Los Banos Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Banos, California.
- Location
- 931 Idaho Ave., Los Banos, California 93635
- CMS Provider Number
- 055028
- Inspections on file
- 19
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Los Banos Post Acute during CMS and state inspections, most recent first.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day, as required, on multiple occasions. Staff interviews and record reviews confirmed that on several days, no RN was present to provide necessary services, including care for residents with IV therapy or PICC lines. The DON and Administrator acknowledged difficulties in hiring and retaining RNs, and the facility's own policy requiring daily RN coverage was not followed.
The facility did not employ enough staff with the necessary competencies and skills in the food and nutrition service, including lacking a qualified dietician.
A dietary staff member was found not competent in calibrating food thermometers according to facility policy, as observed during a kitchen inspection. The staff member incorrectly allowed the thermometer stem to touch the bottom of the cup during calibration and was unable to recall proper procedures or recent training. This failure affected the majority of residents receiving food from the kitchen, as confirmed by interviews with the Dietary Service Manager and Registered Dietician.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not ensure the required Medical Director attended three consecutive quarterly QAA committee meetings, as confirmed by sign-in sheets and administrator statements. This resulted in the Medical Director not participating in oversight activities related to resident care policies and ongoing quality improvement projects, such as those addressing falls and UTIs.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact actions or events that led to this failure.
Residents were not fully informed about their health status, care, and treatments, resulting in a lack of understanding and participation in care decisions.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements.
Two residents experienced deficiencies in care: one received tube feeding flushes from an unlabeled bag, contrary to facility policy and staff expectations, while another had a significant weight gain that was not rechecked or reported to the RD and physician as required. Staff interviews confirmed that these actions did not meet professional standards or facility protocols.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
Surveyors found that a vial of insulin and a bottle of melatonin on a medication cart were not labeled with an open date or expiration date, as required by facility policy. An LVN and the DON both confirmed that all medications should be properly dated to prevent use of expired drugs, and the Pharmaceutical Consultant verified that the policy requires visible expiration dates and dating of multi-dose vials.
Two garbage bins were observed with their lids open, contrary to facility policy requiring all waste containers to be covered to prevent access by rodents and insects. Both the Housekeeping Supervisor and Maintenance Supervisor confirmed that trash should always be covered to prevent disease transmission.
A resident with multiple chronic conditions and newly admitted to hospice care did not receive a required significant change of condition assessment. This omission resulted in the resident's change in status not being communicated to direct care staff, the RN, physician, family, or nursing leadership, contrary to facility policy and job expectations.
A resident with diabetes and moderate cognitive impairment, who required substantial assistance with daily living activities, was found with long, dirty fingernails after staff failed to provide necessary nail care. Staff interviews revealed confusion about responsibilities and a lack of documentation, resulting in the resident not receiving appropriate personal hygiene as outlined in facility policy.
A CNA at a facility used a resident's debit card without consent, resulting in unauthorized charges of $376.38. The resident, who had no cognitive impairment, initially asked the CNA for help with a food delivery order. The CNA saved the card information and made further unauthorized purchases. The facility lacked protocols and training to prevent such incidents, leading to the CNA's termination and law enforcement involvement.
A resident with no cognitive impairment left a facility without a doctor's order, which the Administrator deemed as leaving AMA. Upon return, the resident was informed of discharge and denied medications. The facility lacked a policy requiring a doctor's order for leaving, and the discharge was not documented as per regulations. The resident later signed an AMA form with an incorrect date.
A resident with a history of falls and dementia was found to be using a lap buddy as a physical restraint, contrary to facility policy. The restraint had been in place since the resident's admission, with no attempts to use a less restrictive device or ongoing monitoring. Staff interviews confirmed the restraint's continuous use, and the DON acknowledged that falls were not a valid medical symptom for its use.
The facility did not update its facility-wide assessment annually as required, with the last update recorded nearly two years ago. This lapse potentially affected all 55 residents. Interviews with the DON and NC indicated they were aware of changes in resident acuity and had been working on the assessment since 2023, but it remained incomplete. Both the DON and Administrator expected annual reviews, highlighting a failure to adhere to policy.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours each day, as required by policy and regulation. Record reviews and staff interviews confirmed that on eight specific days within a 90-day period, there was no RN present to provide services. The Staff Coordinator acknowledged that no RNs were scheduled on those days and clarified that the responsibility for RN scheduling belonged to the Director of Nursing (DON). The DON admitted that maintaining daily RN coverage was difficult and that the absence of an RN could have impacted the quality of care, particularly for residents requiring specialized services such as intravenous (IV) therapy or care for peripherally inserted central catheters (PICC lines). The DON also stated that the facility did not follow its own policy and procedure regarding RN coverage. The Administrator confirmed ongoing challenges in retaining and scheduling RNs, noting that the facility had a revolving roster of RNs and was unable to consistently staff an RN each day. Both the DON and Administrator emphasized the importance of having an RN available daily, especially for residents needing advanced nursing care such as IV therapy. Review of the facility's policy indicated a clear requirement for RN coverage for at least eight consecutive hours every 24 hours, seven days a week, which was not met on the identified dates.
Insufficient Qualified Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. This included not having a qualified dietician as required. The deficiency was identified based on the facility's staffing and qualifications in the food and nutrition department.
Failure to Ensure Competency in Thermometer Calibration in Dietary Services
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in performing thermometer calibration according to the facility's policy and procedure, affecting 55 of 58 residents who received food from the kitchen. During an observation, the dietary staff member was seen calibrating a thermometer by placing it in a cup of ice water with the stem touching the bottom of the cup, contrary to the facility's policy, which specifies that the stem should not touch the bottom or sides and must remain in the ice water for one minute. The staff member was unable to recall the last in-service training and initially stated it was acceptable for the stem to touch the bottom, later acknowledging this was incorrect and could result in inaccurate temperature readings. Interviews with the Dietary Service Manager and Registered Dietician confirmed that the staff member's method did not comply with the facility's policy and could have led to inaccurate food temperature readings. Both indicated that improper calibration could result in food being served at incorrect temperatures. The Dietary Service Manager and Registered Dietician both stated that the staff member was not competent in this procedure, and the facility's policy was not followed during the calibration process.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
QAA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the required members, specifically the Medical Director, during its quarterly meetings. Record review and interviews with the Administrator revealed that the Medical Director did not attend three consecutive quarterly QAA committee meetings. Sign-in sheets for the meetings confirmed the absence of the Medical Director or a designee, and the Administrator acknowledged that the Medical Director was not always present at these meetings. Facility documents also indicated that the Medical Director was a required member of the QAA committee, but attendance records did not reflect their participation. The Administrator stated that the QAA committee, which also functioned as the Continuous Quality Improvement (CQI) committee, met regularly to address ongoing issues such as resident falls and urinary tract infections. However, the lack of the Medical Director's attendance meant that they were not informed of or involved in oversight activities, including identifying, analyzing, and correcting problems in resident care policies and areas. The Administrator recognized the importance of the Medical Director's involvement in these meetings, as they are responsible for the physicians and the management of resident care within the facility.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Inform Residents of Health Status and Treatments
Penalty
Summary
Residents were not fully informed about their health status, care, and treatments. The facility failed to ensure that residents received adequate information and understanding regarding their medical conditions and the care or treatments being provided. This lack of communication resulted in residents not being able to participate meaningfully in decisions about their care. The deficiency was identified through observations and interviews, which revealed that residents did not have a clear understanding of their current health status or the treatments they were receiving.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Label Tube Feeding Flush Bag and Notify Clinicians of Significant Weight Gain
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. For one resident with a history of traumatic subarachnoid hemorrhage, schizophrenia, dysphagia, and cognitive impairment, the tube feeding flush bag was observed to be unlabeled with the date and time it was hung. The bag contained approximately 450 ml of fluid remaining in a 1000 ml bag. Staff interviews revealed inconsistent understanding of labeling requirements, with one LVN stating that the flush and feeding were connected as a set and did not require separate labeling, while another LVN and the DON confirmed that the flush bag should have been labeled to ensure timely changes and prevent the use of expired fluids. Facility policy and lesson plans also indicated the need for labeling and dating G-tube supplies. Another resident, admitted with severe protein-calorie malnutrition, COPD, muscle weakness, obstructive sleep apnea, and gastrostomy, experienced a 6.2-pound weight gain over five days. The weight gain was not rechecked for accuracy, and the Registered Dietician (RD) and physician were not notified as required. The Restorative Nursing Assistant (RNA) acknowledged that the weight should have been rechecked and reported, and the Assistant Director of Nursing (ADON) admitted that the physician and RD should have been notified within 24 hours. The DON and RD both confirmed that the weight gain should have prompted immediate notification and further assessment. Facility policy required staff to report significant weight changes to the physician. The failure to label the tube feeding flush bag and to notify the RD and physician of significant weight gain represent lapses in following professional standards and facility protocols. These deficiencies were identified through observation, interviews, and record reviews, and were confirmed by multiple staff members, including the DON and RD.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Label and Date Medications on Medication Cart
Penalty
Summary
Surveyors observed that one medication cart contained a vial of insulin and a bottle of melatonin that were not labeled with an open date or expiration date, contrary to the facility's Medication Labeling and Storage policy. During the observation, an LVN confirmed that all medications are required to have an open date and a visible expiration date to prevent administration of expired medications. The Director of Nursing also stated the expectation that all medications be properly dated. Review of the facility's policy with the Pharmaceutical Consultant confirmed that multi-dose vials must be dated when opened and discarded within 28 days, and that expiration dates must be visible on all medication labels. These findings indicate that the facility failed to ensure medications were labeled and stored according to policy, as required.
Improper Waste Disposal Due to Uncovered Garbage Bins
Penalty
Summary
During an observation outside the facility, two out of four garbage bins were found with their lids open. The Housekeeping Supervisor confirmed that trash bins are required to be covered at all times to prevent rodents and insects from accessing the trash and potentially entering the facility. The Maintenance Supervisor also stated that all trash, both inside and outside the facility, should be covered to prevent the spread of disease. A review of the facility's policy on garbage and rubbish disposal indicated that all waste containers must have tight-fitting lids or covers and be made inaccessible to vermin. The failure to keep the garbage bins covered was directly observed and acknowledged by facility staff.
Failure to Complete Significant Change Assessment Upon Hospice Admission
Penalty
Summary
The facility failed to complete a significant change of condition assessment for one resident when the resident was admitted to hospice care. The resident, who had a history of paraplegia, chronic kidney disease, obstructive and reflux uropathy, adult failure to thrive, and was receiving palliative care, was observed to have hand contractures and required assistance with mobility. Despite a documented order for hospice care and a hospice consult, there was no evidence that a change of condition assessment was completed at the time of the transition to hospice services. Interviews with staff, including an LVN and the DON, confirmed that such an assessment was required by facility policy and should have been conducted immediately upon the resident's change in status. The absence of this assessment meant that the resident's change in condition was not reported to direct care staff, the RN, attending physician, family, interdisciplinary team members, or nursing leadership. Facility policy and job descriptions reviewed indicated that prompt notification and comprehensive assessment are required when a significant change in a resident's condition occurs. The failure to complete and communicate the assessment had the potential to result in unmet care needs for the resident.
Failure to Provide Personal Hygiene and Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes, muscle weakness, and moderate cognitive impairment was found to have long fingernails with black particles underneath, indicating a lack of personal hygiene care. The resident required substantial to maximal assistance with activities of daily living, including upper body dressing, and expressed concern about the risk of injury or scratching herself due to the length of her fingernails. She stated that her fingernails were kept short at home and that she preferred them that way, but the facility had not offered to cut them. Interviews with staff revealed confusion regarding responsibility for nail care, particularly for diabetic residents. Certified Nursing Assistants (CNAs) believed that nurses were responsible for cutting fingernails for diabetic residents, while CNAs were expected to file and clean nails weekly. Both the CNA and a Licensed Vocational Nurse (LVN) acknowledged that the resident's fingernails were dirty and that there was no documentation or log indicating that nail care had been performed as required. The Director of Nursing confirmed that nurses should cut fingernails for diabetic residents and that documentation was lacking. Facility policy required assistance with personal hygiene for residents unable to perform these tasks independently, but this was not followed in the resident's case.
Unauthorized Use of Resident's Debit Card by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property and personal belongings when a Certified Nursing Assistant (CNA) used the resident's debit card without consent, resulting in unauthorized charges totaling $376.38. The resident, who had no cognitive impairment as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), initially asked the CNA to assist with a food delivery order using the CNA's phone and account. However, the CNA saved the resident's debit card information and continued to make unauthorized purchases for personal use. Interviews with facility staff, including the Director of Nurses (DON) and the Activity Director (ACTDIR), revealed that the facility lacked a protocol to prevent such incidents, and no formal education or training was provided to staff regarding the handling of residents' personal funds. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not effectively implemented, as evidenced by the CNA's actions. The CNA was terminated for financial elder abuse, and law enforcement was notified. The resident was eventually reimbursed by the facility after the investigation.
Inappropriate Discharge of Resident Against Medical Advice
Penalty
Summary
The facility failed to appropriately discharge a resident, identified as Resident 1, who left the facility on a leave of absence without a doctor's order. The resident, who had no cognitive impairment as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) assessment, was admitted with conditions including alcoholic cirrhosis, chronic kidney disease, and neuropathy. On the day of the incident, the resident left the facility without signing out or obtaining a doctor's order, which the Administrator deemed as leaving against medical advice (AMA). Upon the resident's return two hours later, the Administrator and Social Service Director informed him that he had been discharged AMA and his belongings had been packed. The resident was not provided with his scheduled medications after leaving the facility, and there was no policy requiring a doctor's order for a resident to leave. The Director of Nurses confirmed that the resident had left the facility before without such an order and questioned what medical advice the resident was going against. The facility's policy on transfer or discharge requires that residents be informed of their right to appeal such decisions, but there was no documentation of a discharge order for the resident. The Social Service Director later had the resident sign an AMA form, which was incorrectly dated. The facility's actions were not in compliance with their own policies or state regulations, which allow for discharge only for specific reasons such as medical necessity or nonpayment.
Failure to Ensure Resident is Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as required by their policy. The resident, who had a medical history of muscle weakness, dementia, repeated falls, difficulty in walking, and dependence on a wheelchair, was observed using a lap buddy as a physical restraint. The facility's policy stated that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully, and should not be used for falls prevention. However, the resident's care plan included the use of a lap buddy due to confusion and falls, and the resident was observed with the lap buddy in place during activities. Interviews with facility staff, including the Director of Nursing (DON), revealed that the lap buddy had been in use since the resident's admission in 2022 due to frequent falls. The DON confirmed that a lesser restrictive device had not been attempted and there was no ongoing monitoring of the physical restraint. Additionally, the DON acknowledged that falls were not a medical symptom justifying the use of a physical restraint. Other staff members, including a CNA and an LVN, confirmed that the lap buddy had been consistently used for the resident, and the Physical Therapist noted that therapy had not been consulted about its use.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was reviewed and updated annually, as required by their policy. The last documented assessment was dated 09/27/2022, indicating that the assessment had not been updated for nearly two years. This oversight had the potential to affect all 55 residents currently residing in the facility. The facility's policy, revised in 10/2018, mandates an annual review and update of the facility assessment to determine the resources necessary to meet the needs of residents during both day-to-day operations and emergencies. Interviews with the Director of Nursing (DON) and Nurse Consultant (NC) revealed that they had been working on updating the facility assessment since 2023, acknowledging that the acuity of the resident population had changed significantly. Despite this, the assessment had not been completed. Both the DON and the Administrator expressed that it was their expectation for the facility assessment to be reviewed annually by the facility management team. However, the delay in updating the assessment suggests a lapse in adhering to the facility's policy and procedures.
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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