Pacific Gardens Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 577 S. Peach Ave., Fresno, California 93727
- CMS Provider Number
- 056207
- Inspections on file
- 27
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pacific Gardens Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that nursing staff failed to document ordered wound and skin treatments for five residents with complex medical conditions, including diabetes, COPD, venous stasis ulcers, skin tears, peri-anal rash, MASD, and fungal rash. Review of Treatment Administration Records showed multiple missing nurse initials for ordered treatments on specific shifts, despite physician orders for daily or every-shift wound care. Facility leadership, including the DON, ADON, and Administrator, stated that standard practice requires following physician orders and documenting care, and that if wound care is not documented, it is considered not done. Another LVN confirmed that documentation after providing wound care is required to ensure continuity of care and to reflect the treatments residents receive, indicating that the missing entries represented a failure to meet professional standards and facility policy for charting and documentation.
The facility did not ensure that all residents were treated equally in matters of transfer, discharge, and service provision, regardless of their payment source.
A resident did not receive restorative nursing assistant (RNA) services after being discharged from physical therapy, leading to a contracture in the right hand. The resident, with a history of hemiplegia and hemiparesis, was not transitioned to RNA services due to a lack of coordination between PT and RNA staff. The Director of Nursing acknowledged the failure to follow the process, which was crucial for maintaining the resident's activities of daily living.
The facility failed to inform and document information on how to formulate an advance directive for four residents, violating their rights. Interviews revealed that residents were not informed about advance directives, and staff acknowledged the lack of documentation. The facility's policy requires informing residents of their rights to establish an advance directive, but this was not consistently followed.
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by cold room temperatures, exposed wiring, and malfunctioning equipment. Two residents experienced discomfort due to cold rooms, while another resident's room had holes with exposed insulation and wiring. Additionally, a resident faced issues with a broken bed and poor TV reception, affecting their comfort and quality of life.
A facility failed to properly store and label medications, with two inhalers lacking open and expiration dates, and two medication refrigerators operating outside the recommended temperature range. This affected medications for several residents, risking their potency and effectiveness. Observations and interviews confirmed these deficiencies, highlighting the need for adherence to storage and labeling policies.
The facility's cook staff failed to accurately measure milk and margarine for pureed rice, affecting 12 residents on a pureed diet. Cook 1 used incorrect measuring techniques, leading to potential inconsistencies in nutrient content. The RD acknowledged the importance of following recipes but had not verified staff measurements. The DON noted the absence of a policy for pureed food preparation, while Cook 2 described a different measurement approach.
The facility failed to maintain safe and sanitary food preparation and storage practices. Observations included unlabeled potatoes and thawing beef kabobs, a dietary aide not washing hands after scratching their ear, and dust on the ceiling above a fan in the food storage room. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to maintain effective infection control, with issues such as improper storage of nebulizer mouthpieces, catheter bags on the floor, and lack of Enhanced Barrier Precautions for residents with wounds. Additionally, oxygen tubing was found on the floor, and opened medical supplies were improperly stored, posing infection risks.
The facility failed to maintain secure handrails in the hallways, increasing fall risk for residents. Observations revealed broken and loose handrails, with missing parts exposing metal brackets and screws. The Maintenance Supervisor acknowledged the risk and noted the use of the TELS System for repair notifications, but obsolete parts hindered replacements. Facility policies emphasized a safe environment, yet the handrails were not adequately maintained.
Two residents in the facility were observed without dignity bags covering their foley catheter drainage bags, leaving the urine visible and violating their right to dignity. Staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The facility's policies emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Two residents were transferred to the hospital without receiving written information about the facility's bed hold policy, despite verbal notifications. The facility's policy required written notice, but it was not provided, leading to potential confusion and disputes over bed availability.
The facility failed to implement comprehensive care plans for several residents, leading to potential risks and unmet needs. A resident with a Foley catheter lacked a care plan, increasing infection risk. Another resident's visual needs were unmet due to missing glasses, risking injury. Two residents on anticoagulants lacked care plans for monitoring side effects, highlighting the need for individualized care plans.
A facility failed to update a resident's care plan after a stage two pressure ulcer had healed, leaving active treatment interventions in place. Staff interviews revealed that accurate care plans are crucial for guiding resident care, and the Director of Nursing acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy requires regular evaluation and revision of care plans.
Two residents in the facility received incorrect oxygen flow rates, contrary to physician orders. One resident with COPD was given 2.5 LPM instead of the ordered 2 LPM, while another resident with multiple health issues had an oxygen flow rate set at 3 L/min instead of 2 L/min. Additionally, the second resident's oxygen tubing was not labeled with the date, risking infection. These actions were against the facility's policy and procedure for oxygen administration.
A resident with reduced mobility and no cognitive deficits experienced discomfort due to long, jagged toenails, as the facility failed to provide proper toenail care. Despite policies requiring routine care, staff did not adequately trim, file, or document the resident's toenail care, leading to potential risks of injury or infection.
A resident's foley catheter tubing was improperly managed, being wrapped around her prosthetic leg, posing a risk of falls or injury. Staff interviews revealed a lack of training and adherence to facility policies, highlighting a deficiency in ensuring resident safety.
The facility did not post accurate daily staffing information, omitting the total number and actual hours worked by RNs, LVNs, and CNAs. The Assistant Staff Development Coordinator admitted the posted form was incomplete, and the Administrator was unaware of CMS requirements. This deficiency prevented residents and families from accessing accurate staffing details.
A resident was administered mirtazapine for several months without documented attempts at a gradual dose reduction (GDR), despite no recorded depressive episodes. The facility's policy requires quarterly evaluations and documentation of GDR assessments, which were not followed.
A resident in an LTC facility was administered potassium chloride 20MEQ by RN 1 without following the manufacturer's instructions. The medication was given without a meal and the resident was allowed to lie down immediately after, contrary to guidelines. The resident had a history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease, and was cognitively intact.
A resident in an LTC facility did not have a completed POLST on file, despite being admitted with multiple serious health conditions. The resident was cognitively intact and had expressed a DNR preference, but the lack of a POLST meant their end-of-life wishes might not be honored in an emergency. The facility's policy required timely completion of such documents, but the POLST remained incomplete for a month, which was acknowledged as unacceptable by the ADON.
An LVN at an LTC facility failed to perform necessary assessments and inaccurately documented care for a resident who was hospitalized. The LVN recorded vital signs, pain assessments, and enteral feeding interventions that were not provided while the resident was in a general acute care hospital. This resulted in an inaccurate clinical record, as confirmed by the ADON and DON, who stated the documentation was unacceptable and illegal.
A facility failed to ensure accurate documentation by an LVN, who recorded care for a resident while they were hospitalized. The resident, with multiple health conditions, was transferred to a hospital for shortness of breath, yet the LVN documented vital signs, pain assessments, and enteral feeding as if the resident were still in the facility. Interviews with the ADON and DON confirmed the documentation was inappropriate and illegal, as it falsely indicated care was provided. The LVN admitted to the mistake, acknowledging the failure to accurately document the resident's care.
The facility's kitchen was found in unsanitary conditions with debris, buildup, and dead cockroaches present. Observations revealed a golden-colored buildup behind the stove, debris on the floor in various areas, and a black substance on the pantry storage counter. The presence of dead cockroaches was also noted, indicating a failure to maintain cleanliness and pest control as per the facility's guidelines and FDA Food Code.
The facility failed to maintain an effective pest control program, evidenced by dead cockroaches in the kitchen and other areas. Staff confirmed awareness of the issue, and pest control reports indicated ongoing live cockroach activity despite treatments. The facility did not adhere to FDA Food Code requirements for pest prevention and cleanliness.
A resident developed a preventable Stage 3 pressure ulcer due to the facility's failure to implement the prescribed skin integrity care plan, including daily and weekly skin assessments. The resident, who had multiple diagnoses and moderate cognitive deficits, was admitted without pressure ulcers but later readmitted to an acute hospital with a Stage 3 ulcer. Staff interviews confirmed the care plan was not followed, and the Director of Nursing acknowledged the facility's failure to adhere to its skin integrity policy.
Failure to Document and Perform Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services and documentation met professional standards of quality and the facility’s own Charting and Documentation policy for five residents. Surveyors identified multiple instances where ordered wound and skin treatments were not documented on the Treatment Administration Records (TARs), and facility leadership consistently stated that if care was not documented, it was considered not done. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator all confirmed that complete and accurate documentation is required to reflect the care provided and that staff are expected to follow physician orders and document wound care after it is performed. For one resident with a history including metabolic encephalopathy, COPD, chronic venous hypertension with ulcer and inflammation of the left lower extremity, prediabetes, and dependence on a respirator and supplemental oxygen, physician orders directed daily-shift wound care to a venous stasis wound on the right lower leg and skin tears on both arms. Review of the TAR for December showed that on a specific day, there were no licensed staff initials for the ordered wound care during the day shift. The ADON stated that LVN 1 had been assigned to this resident for that shift and should have initialed the TAR to indicate the wound care was provided, but did not, and reiterated that if it was not documented, it was not done. For a second resident with diabetes mellitus type 2, cervical disc disorder with radiculopathy, and malignant neoplasm of the skin, the TAR contained an order to cleanse and dress a rash on the right hand every shift until the order was discontinued. On one night shift, there were no licensed staff initials to show that the treatment was provided. The DON stated that LVN 2 had been assigned to this resident that night and should have initialed the TAR but did not, and stated that if LVN 2 did not document the wound care, then it was not provided. For a third resident with hypertensive heart disease, dementia, diabetes mellitus type 2, malignant neoplasm of the prostate, and a cardiac pacemaker, the TAR showed an order for daily care of a skin tear with flap on the left dorsal hand, including cleansing with normal saline, applying steri-strips, and covering with a dry dressing. On a reviewed night shift, there were no licensed staff initials indicating that the ordered treatment was completed. The DON confirmed LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that lack of documentation meant the care was not provided. For a fourth resident with paraplegia, diabetes mellitus type 2, hypertensive chronic kidney disease, severe morbid obesity, and malignant neoplasm of the large intestine, the TAR contained orders to apply antifungal powder to a peri-anal rash every shift and as needed after incontinence episodes, and to cleanse and treat moisture-associated skin damage at the coccyx with a menthol and zinc oxide ointment every shift and as needed after incontinence. On the reviewed night shift, there were no licensed staff initials for these treatments. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR to show the treatments were provided but did not, and reiterated that if LVN 2 did not document the wound care, then it was not provided. For a fifth resident with congestive heart failure, COPD, diabetes mellitus type 2, severe morbid obesity, benign neoplasm of cranial nerves, schizoaffective disorder, and dependence on a respirator and supplemental oxygen, the TAR showed an order to cleanse abdominal folds, pat dry, apply antifungal powder, and monitor and report to the MD for worsening every shift for a fungal rash over a 14-day period. On the reviewed night shift, there were no licensed staff initials indicating that this treatment was performed. The DON stated LVN 2 was assigned to this resident that night and should have initialed the TAR but did not, and again stated that if LVN 2 did not document the wound care, then it was not provided. LVN 1 and LVN 2 were not available for interview. Another LVN stated that standard practice is to follow physician wound care orders and document after providing care, and that if wound care is not documented, it is considered not provided, emphasizing that documentation is required to indicate continuity of care and to reflect the wound care residents receive. The facility’s Charting and Documentation policy defined the resident’s clinical record as an account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition, and stated that it provides a multidisciplinary record of the physical and mental status of the resident. The identified missing documentation of ordered wound and skin treatments for all five residents showed that the facility did not adhere to this policy or to the stated standard of practice that care must be documented to demonstrate it was provided.
Unequal Treatment in Transfers, Discharges, and Services Based on Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Failure to Provide Restorative Nursing Services Post-PT Discharge
Penalty
Summary
The facility failed to provide necessary restorative nursing assistant (RNA) services to a resident after the discontinuation of physical therapy (PT) services. The resident, who was discharged from PT on March 6, 2024, did not receive the prescribed range of motion (ROM) exercises until February 4, 2025, resulting in a lapse of nearly 11 months. This failure potentially contributed to the development of a contracture in the resident's right hand, as observed by the occupational therapist during a reevaluation. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was initially receiving PT and occupational therapy (OT) services to address functional limitations and prevent further decline. Despite the PT discharge summary indicating a good prognosis with consistent staff follow-through, the transition to RNA services was not executed. The RNA program, which was supposed to maintain the resident's current level of function, was not implemented due to a lack of coordination and communication between the PT and RNA staff. Interviews with facility staff revealed that the process for transitioning residents from PT to RNA services was not followed. The RNA did not receive the necessary restorative therapy referral form from the PT, and the MDS Coordinator was not informed of the need for RNA services. The Director of Nursing acknowledged the breakdown in the process and the importance of following through with PT recommendations to maintain residents' activities of daily living (ADLs).
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to inform and provide written information on how to formulate an advance directive for four residents, which is a violation of their rights. The deficiency was identified through interviews and record reviews, revealing that the facility did not document information on how to obtain an advance directive in the residents' charts. This oversight could potentially prevent the residents' wishes from being followed if they become unable to make decisions. Interviews with residents revealed that they were not informed about the option to formulate an advance directive. For instance, one resident stated that the facility did not discuss advance directives with her, and another resident mentioned that he had provided a copy of his advance directive to the facility, but it was not documented in his medical record. The facility's staff, including the Licensed Vocational Nurse and the Social Services Director, acknowledged that there was no documentation of discussions about advance directives with the residents. The facility's policy and procedure documents indicate that residents should be informed of their rights to establish an advance directive upon admission. However, interviews with staff members, including the Director of Nursing and the Assistant Director of Nursing, revealed that the facility did not consistently follow these procedures. The Social Services Director and other staff members admitted that there was no documentation to show that residents were offered assistance with formulating an advance directive, highlighting a systemic issue in the facility's handling of advance directives.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. Two residents, identified as Resident 34 and Resident 57, experienced discomfort due to cold room temperatures at night. Despite complaints to the staff, the room temperatures were not maintained within the recommended range of 71-81 degrees Fahrenheit. The Maintenance Supervisor admitted to checking room temperatures only during the day and not at night, which contributed to the residents' discomfort and potential health risks. Another deficiency was observed in Resident 42's room, where a large hole and a smaller hole with exposed insulation and wiring were found behind the bed. The holes posed potential environmental hazards, including the risk of electrocution. Despite the presence of these hazards, no maintenance order was placed in the TELS system to address the issue, and the holes remained partially unaddressed for some time. The Maintenance Assistant and Supervisor acknowledged the oversight and the potential risks associated with the exposed wiring and uncovered outlets. Additionally, Resident 305 experienced issues with a malfunctioning bed and poor television reception, which affected the resident's comfort and quality of life. The bed was stuck in a seated position, and the TV channels were not clear due to antenna issues. Although the Maintenance Supervisor was aware of the problems, there was a lack of timely and effective repairs, as indicated by the absence of recent maintenance requests in the TELS system. These deficiencies highlight the facility's failure to provide a homelike environment and ensure the safety and comfort of its residents.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to properly store and label drugs and supplies in accordance with acceptable standards of practice. Two inhalers, belonging to two residents, were not labeled with an open date or expiration date. This oversight was confirmed during observations and interviews with LVNs and the Director of Infection Prevention. The lack of labeling could lead to the administration of expired medications, which may not be effective and could potentially cause adverse reactions. The facility's policy requires medications to be labeled with open and expiration dates to ensure their potency and effectiveness. Additionally, the facility did not maintain proper temperature control in two of its medication refrigerators. Observations revealed that the temperatures in these refrigerators were outside the recommended range of 36°F to 46°F. Medications stored in these refrigerators, belonging to three residents, were at risk of losing their potency due to improper storage conditions. Interviews with the ADON and DON confirmed that the refrigerators were out of range for several hours, and the medications stored within them were discarded and replaced. The facility's policy on the storage and expiration of medications emphasizes the importance of maintaining appropriate temperature and sterility conditions. The failure to adhere to these guidelines resulted in the potential degradation of medications, which could lead to ineffective treatment and adverse reactions for the residents involved. The report highlights the need for regular inspections and compliance with storage requirements to ensure the safety and efficacy of medications administered to residents.
Inaccurate Measurement of Ingredients in Pureed Diets
Penalty
Summary
The facility's cook staff failed to accurately measure milk and margarine while preparing a pureed rice recipe for 12 residents on a pureed diet. During an observation, Cook 1 used a 1/2 cup metal measuring cup three times to measure 1.5 cups of milk, but the milk did not level to the top edge of the measuring cup each time. Additionally, Cook 1 used a round plastic measuring cup to measure margarine, which left open areas between the block of margarine and the measuring cup wall, resulting in an inaccurate measurement. Cook 1 added a total of 2 additional cups of 2% milk to achieve the targeted pudding texture for the pureed rice. Cook 1 acknowledged the importance of following the recipe to ensure the correct consistency and nutrient content. The Registered Dietician (RD) confirmed the importance of following pureed recipes to achieve the right consistency and stated that additional milk would not significantly increase protein content or harm residents. However, the RD had not verified whether staff were properly measuring ingredients. The Director of Nursing (DON) stated that the facility did not have a policy for pureed food preparation but expected cooks to follow recipes. Cook 2, who also prepared pureed rice, described a different measurement approach, using a cylinder plastic measuring cup for milk and melted margarine for easier blending. The facility's job descriptions emphasized the importance of preparing food according to standardized recipes and ensuring high-quality food provision.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, as observed during a survey. A box of potatoes was found in the kitchen without a label indicating the received date or use-by date. The Dietary Manager (DM) acknowledged that the potatoes were not dated and stated that all food should be labeled to ensure kitchen staff are aware of how long food has been on the shelf. The Registered Dietician (RD) also confirmed that unlabeled or undated foods pose a risk of serving expired or spoiled food to residents, potentially leading to foodborne illnesses. Additionally, a dietary aide was observed scratching their ear and continuing to handle clean cups without washing their hands. The DM stated that staff should wash their hands after touching their head or face to prevent cross-contamination. The RD emphasized the importance of handwashing to promote infection control and food safety practices, noting that failure to do so could result in residents acquiring foodborne illnesses. Further observations revealed that thawing frozen beef kabobs in the walk-in refrigerator were not labeled with a prepared by or use-by date. The DM admitted that the kabobs should have been labeled and dated, as this practice helps prevent the use of old food that could be contaminated. Dust was also identified on the ceiling above the fan in the food storage room, which the DM stated could affect temperature control and lead to spoiled food. The Supervisor of Maintenance acknowledged the responsibility to clean the fan and ceiling, noting that dust in the storage room could create a fire hazard and potentially contaminate food, leading to foodborne illnesses for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. Resident 34's nebulizer mouthpiece was found on top of the machine next to a urinal, which was not stored in a bag as required to prevent cross-contamination. This oversight was acknowledged by both the Licensed Vocational Nurse and the Director of Infection Prevention, who confirmed that the improper storage posed a risk for respiratory infections. Resident 37's foley catheter bag and tubing were observed on the ground, which is against the guidelines for catheter maintenance. The Registered Nurse and the Director of Staff Development both recognized that this practice increased the risk of cross-contamination and infection. Similarly, Resident 152's urinal was found on a bedside table with food and personal items, which was not sanitary and posed a risk for infection, as noted by the Certified Nursing Assistant. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with surgical wounds, as observed with Residents 152 and 305. Licensed nurses did not use gowns during wound care, and therapy staff did not follow EBP when assisting Resident 306 with Activities of Daily Living. Additionally, Resident 505's oxygen tubing was found on the floor, which was not stored properly, increasing the risk of contamination. The facility's storage practices were also deficient, as evidenced by an opened debridement tray found in a treatment cart and staff personal belongings stored in a utility supply room, both of which posed potential infection control issues.
Failure to Maintain Secure Handrails in Hallways
Penalty
Summary
The facility failed to ensure that corridors were equipped with firmly secured handrails on each side, which increased the risk of falls for residents using the handrails for assistance with walking. During an observation in the Station 2 Hallway, a handrail was found to be broken and loose, and another was missing a curved piece of wood, exposing the metal bracket and screws. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged that broken and loose handrails posed a risk of injury to residents. The Maintenance Supervisor stated that the facility used the TELS System to notify the maintenance department of repair needs, and any staff member could access this system. Despite being notified of the broken handrails, the curved ends were obsolete and could not be replaced. The facility's policy and procedure documents emphasized the importance of maintaining a safe, clean, and comfortable environment, with regular facility rounds and oversight by the Executive Director, Director of Nursing, and Maintenance/Housekeeping Supervisor. However, the failure to maintain the handrails in good condition was a deviation from these policies.
Failure to Provide Dignity Bags for Catheter Drainage
Penalty
Summary
The facility failed to ensure dignity for two residents by not providing dignity bags for their foley catheter drainage bags, leaving the urine visible to anyone entering their rooms. For Resident 3, observations on multiple occasions revealed that the catheter bag was uncovered, and staff members, including CNAs and an LVN, acknowledged that this was against the facility's policy and did not provide dignity or privacy. The Director of Nursing confirmed that Resident 3's right to dignity was violated due to the lack of a privacy bag. Similarly, Resident 305 was observed with an uncovered catheter bag while lying in bed. The resident, who was cognitively intact, was unaware if the urinary bag was covered when outside the room. Staff members, including a CNA and an LVN, stated that a dignity cover should have been used to protect the resident's privacy and dignity. The facility's policies on resident rights and dignity emphasize the importance of maintaining resident privacy and treating them with respect and dignity.
Failure to Provide Written Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide written information regarding the bed hold policy to two residents, Resident 3 and Resident 455, during their transfers to the hospital. Resident 3 was transferred to the hospital without receiving a written notice of the facility's bed hold policy, despite verbal notifications being made to the resident's responsible party (RP). Interviews with the Licensed Vocational Nurses (LVN) and the Admissions Coordinator (AC) revealed that while verbal communication occurred, no physical documentation of the bed hold policy was provided, which is a requirement according to the facility's policy and procedure. Resident 455, who was cognitively intact, also did not receive a written bed hold policy upon transfer to the hospital. The Social Services Director (SSD) and LVN confirmed that the resident was not provided with the policy, as it was not standard practice for residents with non-Medi-Cal insurance. The facility's policy and procedure documents did not clearly mandate the provision of a physical copy of the bed hold policy upon transfer, leading to this oversight. The Director of Nursing (DON) acknowledged the importance of providing the bed hold policy to ensure residents and their representatives understand the terms and can ask questions if needed. The facility's failure to provide the necessary documentation could lead to confusion and disputes regarding bed availability and the terms of the bed hold, as the residents were not adequately informed in writing as required by the facility's own policies.
Deficiencies in Care Plan Implementation in LTC Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to potential risks and unmet needs. Resident 37 did not have a care plan developed for an indwelling Foley catheter, which was necessary due to a neurogenic bladder. This oversight was attributed to a breakdown in communication among staff, resulting in the absence of a care plan that could guide staff in monitoring and managing the catheter, potentially increasing the risk of infection and compromising the resident's safety. Resident 26's care plan interventions for visual needs were not implemented, resulting in the resident not wearing glasses for five days. This failure was due to staff not following the care plan, which required ensuring the resident wore glasses when up. The absence of glasses increased the risk of injury and decreased participation in activities of daily living, as the resident struggled with vision-related tasks and required assistance from staff. Residents 409 and 86 did not have care plans addressing the use of anticoagulants, which are critical for monitoring potential side effects such as bruising and bleeding. The lack of a care plan for Resident 409 meant that the resident did not receive education on anticoagulant side effects or complications, while Resident 86's care plan lacked monitoring interventions for bleeding or bruising. These deficiencies highlighted the importance of having individualized care plans to ensure appropriate monitoring and education for residents on anticoagulant therapy.
Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan for a resident, identified as Resident 120, after a stage two pressure ulcer had healed. The care plan still contained active treatment interventions for the ulcer, which had already resolved. This oversight was discovered during a review of Resident 120's records, which showed that the pressure ulcer had healed on January 15, 2025, but the care plan dated December 2, 2024, had not been updated to reflect this change. Interviews with staff, including CNAs and an LVN, revealed that care plans are essential for guiding resident care, and if they are not accurate, specific care for the resident could be missed. The Director of Nursing (DON) confirmed the importance of accurate care plans for communicating resident needs and acknowledged the potential for negative outcomes if care plans are not updated. The facility's policy and procedure on comprehensive care plans, dated December 2017, indicated that resident progress should be regularly evaluated and care plans revised as appropriate. The DON stated that the care plan for Resident 120 should have been resolved by the end of the nurse's shift on the day the wound was considered healed.
Oxygen Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to adhere to professional standards of practice for two residents, Resident 112 and Resident 306, regarding the administration of oxygen. Resident 112, who had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), emphysema, and obstructive sleep apnea, was observed receiving oxygen at a rate of 2.5 liters per minute (LPM) instead of the ordered 2 LPM. This discrepancy was noted over several days, and the registered nurse (RN) acknowledged the error, stating that the oxygen order was not followed. The Director of Nursing (DON) confirmed that the resident received more oxygen than ordered, which could be detrimental to the resident's health. Resident 306, who was admitted with multiple diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA), Parkinson's disease, and congestive heart failure, was observed with an oxygen flow rate set at 3 L/min instead of the prescribed 2 L/min. The Licensed Vocational Nurse (LVN) confirmed that the oxygen saturation was at 96% and did not require oxygen at the time, indicating that the physician's order was not followed. Additionally, Resident 306's oxygen tubing was not labeled with the date it was placed, which is a requirement to prevent infection and ensure timely changes of the equipment. The facility's policy and procedure for oxygen administration require checking the physician's order for the correct flow rate and method of administration, as well as labeling and changing the oxygen tubing regularly. The failure to follow these procedures for both residents put them at risk for potential health complications, including infection and respiratory issues. The Assistant Director of Nursing (ADON) emphasized the importance of following physician orders and maintaining proper labeling to prevent such risks.
Failure to Provide Proper Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for Resident 28, resulting in long, jagged, and uncomfortable toenails. Resident 28, who was admitted with a displaced intertrochanteric fracture of the right femur and required assistance with personal care due to muscle weakness and reduced mobility, reported discomfort from her toenails. Despite having no cognitive deficits, she relied on staff for toenail care, which was inadequately performed, leaving her toenails sharp and uneven. Interviews with staff, including CNAs and LVNs, revealed that routine toenail care was expected to be performed twice a week with each shower, including trimming, filing, and cleaning. However, Resident 28's toenails were observed to be long and jagged, with the right big toenail growing at an angle into the toe, causing discomfort. The staff acknowledged the risk of long, jagged toenails leading to potential injury or infection, yet the care was not documented or performed as required. The facility's policies and training materials emphasized the importance of proper toenail care to prevent infection and maintain hygiene. Despite this, the documentation on the Shower Day Inspection form indicated that Resident 28's routine toenail care was not completed. The Director of Nursing and other staff members confirmed the expectations for toenail care and the failure to meet these standards, as evidenced by the condition of Resident 28's toenails.
Improper Foley Catheter Management Poses Risk to Resident
Penalty
Summary
The facility failed to ensure a resident was free from accidents when the resident's foley catheter tubing was wrapped around her prosthetic right lower leg while she was sitting in her wheelchair. This situation posed a risk of causing a fall or injury to the resident, either by tripping her during a transfer or by the catheter being pulled from her bladder. The resident, who was cognitively intact, was unaware of the tubing being wrapped around her leg and acknowledged the potential danger it posed. Interviews with staff revealed that the catheter was identified as a trip hazard, and it was noted that the physical therapy assistant who transferred the resident was not trained on the proper placement of the catheter. The Director of Staff Development and other staff members acknowledged that the catheter should not have been wrapped around the resident's leg and that the facility's policies and procedures regarding falls management and incident management were not followed. The facility's Incident Management Policy emphasizes the need to provide a safe environment and reduce the incidence of reoccurrence, which was not adhered to in this case.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to post accurate daily staffing information, specifically the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). During an observation, it was noted that the Census and Direct Care Services Hours Per Patient Day (DHPPD) form did not include these details. The Assistant Staff Development Coordinator (ASDC) admitted that the posted form did not reflect the actual hours worked and that the detailed hours were only available on a separate worksheet not accessible to residents or their families. This omission prevented residents and their families from having access to the actual direct care staff hours and the total number of staff providing care daily. In an interview, the Administrator acknowledged that the DHPPD form lacked the necessary information about RN and LVN hours and confirmed that this information should have been posted. The Administrator was unaware of the requirement by the Centers for Medicare & Medicaid Services (CMS) to post such information. The facility used a form provided by the California Department of Public Health (CDPH), but it did not meet the CMS requirements. This oversight resulted in a deficiency as it failed to provide transparency to residents and their families regarding the staffing levels and hours worked by direct care staff.
Failure to Document Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, a resident was administered mirtazapine, a medication used to treat depression, from November 2, 2024, to February 6, 2025, without any documented attempts at a gradual dose reduction (GDR). The resident, who was admitted with diagnoses of depression and anxiety, received mirtazapine daily despite having no recorded depressive episodes. The Licensed Vocational Nurse (LVN) acknowledged that the resident would have benefitted from a GDR and confirmed that no GDR attempt was documented. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the last medication review was conducted in November 2024, but no GDR was recommended. The SSD admitted to not properly documenting the doctor's recommendation regarding a GDR, which would have explained why a GDR was not performed. The facility's policy on psychotropic medication management requires the interdisciplinary team to evaluate the necessity of such medications quarterly, including documentation of GDR assessments, which was not adhered to in this case.
Medication Administration Error for Potassium Chloride
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 556, was free from significant medication errors. The error occurred when RN 1 administered potassium chloride 20MEQ to Resident 556 without following the manufacturer's instructions. The instructions specified that the medication should be taken with a meal and that the resident should avoid lying down for at least 10 minutes after administration. However, RN 1 gave the medication at around 10:10 a.m., after the resident had breakfast at 7:30 a.m., and allowed the resident to lie back down immediately after taking the medication. Resident 556, who was cognitively intact with a BIMS score of 15, had a medical history of paroxysmal atrial fibrillation and gastro-esophageal reflux disease. The Assistant Director of Nursing confirmed that RN 1 did not adhere to the manufacturer's guidelines, which could have affected the medication's absorption and effectiveness. The facility's policy emphasized the importance of verifying medication instructions to prevent errors, but this was not followed in this instance.
Incomplete POLST for Resident in LTC Facility
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding the Physician Orders for Life-Sustaining Treatment (POLST). The POLST, which contains critical medical orders for end-of-life care, was not completed for the resident, who had been admitted to the facility from an acute care hospital with multiple diagnoses including MRSA, Parkinson's disease, schizoaffective disorder, congestive heart failure, and depression. The resident was observed to be cognitively intact with a BIMS score of 15, indicating the ability to make informed decisions about their care. During the review of the resident's records, it was found that there was no completed POLST on file, which was confirmed by the Medical Records Administrator (MRA). The MRA acknowledged the importance of the POLST in emergencies to ensure the resident's treatment preferences, such as DNR status, are honored. The Assistant Director of Nursing (ADON) also emphasized the significance of the POLST in respecting the resident's wishes for medical interventions. The facility's policy required timely completion and auditing of health records, but the POLST had remained incomplete for a month, which was deemed unacceptable by the ADON.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to provide services that meet professional standards of practice for a resident when an LVN did not perform necessary assessments and continued to document on the resident's clinical record during a period when the resident was admitted to a general acute care hospital. The LVN documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions that were not provided from December 25 to December 30, 2021, while the resident was hospitalized. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. The resident had been admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. On December 25, 2021, the resident was transferred to the hospital due to shortness of breath. Despite the resident's absence from the facility, the LVN documented various medical interventions and assessments as if they had been performed, which was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. The ADON and DON acknowledged that the documentation by the LVN was unacceptable and illegal, as it falsely indicated that services and treatments were provided when they were not. The LVN admitted to the mistake, stating that her electronic signature was on the Medication Administration Record (MAR) and that she was responsible for the inaccurate documentation. The facility's policy and procedure documents emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Inaccurate Documentation by LVN During Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a licensed nurse performed accurate assessments and documentation for a resident who was admitted to a general acute care hospital. The Licensed Vocational Nurse (LVN 1) documented vital signs, pain assessments, feeding tube assessments, enteral feeding intake, and non-pharmacological pain interventions for Resident 1 from December 25 to December 30, 2021, despite the resident being hospitalized during this period. This resulted in an inaccurate clinical record that did not reflect the resident's current medical status. Resident 1 had multiple diagnoses, including hemiplegia, hemiparesis, type 2 diabetes mellitus, morbid obesity, dysphagia, aphasia, vascular dementia, sepsis, and chronic kidney disease. The resident was transferred to the hospital on December 25, 2021, due to shortness of breath. Despite this, LVN 1 continued to document care and treatments as if the resident were still in the facility, including enteral feeding orders and pain management interventions. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that LVN 1's documentation was inappropriate and illegal, as it falsely indicated that care was provided when the resident was not present in the facility. LVN 1 admitted to the mistake, acknowledging that her electronic signature was on the Medication Administration Record (MAR) and that she failed to accurately document the resident's care. The facility's policies and procedures emphasize the importance of accurate documentation and adherence to professional standards, which were not followed in this case.
Unsanitary Kitchen Conditions and Pest Presence
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. There was a golden-colored buildup and debris accumulation behind the stove, and the floor in various areas, including next to the water inlet, behind the ice machine, and between the pantry and kitchen, was littered with soiled napkins, straws, beverage cups, wrappers, and food debris. The pantry floor had a dark granular substance and a dark glob, while the floor underneath the pantry wire storage rack was scattered with debris such as utensils, jelly cups, brown paper bags, napkins, a hairnet, and saltine crackers in plastic wrap. Additionally, a one-foot length of vinyl baseboard molding was found peeled off and on the floor in the pantry, and the pantry storage counter holding five-gallon water jugs had a black substance buildup. The presence of pests was also noted, with two dead cockroaches found under the food preparation table, one beneath the three-compartment sink area, and another caught in a web near the ceiling by the dishwasher. These unsanitary conditions were confirmed by both the Dietary [NAME] and the Dietary Manager during observations and interviews. The facility's Employee Handbook and the Food and Drug Administration's Food Code emphasize the importance of maintaining clean work areas and controlling pests, which the facility failed to adhere to, potentially risking foodborne illness among residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of multiple dead cockroaches in critical areas such as the kitchen floor beneath the food preparation area, the three-compartment sink, and behind the hallway ice machines. These observations were made during a survey, and interviews with staff confirmed awareness of the cockroach problem. The Dietary Manager and Dietary staff validated the presence of dead cockroaches in the kitchen and pantry areas, acknowledging the importance of cleanliness, which was not maintained. The facility's pest control company had previously treated the kitchen and other areas with roach gel bait, as indicated in service tickets from August 2024. However, the problem persisted, with live cockroach activity noted in the pest control reports. The Food and Drug Administration's Food Code requires that food establishments be protected against pests by sealing openings and maintaining cleanliness, which the facility failed to uphold, leading to the deficiency.
Failure to Implement Skin Integrity Care Plan
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as a moderate risk for developing pressure ulcers, did not develop such ulcers. The nursing care plan, which included daily and weekly skin assessments, was not implemented from 1/6/24 to 1/19/24. This failure resulted in the resident developing a preventable Stage 3 pressure ulcer on the sacrum area. The resident was admitted to the facility with no pressure ulcers or open skin and was later readmitted to an acute hospital with a Stage 3 pressure ulcer due to the facility's negligence in following the care plan. The clinical record review revealed that the resident had multiple diagnoses, including acute respiratory failure, generalized muscle weakness, hypertension, mild cognitive impairment, pneumonia, and morbid obesity. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive deficits. Despite the facility's policy requiring routine skin assessments and an interdisciplinary care plan to maintain skin integrity, these measures were not followed. The resident's skin was not assessed daily or weekly, leading to the late recognition of the pressure ulcer. Interviews with staff, including a CNA and RN, confirmed that the resident's skin integrity care plan was not implemented. The CNA, who was new and assigned to the resident, did not receive proper instructions or documentation regarding the resident's skin assessment. The RN and Assistant Directors of Nursing (ADONs) acknowledged the failure to conduct the required skin assessments. The Director of Nursing (DON) admitted that the facility did not follow its policy on skin integrity, contributing to the development of the Stage 3 pressure ulcer.
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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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