the DON acknowledged that an order for sack lunches was never obtained at admission. The resident experienced notable weight loss during this period.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Staff did not assess or document the condition of a resident's dialysis access site or general condition after the resident returned from scheduled hemodialysis treatments, despite care plan and policy requirements. The required Hemodialysis Communication Observation/Assessment forms were left incomplete on two occasions, and the DON confirmed that these assessments should have been performed and documented.
Three expired over-the-counter medications—Simethicone, Vitamin A, and Vitamin B complex—were found stored in a medication cabinet. Both the RNS and DON confirmed these medications should have been discarded per facility policy, but the expired drugs remained accessible in the medication storage room.
The facility did not post its most recent recertification survey results, leaving residents and visitors unable to access this information. A binder intended to contain survey results for multiple years was missing the latest report, and the Administrator confirmed the results were not available elsewhere in the facility, contrary to facility policy requiring survey reports to be readily accessible.
A resident with multiple medical conditions and a high fall risk assessment experienced an unwitnessed fall after being left in a room located in a busy hallway rather than near the nurse station. Despite care plan directives and facility policies requiring targeted interventions for fall prevention, the supervision and measures provided were insufficient, resulting in the resident being found on the floor and sent to the hospital for evaluation.
A facility failed to complete and transmit a discharge MDS for a resident, as required by CMS guidelines. The resident was readmitted and later discharged, but the discharge MDS was not completed within the required timeframe. Interviews with the MDS Coordinator, DON, and Administrator confirmed the oversight and highlighted the expectation for timely and accurate MDS assessments.
A resident with a complex medical history was found unresponsive with an unprescribed bottle of pills at their bedside, leading to a suspected narcotic overdose. The facility failed to report the incident to the state agency within the required 24-hour timeframe, as confirmed by the DON. The resident was later diagnosed with cardiac arrest and opioid overdose at an acute hospital.
Unsanitary Kitchen Conditions and Expired Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during inspection. Dish drying racks used for air-drying sanitized dishes were found to have significant black-colored substance build-up, scratches, cracks, and corrosion on both the interior and exterior surfaces, as well as on supporting pillars. The Director of Kitchen confirmed these unsanitary conditions and acknowledged the risk of cross-contamination, noting delays in receiving replacement racks. Additionally, three scoops with dry food residue were discovered stored among other clean scoops in a drawer designated for clean utensils. The Director of Kitchen was unable to explain how these unsanitary scoops were placed with clean ones. Further inspection revealed four bags of wheat tortillas in the walk-in refrigerator that were past their expiration date, which the Director of Kitchen confirmed should have been discarded. Review of facility policies and procedures indicated that the Food and Nutrition Services Director is responsible for ensuring sanitation and that no food should be kept beyond its expiration date. The Director of Kitchen acknowledged that these policies were not followed. Reference to the FDA Federal Food Code highlighted the requirement for non-food-contact surfaces to be free of food residue and other debris.
Failure to Accurately Update PASARR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) assessment for a resident who was admitted with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Upon review, it was found that the PASARR assessment used for admission did not include the resident's diagnoses of major depressive disorder and anxiety disorder, and incorrectly indicated that the resident did not have a serious mental illness. The resident's medical records showed ongoing treatment with buspirone for anxiety and fluoxetine for depression, and these conditions were documented in the admission and social history records. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was responsible for reviewing the completion and accuracy of PASARR assessments for all new admissions. The MDS nurse acknowledged that the PASARR assessment was inaccurate and should have been revised to reflect the resident's mental health diagnoses, but this was not done. The facility's policy required all new admissions to be screened for mental disorders per the PASARR process, but the discrepancy in the resident's assessment was not identified or corrected.
Failure to Notify State Authorities and Complete PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to notify the State Mental Health authority or the State Intellectual Disability authority when a resident was newly diagnosed with Paranoid Schizophrenia. The resident, who had a history of bipolar disorder, unspecified dementia with behavioral disturbance, and post-traumatic stress disorder, was diagnosed with Paranoid Schizophrenia and Schizophreniform Disorder on December 3, 2024. A review of the clinical record showed there was no documentation that a Preadmission Screening and Resident Review (PASARR) was completed following the new diagnosis, nor was there evidence that the California Department of Health Services or the State Mental Health Department were notified as required. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that the responsibility for making such notifications and referrals lies with the MDS Coordinator. The MDS Coordinator acknowledged the requirement to notify the appropriate state authorities and complete a new PASARR when a resident is identified with a new mental disorder diagnosis or experiences a significant change in status. However, the MDS Coordinator could not explain why these actions were not taken for this resident. Review of the facility's policy and procedure confirmed the requirement for prompt notification and PASARR completion, which was not followed in this instance.
Failure to Provide Ordered Physical Therapy and Document Missed Sessions
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including end stage renal disease, encephalopathy, respiratory failure, wounds, and legal blindness, did not receive physical therapy services as ordered by the physician. The resident was supposed to receive physical therapy four times a week for four weeks, as documented in the care plan and physician's orders. However, during the week in question, the resident only received three physical therapy sessions instead of the prescribed four. There was no documentation in the clinical record explaining the missed session or the reason for the deviation from the physician's order. Interviews and record reviews confirmed that facility staff did not document the missed physical therapy visit or provide a reason for the absence, despite facility policy requiring such documentation. The lack of adherence to the prescribed therapy schedule and the absence of required documentation were confirmed by the Regional Rehab Resource during a review of the resident's clinical record. Facility policies and best practices reviewed also indicated that all missed or refused treatments should be documented, which was not done in this case.
Failure to Provide Required Sack Lunches for Dialysis Resident
Penalty
Summary
Staff failed to provide required nutritional services to a resident dependent on dialysis, as the resident was not consistently given a sack lunch to take to dialysis appointments on multiple occasions. The resident, who had chronic kidney disease, anemia, and sepsis, reported not receiving a sack lunch on several dialysis days and sometimes missing breakfast as well. Review of the facility's records confirmed that on several documented dates, the resident was not provided a sack meal for dialysis, despite physician orders specifying a renal diet and nutritional supplements. The facility's policy required notification of dietary staff for sack lunches on dialysis days and monitoring of special diets, but this was not followed. The DON acknowledged that a physician's order for a sack lunch should have been obtained at admission but was not. The resident experienced a 5.17% weight loss over a three-month period, as documented in the clinical record, during the time when sack lunches were not consistently provided.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this failure, nor does it include information about the resident's medical history or condition at the time.
Failure to Assess and Document Dialysis Access Site Post-Treatment
Penalty
Summary
Facility staff failed to provide required assessment and monitoring for a resident who was dependent on hemodialysis. The resident, admitted with chronic kidney disease, dependence on renal dialysis, anemia in chronic kidney disease, and sepsis, had physician orders for dialysis three times weekly at an outside facility. The resident's care plan specified that staff should monitor, document, and report any signs or symptoms of infection or complications at the dialysis access site, including redness, swelling, warmth, drainage, bleeding, or hemorrhage. However, on two separate occasions following the resident's return from dialysis, there was no documented evidence that staff assessed the dialysis access site or the resident's general condition, as required by both the care plan and facility policy. Review of the Hemodialysis Communication Observation/Assessment forms for the relevant dates showed that sections for access site assessment, general condition, and pain level were left blank. The DON confirmed that staff were expected to assess and document the resident's status and access site immediately upon return from dialysis, but this was not done. Facility policy also required such assessments to be completed and documented. The lack of assessment and documentation was confirmed through record review and staff interview.
Expired Medications Found in Storage
Penalty
Summary
During an inspection of the medication storage room, three over-the-counter bottles of medication—Simethicone, Vitamin A, and Vitamin B complex—were found stored past their expiration dates. The Simethicone had expired in January 2025, the Vitamin A in June 2024, and the Vitamin B complex in September 2024. These expired medications were discovered in a medication cabinet accessible within the facility. Interviews with the Registered Nurse Supervisor (RNS) and the Director of Nurses (DON) confirmed that the expired medications should have been discarded according to the facility's policies and procedures. The facility's policies, reviewed during the survey, clearly state that expired medications must be removed from active supply and destroyed, and that discontinued, expired, or deteriorated drugs and biologicals are not to be used. Both the RNS and DON acknowledged that these policies were not followed, resulting in the continued storage of expired medications.
Failure to Post Most Recent Survey Results
Penalty
Summary
The facility failed to post the results of its most recent recertification survey, as required, resulting in residents and visitors being unable to view the survey results and assess the facility's compliance with regulations. During an observation, a binder labeled as containing survey results for 2022, 2023, and 2024 was found posted in a main hallway, but upon review, it did not contain the 2024 recertification survey results. The Administrator confirmed that the most recent survey results were supposed to be in the binder but were missing, and also stated that the survey results were not posted anywhere else in the facility. The facility's policy indicated that survey reports and plans of correction should be readily accessible to residents, family members, resident representatives, and the public, and that a copy of the most recent survey report and any plans of correction should be kept in a binder in the residents' day room.
Failure to Provide Adequate Supervision for High-Risk Fall Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents for a resident who was identified as high risk for falls. The resident, who had multiple diagnoses including pulmonary edema, abnormalities of gait and mobility, hypertension, respiratory failure, and colon cancer, was assessed as a high fall risk upon admission. The care plan indicated the resident was at risk for falls due to altered balance, unsteady gait, and confusion, and required assistance with activities of daily living. Despite these identified risks, the resident experienced an unwitnessed fall during the night, after being last repositioned by a CNA and later found on the floor calling for help. The facility's fall risk management policies required staff to identify and implement interventions based on the resident's specific risks and causes for falling. However, the resident was not placed near the nurse station and was located in a busy hallway instead. The bed was in the lowest position, and staff reminded the resident to use the call light, but the resident was not ambulatory and required assistance. The fall resulted in the resident being sent to an acute hospital for evaluation. Documentation and interviews confirmed that the interventions in place were insufficient to prevent the fall, despite the resident's high-risk status and care plan directives.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) for a resident, as required by the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The facility's policy, revised in March 2022, mandates that a comprehensive assessment of every resident's needs be conducted at intervals designated by OBRA and PPS requirements, including a discharge assessment. However, the discharge MDS for the resident, who was readmitted on September 10, 2022, and discharged on March 13, 2024, was not completed. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator revealed that the discharge MDS was overlooked. The MDS Coordinator acknowledged the oversight and stated that she had 14 days to complete and submit the discharge MDS after a resident's discharge. The DON confirmed that the discharge MDS was missed and emphasized the expectation for MDS assessments to be completed accurately and submitted timely. The Administrator also expressed the expectation for timely and accurate completion and submission of MDS assessments.
Failure to Timely Report Narcotic Overdose Incident
Penalty
Summary
The facility failed to report a possible overdose of narcotics for a resident within the required 24-hour timeframe to the state agency, as per their policy. The resident, who had a complex medical history including chronic respiratory failure, end-stage renal disease, and type 2 diabetes, was found unresponsive with shallow breathing and low oxygen levels. An unprescribed and unlabeled bottle of pills was discovered on the resident's bedside table, leading to the suspicion of a narcotic overdose. The resident was sent to an acute hospital where they were diagnosed with cardiac arrest and opioid overdose. The Director of Nursing (DON) acknowledged that the incident, which occurred on a specific date, was not reported to the California Department of Public Health (CDPH) until several days later, following a verbal report from a hospital social worker about the resident's death due to overdose. The facility's policy required unusual occurrences to be reported via telephone within 24 hours and a written report within 48 hours. The delay in reporting was confirmed by the DON, who stated that they were waiting for updates from the hospital and family before making the report.
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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