Menifee Lakes Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sun City, California.
- Location
- 27600 Encanto Drive, Sun City, California 92586
- CMS Provider Number
- 056185
- Inspections on file
- 53
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Menifee Lakes Post Acute during CMS and state inspections, most recent first.
The facility did not complete required annual performance evaluations for three CNAs, leaving their personnel records without current assessments of job performance, goals, attendance, and policy adherence. The DSD, who is responsible for CNA evaluations, confirmed that no annual evaluations had been done and acknowledged their importance for ensuring staff competency in providing resident care. The DON also confirmed that these evaluations had not been completed and should have been, noting they are necessary to ensure staff can provide appropriate care and meet residents’ needs. This failure was not consistent with the facility’s written evaluation policy, which requires formal written annual evaluations for employees.
A resident with contractures of the left arm, documented as having decision-making capacity, reported to a family member and later to an RN supervisor that a CNA handled her roughly during perineal care, including slamming her left arm onto the bed. The resident expressed feeling unsafe and wanting to leave. Despite facility policy requiring physician consultation for significant physical, mental, or psychosocial changes, and staff acknowledgment that such an allegation constitutes a change in condition, there was no documentation that the physician was notified of the incident.
A resident with contractures and intact decision-making capacity reported to a family member and later to the RNS that a CNA was rough during perineal care and slammed the resident’s arm on the bed, causing the resident to feel unsafe and want to leave. Despite facility policy and expectations requiring all abuse allegations to be reported to the DON, administrator, and State Agency within two hours, the RNS did not report the allegation, and there was no documentation of timely notification to required authorities.
A resident with contractures of the left arm, who was capable of making decisions, reported that a CNA slammed her arm on the bed during nighttime incontinence care. Facility records showed no assessment for injury, pain, or emotional distress and no monitoring or interventions initiated after the allegation. An RN supervisor and the DON both acknowledged that this should have been treated as a change of condition under facility policy, with assessment and physician notification, but confirmed that no such assessment or monitoring was completed.
A resident admitted with CHF and angina, who had documented decision-making capacity, did not receive a written summary of the baseline care plan as required by facility policy. Record review showed no evidence that the baseline care plan summary was provided, and staff interviews revealed confusion and lack of awareness about required timeframes and the obligation to give a copy to the resident or responsible party. The MDS nurse described a practice of completing baseline care plans within 72 hours and providing copies, while an LVN reported unfamiliarity with baseline care plans and the RN supervisor was unaware of the 48–72 hour requirement or the need to share the plan. The DON stated that the admission nurse and department heads are responsible for initiating and completing the baseline care plan within 48 hours and that a copy should be given to the resident or representative, but confirmed there was no documentation that this occurred for the resident.
A resident with a traumatic subdural hematoma, history of falls, and abnormal gait, care planned as a fall risk with an intervention to keep the call light within reach, was observed with the call light hanging out of reach on the side of the bed. The resident reported normally using the call light for assistance but could not locate it. A CNA acknowledged missing the call light and confirmed it should have been secured in front of the resident. Facility policies on call light accessibility and the fall prevention program require staff to keep call lights within reach, which was not done in this case.
A resident with Parkinson’s disease and mild cognitive impairment, previously assessed as having bed mobility and balance difficulties and whose representative had requested grab bars, was observed without bed rails/grab bars in place. After a hospital transfer and subsequent readmission, the facility did not complete a required reassessment for bed rail/grab bar use, despite facility policy and prior recommendations, and the DON confirmed that this reassessment should have occurred but did not.
A resident with recurrent UTIs caused by multidrug-resistant Pseudomonas aeruginosa did not have required infection precautions implemented despite multiple positive urine C&S results. The IPN and DON stated that facility practice and policy required EBP or CIP, physician orders, PPE use, and precaution signage when an MDRO such as Pseudomonas is identified, yet there was no documentation of orders or initiation of EBP or CIP after the initial symptomatic MDRO UTI or after the resident’s readmission from the hospital with continued MDRO Pseudomonas. Surveyors observed the resident on antibiotics without any precaution signage posted, and record review confirmed that the facility’s own policies on EBP and transmission-based precautions for MDROs were not followed.
A resident with diabetes and other complex medical conditions was admitted without documentation of baseline blood glucose or meal intake. Insulin was administered before confirming food intake, and staff failed to communicate essential information about the resident's status. This led to a hypoglycemic event requiring emergency intervention, in violation of facility policy for diabetic care.
The facility did not ensure that several residents had copies of their advance directives (ADs) in their medical records or that residents and their representatives were provided with information and education about formulating ADs. In multiple cases, documentation was missing to show that ADs or DPOAs were obtained or discussed, despite residents being cognitively intact and assessments indicating these steps should have been taken.
Nursing staff failed to properly document the administration and wasting of controlled substances for two residents. In both cases, CS medications were signed out on the count sheet but not recorded on the MAR, and one instance of medication waste lacked a second nurse's witness signature, resulting in unaccounted doses and incomplete records as confirmed by the DON and an LVN.
A resident with type 2 diabetes was not provided a controlled carbohydrate diet after being discharged from hospice and remaining in LTC. Despite fluctuating blood sugar levels and an elevated Hgb A1c, the resident continued on a regular diet without physician review or dietary adjustment, contrary to facility policy and care plan directives.
Nursing staff did not properly disinfect shared equipment such as BP cuffs, stethoscopes, and glucometers according to manufacturer instructions, and a neurotherapy nurse failed to wear required PPE while providing care to a resident on enhanced barrier precautions. These actions were not consistent with facility policy or infection control protocols.
A resident with a history of chronic subdural hemorrhage and nasal septal deviation experienced ongoing shortness of breath and difficulty breathing, but staff did not assess the condition, update the care plan, or document the change as required by facility policy.
A resident with ESRD did not receive required post-hemodialysis weight assessments on two occasions, as the responsible nurse failed to document or perform these checks after dialysis treatments. This was confirmed by both LVN and RN staff during interviews and record reviews, and was not in accordance with the facility's policy for ongoing assessment after dialysis.
The facility did not ensure timely medically-related social service referrals for two residents. One resident with a history of stroke and blood thinners experienced gross hematuria and had a physician order for a CT scan, but the referral was not completed due to unresolved authorization issues. Another resident with a deviated nasal septum and chronic subdural hemorrhage had a physician order for an ENT evaluation for shortness of breath, but no referral was made, and staff were unaware of the order.
A resident with multiple diagnoses and prescribed several sedating medications experienced two falls after changes in their medication regimen. Facility staff did not request an intermediate medication regimen review (MRR) following these falls, and the consultant pharmacist was not notified or able to make recommendations regarding the potential contribution of polypharmacy to the falls. The facility's policies requiring additional MRRs after significant changes in condition were not followed, and the monthly MRRs did not address the risk of medication-related adverse effects.
A surveyor found an opened multi-dose vial of Tuberculin PPD stored unrefrigerated in a medication cart, contrary to manufacturer instructions and facility policy requiring refrigeration. The LVN present could not confirm how long the vial had been unrefrigerated, and the DON acknowledged the storage error.
A resident with multiple health conditions reported an abuse allegation involving a staff member, which was not reported to the CDPH within the required two-hour timeframe. Despite staff awareness of the reporting policy, the incident was reported approximately 10 hours later, violating the facility's policy.
The facility failed to conduct annual fit testing for N-95 respirators for a PT treating COVID-19 residents, contrary to its Respiratory Protection Plan. The PT had not been fit tested for approximately two years, despite the policy requiring annual testing. This oversight could contribute to the spread of COVID-19 among vulnerable residents.
The facility failed to accommodate the needs of two residents. One resident was not provided with bedrails for repositioning despite a documented need, and another resident's call light was not within reach, contrary to her care plan and facility policy. These oversights could lead to unmet needs and lack of timely assistance.
A resident's room in the facility was found to have missing slats in the curtain blinds, which were not documented in the maintenance repair log. The resident, with a history of palliative care and various medical conditions, was aware of the issue but could not recall reporting it. Interviews with staff revealed inconsistencies in the process of reporting and documenting maintenance issues, with some staff unaware of the maintenance log's existence.
A resident's legal representative requested access to medical records, but the facility failed to provide them within the required timeframe. The Medical Records Director delayed forwarding the request to the legal team, resulting in a breach of the facility's policy and potentially impacting the resident's care.
Failure to Complete Required Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to maintain current personnel records by not completing required annual performance evaluations for three CNAs, resulting in an inability to assess staff performance, identify areas needing improvement, and ensure competency in providing resident care. Review of personnel files on March 13, 2026, showed no documented annual performance evaluations for CNA 1, hired August 16, 2022, CNA 2, hired August 30, 2023, and CNA 3, hired February 28, 2024. During a concurrent interview and record review, the Director of Staff Development (DSD) acknowledged responsibility for completing CNA performance evaluations and confirmed there was no documentation of annual evaluations for these three CNAs, stating that such evaluations are important to ensure staff competency in resident care. In a separate interview, the Director of Nursing (DON) confirmed that the DSD is responsible for CNA evaluations, acknowledged that annual evaluations for these CNAs had not been completed and should have been, and stated that annual evaluations are necessary to ensure staff are competent in providing appropriate care and meeting residents’ needs. A review of the facility’s policy titled “Evaluation Process,” dated December 19, 2022, indicated that the facility is to review employee work performance with a formal written evaluation annually, considering factors such as job performance, achievement of preset goals, attendance records, and adherence to workplace policies. The absence of annual performance evaluations for the three CNAs was therefore not in accordance with the facility’s own written policy and represented a failure to follow established procedures for monitoring and documenting staff performance and competency.
Failure to Notify Physician After Resident’s Allegation of Rough Handling
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition after a resident alleged rough handling by staff. On the night of February 25, 2026, the resident told a family member that a CNA slammed her left arm onto the bed while attempting to wake her for a brief change. The family member reported that the resident subsequently stated she did not feel safe and wanted to leave the facility. The resident’s admission record showed she was admitted on September 17, 2025, with contractures of the left elbow, wrist, and hand, and her history and physical dated September 18, 2025, documented that she had the capacity to understand and make decisions. The RN supervisor reported that on the morning of February 25, 2026, she became aware of the incident when the resident reported that the CNA was rough with her during perineal care. The RN supervisor stated this alleged incident was considered a change of condition and that the physician should have been notified. The DON stated that staff are expected to notify the physician of significant changes in condition, including allegations of abuse, and that the licensed nurse should have reported the change in condition to the resident’s physician. A review of the medical record showed no documentation that the physician was notified following the allegation of abuse, despite the facility’s “Notification of Changes” policy requiring consultation with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
Failure to Timely Report Allegation of Abuse to DON and State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of abuse involving a resident with contractures of the left elbow, wrist, and hand. The resident, who had documented capacity to understand and make decisions, told a family member that during the night a CNA slammed her left arm on the bed while attempting to wake her for a brief change. The resident reported feeling unsafe and wanting to leave the facility following the incident. There was no documented evidence in the electronic medical record that this allegation was reported to the DON, the administrator, or the State Agency within two hours of the allegation being made, as required. On the morning of the same date, the RNS became aware of an incident when the resident reported that the CNA had been rough with her during perineal care. The RNS acknowledged that this was considered an allegation of abuse that should have been reported immediately to the DON and to the State Agency, in accordance with facility expectations and policy. The RNS stated she did not report the incident to the DON or the State Agency. The DON confirmed that staff were expected to report any allegations of abuse to the DON and administrator within two hours and that such allegations should be reported to the State Agency. The facility’s Abuse, Neglect, and Exploitation policy required reporting all alleged violations to the administrator, state agency, and other required agencies immediately, but not later than two hours after the allegation is made.
Failure to Assess and Monitor Resident After Alleged Rough Handling During Care
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a resident after the resident alleged that a staff member handled her roughly during care. The resident, who was admitted with contractures of the left elbow, wrist, and hand and had documented capacity to understand and make decisions, reported that during the night a CNA slammed her left arm on the bed while attempting to wake her for a brief change. Record review showed no documented evidence that the resident was assessed following this incident for injury, pain, or emotional distress, and no evidence that any monitoring or interventions were initiated in response to the allegation. The RN Supervisor stated she became aware the morning after the incident that the resident reported the CNA was rough during care and acknowledged this should have been treated as a change of condition. She stated the resident should have been assessed and monitored, but no assessment or monitoring was completed. The DON similarly stated that licensed nurses were expected to complete a change of condition assessment, notify the physician, and perform assessment and monitoring when a concern is identified, and confirmed that this was not done for this resident after the alleged incident. The facility’s “Notification of Changes” policy required informing the resident and consulting with the physician when there is a significant change in the resident’s physical, mental, or psychosocial condition.
Failure to Provide Written Baseline Care Plan Summary to Newly Admitted Resident
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a newly admitted resident, identified as Resident C. Resident C was admitted with diagnoses including congestive heart failure and angina pectoris, and a History and Physical documented that the resident had the capacity to understand and make decisions. During an unannounced survey, record review showed no evidence that a written summary of the baseline care plan had been provided to the resident or the resident’s representative, despite the facility’s policy requiring development of a baseline care plan within 48 hours of admission and provision of a written summary to the resident and representative. Interviews with staff revealed inconsistent understanding and implementation of the baseline care plan process. The MDS nurse reported that baseline care plans are completed within 72 hours and that nurses are to give a copy to the resident or responsible party. An LVN stated she was not familiar with the baseline care plan because she was not involved in admissions. The RN Supervisor stated she was not aware that the baseline care plan was supposed to be completed within 48 to 72 hours or that residents or responsible parties were to receive a copy. The DON stated that the admission nurse initiates the baseline care plan and department heads complete it within 48 hours, and that a copy should be provided to the resident or representative, but acknowledged there was no proof that any care plan meeting occurred with Resident C or that a copy of the baseline care plan summary was provided.
Call Light Not Kept Within Reach for Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when a resident at risk for falls did not have their call light within reach. During an observation and interview on January 30, 2026, at 8:17 a.m., the resident’s call light button was seen hanging on the left side of the bed, out of the resident’s reach. The resident reported that she normally used the call light when she needed staff assistance but could not locate it at that time. The resident’s admission record showed diagnoses including traumatic subdural hematoma, history of fall, and abnormality of gait. Her care plan documented that she was at risk for falls related to a history of falls prior to admission and unsteady gait/balance, with an intervention specifying that the call light should be placed within reach. At 8:30 a.m. the same day, a CNA assigned to the resident acknowledged during an interview in the resident’s room that she had missed the call light button and that it had been left hanging on the left side of the bed, not within the resident’s reach. The CNA stated the call light should have been positioned and secured in front of the resident. The DON later stated that fall-risk residents are discussed during the morning huddle and acknowledged that a call light not within reach may present a potential risk for falls. Review of facility policies titled “Call Light Accessibility and Timely Response” and “Fall Prevention Program,” both dated December 19, 2022, showed that staff are required to ensure call lights are within reach and secured, and that fall prevention measures include ensuring call lights are within reach, which was not followed in this instance.
Failure to Reassess Bed Rail/Grab Bar Need After Resident Readmission
Penalty
Summary
The deficiency involves the facility’s failure to reassess a resident for the use of bed rails/grab bars upon readmission, as required by its own policy. During an unannounced Quality-of-Care complaint investigation, a resident with Parkinson’s disease and mild cognitive impairment was observed sitting in a wheelchair at bedside with no side rails or grab bars attached to the bed. Review of the resident’s prior bed rail assessment from June 11, 2025, showed documented bed mobility issues, including difficulty moving in bed, moving to a sitting position, and maintaining standing/sitting balance. That assessment also recorded that the resident’s representative reported the resident had fallen at home and requested grab bars, with recommendations for left and right grab bar assistance. Record review showed the resident had been transferred to a general acute care hospital on November 12, 2025, and readmitted on November 16, 2025. There was no documented evidence that the resident was reassessed for the use of bed rails or grab bars following this readmission, and the resident did not currently have grab bars on the bed. In interviews, the DON stated that facility policy requires assessment for bed rails upon admission, readmission, and at the request of the resident/representative or nursing staff, and acknowledged that the resident was not reassessed for grab bar use after readmission despite this policy. The facility’s written policy on proper use of bed rails requires reassessments at least quarterly and upon a significant change in status, but this was not carried out for the resident after returning from the hospital.
Failure to Implement MDRO Infection Precautions for Recurrent Pseudomonas UTI
Penalty
Summary
The deficiency involves the facility’s failure to initiate and maintain appropriate infection prevention precautions for a resident with repeated UTIs caused by multidrug-resistant Pseudomonas aeruginosa. During an unannounced visit, surveyors observed that the resident, who reported being on antibiotics for a UTI and feeling better, had no signage outside the room indicating any infection prevention precautions. The Infection Prevention Nurse (IPN) explained that the facility’s process was to monitor residents on antibiotics during weekday clinical review meetings and that when a urine culture and sensitivity (C&S) showed an MDRO such as Pseudomonas, infection control interventions such as Enhanced Barrier Precautions (EBP) or Contact Isolation Precautions (CIP) should be initiated, with corresponding signage and PPE requirements posted outside the resident’s room. Record review for the cognitively intact resident showed a series of UTIs and positive C&S results for MDRO Pseudomonas. Progress notes documented that on one date in October, the resident complained of painful urination, a C&S was ordered, and antibiotics were started for a UTI. The C&S result reported on a later October date confirmed MDRO Pseudomonas, and the physician changed the antibiotic to one susceptible to the organism. However, there was no documentation that physician orders were obtained or implemented for CIP at that time, despite the IPN’s statement that CIP should have been initiated for this symptomatic MDRO UTI. The DON later confirmed that on that October date, the resident was diagnosed with a symptomatic UTI caused by Pseudomonas and that CIP was not implemented and no physician order was obtained. Further review showed that in early November the resident was transferred to an acute hospital for evaluation of recurrent UTI, where a urine C&S again showed Pseudomonas. The resident was readmitted to the facility with new antibiotic orders for UTI, but there was no documented evidence that EBP or CIP were initiated upon readmission, despite the hospital C&S indicating MDRO Pseudomonas. The IPN stated that EBP should have been started when the resident was readmitted, and the DON stated that an EBP should have been initiated upon admission for the asymptomatic MDRO UTI but was not, and that if a physician’s order is not received, it cannot be verified that precautions were initiated. Facility policies on Enhanced Barrier Precautions and Transmission-Based (Isolation) Precautions identified multidrug-resistant Pseudomonas aeruginosa as an important MDRO and required EBP for the duration of the resident’s stay and transmission-based precautions for residents known or suspected to be infected or colonized with such organisms, but these were not implemented for this resident as required.
Failure to Monitor Blood Glucose and Meal Intake for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to monitor blood glucose levels, assess meal intake, and ensure proper communication among staff for a newly admitted resident with diabetes. The resident, who had a history of type 2 diabetes mellitus with ketoacidosis, chronic kidney disease stage 3, and a below-knee amputation, was admitted without documentation of baseline blood glucose or oral intake. The clinical admission form lacked this essential information, and the physician's order specified insulin administration before breakfast. On the morning following admission, the resident received insulin at 7:00 a.m. with a recorded blood glucose of 99. Shortly after, the resident was found unresponsive with a critically low blood sugar of 25. Emergency interventions included administration of glucagon and orange juice, which gradually improved the resident's condition. Interviews with nursing staff revealed that there was no communication regarding the resident's last meal or baseline blood glucose, and the assigned nurse was unaware of whether the resident had eaten prior to insulin administration. Facility policy required documentation of blood glucose levels and meal intake for diabetic residents, as well as communication of this information among staff. Multiple staff members, including the DON, confirmed that these steps were not followed. The lack of documentation and communication led to the administration of insulin without confirming food intake, resulting in a hypoglycemic event for the resident.
Failure to Provide and Document Advance Directive Information and Accessibility
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were properly managed for six of nine residents reviewed. Specifically, there was no copy of the AD available in the medical record for one resident, and five other residents or their representatives were not provided with information or education regarding the formulation of an AD. In several cases, documentation was missing to show that the facility had followed up on whether residents had an AD or Durable Power of Attorney (DPOA), and copies of these documents were not placed in the residents' records as required. For example, one resident was noted in the social service assessment to have a DPOA, but there was no evidence that a copy was obtained or that the resident or their representative was given information about ADs. Another resident was indicated to have an AD and POLST available, but no copy of the AD was found in the medical record. Multiple residents were cognitively intact, as indicated by their BIMS scores, yet there was no documentation that they or their representatives received education or resources about ADs, nor was there evidence of follow-up regarding their wishes. Interviews with the Social Services Assistant confirmed that assessments should include notations about AD discussions and that copies of ADs and DPOAs should be placed in the medical record. However, the records reviewed did not consistently reflect these practices. The facility's own policy required determining if a resident had executed an AD, providing information and education, and ensuring copies were accessible to staff and physicians, but these steps were not documented for the affected residents.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substance (CS) medications for two residents. For one resident with an order for Ativan 1 mg as needed for anxiety, nursing staff signed out a tablet on the controlled drug count sheet but did not document its administration on the Medication Administration Record (MAR). Additionally, a tablet of Ativan was wasted without a second nurse's witness signature on the count sheet, contrary to facility policy. For another resident with an order for hydrocodone-acetaminophen 5/325 mg as needed for pain, a tablet was signed out on the count sheet but not documented as administered on the MAR. Interviews with the DON and an LVN confirmed that the facility's process requires documentation of CS administration on both the count sheet and MAR, and that two licensed nurses must witness and document any waste of CS medications. The discrepancies resulted in unaccounted doses and incomplete records for both residents, as acknowledged by facility staff during the review of records and interviews.
Failure to Adjust Diabetic Resident's Diet After Change in Health Status
Penalty
Summary
The facility failed to provide a recommended diet for a resident with type 2 diabetes mellitus following a change in health status. After being discharged from hospice services and remaining in long-term care, the resident continued to receive a regular diet despite having diabetes and experiencing fluctuating blood sugar levels. The care plan indicated the need for a dietary consult and ongoing monitoring, but there was no documentation that the resident's diet was reviewed or clarified with the physician after the change in status. The resident expressed a desire for meals with fewer carbohydrates, and laboratory results showed an elevated Hgb A1c of 8.8%. Interviews with facility staff, including a Licensed Vocational Nurse, the Minimum Data Set Nurse, and the Registered Dietitian, confirmed that the resident remained on a regular diet without a controlled carbohydrate intervention. Staff acknowledged that the resident's diet should have been reassessed and clarified with the physician after the significant change in condition. Facility policies required that therapeutic diets be provided as prescribed and that changes in a resident's condition prompt notification and consultation with the physician, but these procedures were not followed in this case.
Failure to Follow Infection Control Practices for Equipment Disinfection and PPE Use
Penalty
Summary
Nursing staff failed to implement proper infection control practices when cleaning and disinfecting shared resident care equipment, including blood pressure cuffs, stethoscopes, and glucometers. During medication pass observations, staff were seen using Sani-Cloth Prime disposable wipes but did not adhere to the manufacturer's specified contact time, which requires the equipment to remain visibly wet for one minute. Both the Infection Preventionist and Director of Nursing confirmed that staff were expected to follow these instructions, but interviews revealed a misunderstanding of the correct procedure, with staff believing that simply wiping and allowing the equipment to air dry was sufficient. Additionally, a neurotherapy nurse did not wear the required personal protective equipment (PPE), specifically an isolation gown, while providing care to a resident on enhanced barrier precautions due to a gastrostomy tube. The nurse entered the resident's room and performed contact care without donning the appropriate PPE, later stating she forgot to check the signage and wear the gown. The Assistant Director of Nursing and Infection Preventionist both confirmed that the expectation was for staff to follow designated precaution protocols and wear PPE as indicated for residents on enhanced barrier precautions. The facility's policies and procedures, as well as the manufacturer's instructions for disinfectant wipes, were reviewed and clearly outlined the requirements for cleaning and disinfecting reusable equipment and the use of PPE for residents on enhanced barrier precautions. Despite these established protocols, staff actions did not align with the documented procedures, resulting in lapses in infection prevention and control.
Failure to Assess and Care Plan for Resident's Respiratory Change
Penalty
Summary
A resident with a history of chronic subdural hemorrhage and nasal septal deviation reported experiencing shortness of breath and difficulty breathing for about a month, with a visibly deviated nasal bridge and nasal-sounding speech. Despite these ongoing symptoms, there was no documentation that the resident had been assessed for shortness of breath, and the issue was not addressed by the nursing staff. Interviews with facility staff revealed that the Minimum Data Set Nurse acknowledged a care plan should have been initiated for the resident's change in condition, but this was not done. Additionally, a Licensed Vocational Nurse was unaware of the resident's nasal septal deviation or respiratory symptoms and confirmed that an assessment, care plan update, and documentation should have occurred. Review of facility policy indicated that changes in resident status require notification, assessment, care plan revision, and communication among staff, none of which were completed in this case.
Failure to Complete Post-Hemodialysis Assessments
Penalty
Summary
The facility failed to complete post-hemodialysis assessments for a resident with End Stage Renal Disease (ESRD) on two separate occasions. Specifically, the licensed nurse did not assess or record the resident's weight after dialysis treatments on January 10, 2025, and January 27, 2025, as documented in the Dialysis Communication Form. This omission was confirmed during interviews and record reviews with both a Licensed Vocational Nurse and a Registered Nurse Supervisor, who acknowledged that the required post-dialysis assessments were not performed on those dates. The facility's policy on hemodialysis care requires ongoing assessment and monitoring of residents before and after dialysis treatments, including the assessment of weight to detect potential complications. The failure to follow this policy resulted in missed opportunities to identify and manage possible complications related to fluid balance for the resident receiving dialysis.
Failure to Obtain Timely Medically-Related Social Service Referrals
Penalty
Summary
The facility failed to ensure that medically-related social service referrals were obtained for two residents. For one resident with a history of stroke, hemiplegia, and hemiparesis, who was on blood thinners due to DVT and had experienced gross hematuria, a physician order was written to schedule a CT scan of the abdomen and pelvis. Although a follow-up call was made to the imaging center and an issue with the authorization address was noted, there was no documentation that the incorrect address was corrected or that the referral process was completed. The social services assistant confirmed that no further follow-up was documented and the CT scan referral remained incomplete. For another resident with chronic subdural hemorrhage and a deviated nasal septum, who reported ongoing shortness of breath and nasal obstruction, a physician order was written for an ENT evaluation. However, there was no documentation that a referral to an ENT specialist was made. The LVN interviewed was unaware of the order, and the social services assistant stated that the department did not receive the referral order until much later, despite the order being dated previously. The facility's policy indicated that the social services department is responsible for identifying and ensuring the provision of medically-related social services, but this process was not followed in these cases.
Failure to Request Medication Review and Address Polypharmacy After Resident Falls
Penalty
Summary
The facility failed to request a medication regimen review (MRR) by a licensed pharmacist following significant changes in a resident's condition, specifically after two falls, and did not ensure that the consultant pharmacist identified or made recommendations regarding potentially sedating medications that could have contributed to these falls. The resident involved was elderly, had multiple complex diagnoses including metabolic encephalopathy, schizoaffective disorder, anxiety, depression, and mobility issues, and was prescribed several medications with sedating effects such as oxycodone-acetaminophen, quetiapine, trazodone, gabapentin, Remeron, Ativan, and Depakote. Despite the addition of new medications and the occurrence of falls, the facility did not initiate an intermediate MRR as outlined in their policies and procedures. Interviews with facility staff, including the ADON, DON, and consultant pharmacist, revealed that the process for requesting an additional MRR after a change in condition, such as a fall, was not followed. The nursing staff did not notify the pharmacy or request a review after the resident's falls, and the consultant pharmacist was not made aware of these incidents. The consultant pharmacist confirmed that if notified, he would have recommended additional monitoring for increased risk of falls, dizziness, and sedation due to the combination of medications. The monthly MRRs conducted in the months surrounding the incidents did not include any recommendations to address the potential for medication-related falls or suggest changes to the resident's medication regimen. The facility's policies required ongoing evaluation of psychotropic medications and specified that an MRR should be conducted during significant changes in a resident's condition. Documentation showed that these procedures were not followed, as no additional MRR was requested after the resident's falls, and the consultant pharmacist did not identify or report the potential for medication-related adverse effects. Interviews with the medical director and psychiatric nurse practitioner further confirmed that the combination of medications could have contributed to the resident's falls, but no action was taken to review or adjust the medication regimen in response to these events.
Improper Storage of Refrigerated Medication
Penalty
Summary
A surveyor inspection of the 300 Hall medication cart, conducted in the presence of an LVN, found an opened and used multi-dose vial of Tuberculin PPD stored unrefrigerated in the top drawer of the medication cart. The LVN was unable to specify how long the vial had been stored outside of refrigeration and acknowledged that the PPD vial should have been kept refrigerated, not in the cart. The Director of Nursing later confirmed that the manufacturer's instructions require the PPD vial to be stored between 2 and 8 degrees Celsius (36 and 46 degrees Fahrenheit). A review of the facility's own medication storage policy, dated December 19, 2022, indicated that all medications requiring refrigeration must be stored in refrigerators. The failure to store the PPD vial according to both manufacturer instructions and facility policy resulted in a deficiency related to improper medication storage.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe to the California Department of Public Health (CDPH). The incident involved a resident who was admitted with multiple diagnoses, including atrial fibrillation, diabetes mellitus with diabetic neuropathy, and anxiety disorder. On February 8, 2025, the resident, who had the capacity to make decisions, reported being abused by a staff member. The resident called the police, claiming that a Registered Nurse (RN) had abused him by squeezing his leg. The police were called around 3 a.m., and the allegation was reported to the facility administrator at approximately 1 p.m., which was about 10 hours after the incident. Interviews with facility staff, including a Registered Nurse, Licensed Vocational Nurse, and the Director of Nursing, revealed that the staff was aware of the requirement to report allegations of abuse within two hours. However, the report to the state agency was delayed. The facility's policy, revised in December 2022, clearly stated that allegations involving abuse should be reported immediately, but not later than two hours after the allegation is made. Despite this policy, the administrator reported the incident to CDPH and the local state agency only after a significant delay, which constituted a failure to comply with the reporting requirements.
Failure to Conduct Annual N-95 Fit Testing
Penalty
Summary
The facility failed to implement its Respiratory Protection Plan by not conducting annual fit testing for N-95 filtering facepiece respirators (FFR) for one of four staff members. During an unannounced visit, it was revealed that the Physical Therapist (PT), who was treating residents with COVID-19, had not been fit tested for his N-95 mask for approximately two years. This was contrary to the facility's policy, which mandates fit testing upon hire and annually thereafter. The Infection Preventionist (IP) confirmed that the facility had two models of N-95 FFRs available and that staff were supposed to be fit tested annually. However, a review of the facility's Fit Test Record indicated that the PT's last fit test was conducted on August 17, 2023, which was not within the required annual timeframe. This oversight had the potential to contribute to the spread of COVID-19 among residents and staff, particularly affecting vulnerable residents with compromised health conditions.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs of Resident A by not providing bedrails for repositioning as requested. Resident A was admitted with a diagnosis that included aftercare following joint replacement surgery and had the capacity to understand and make decisions. The Bedrail Assessment indicated that bedrails were necessary for mobility and transfer purposes. However, the Maintenance Director did not install the bedrail because there was no request made by the nurse for its installation. The facility's policy on the proper use of bedrails emphasized a person-centered approach, but this was not followed in Resident A's case. Resident B's call light was not within reach, which could prevent her from calling for assistance. Resident B was admitted with diagnoses including dementia and legal blindness. During an observation, it was noted that her call light was clipped to the top portion of her bed, far from her reach. The CNA confirmed that the call light should be clipped to her clothes for accessibility. The care plan for Resident B indicated that the call light should be within reach due to her risk of falls. The facility's policy required staff to ensure call lights are accessible, but this was not adhered to for Resident B.
Failure to Maintain Homelike Environment Due to Missing Curtain Slats
Penalty
Summary
The facility failed to ensure a comfortable homelike environment for one of its residents, identified as Resident 2, due to missing slats in the curtain blinds covering the resident's sliding door. This issue was not documented in the maintenance repair log, which is a critical step in ensuring timely repairs. During an unannounced visit, it was observed that four slats were missing from the blinds, and Resident 2 was aware of the issue but could not recall when or to whom it was reported. The resident's medical records indicate a history of palliative care, peripheral vascular disease, vascular dementia, anxiety disorder, and major depressive disorder. Interviews with facility staff, including CNAs, an LVN, the Maintenance Director, and the Director of Nursing, revealed inconsistencies in the process of reporting and documenting maintenance issues. While some staff members stated that maintenance issues should be documented in a log kept at the nurse's station, others denied the existence of such a log. The Maintenance Director confirmed the missing slats and stated that he checks the maintenance book daily, aiming to resolve issues within 24 hours. However, the missing slats in Resident 2's room were not recorded in the maintenance log, indicating a lapse in the facility's maintenance reporting and documentation process.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to personal and medical records for a resident, identified as Resident 3, within the required two working days. The deficiency was identified during an unannounced visit to investigate a resident's rights issue. Resident 3 was admitted to the facility and later discharged, and during their stay, a request for their medical records was made by their legal representative. The initial request was made on May 28, 2024, but due to a mismatch in the resident's name, the request was not processed. A new request was submitted on June 10, 2024, but the Medical Records Director (MRD) did not forward it to the facility's legal team until June 14, 2024, delaying the release of the records. The facility's policy requires that medical records be released within 72 hours of a valid request, and the resident or their legal representative should have access to the records within two days. The Interim Director of Nursing confirmed that the MRD did not follow the facility's policy and procedure, resulting in the delay. This failure to adhere to the policy potentially impacted the resident's physical wellbeing by delaying care and treatment. The report highlights the inaction of the MRD in processing the request promptly, which contributed to the deficiency.
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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