Pleasanton Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasanton, California.
- Location
- 300 Neal Street, Pleasanton, California 94566
- CMS Provider Number
- 056392
- Inspections on file
- 21
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Pleasanton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Food service safety and sanitation deficiencies were identified when a dented can of cherry pie filling was stored with regular cans instead of in the designated dented can area, a cheese grater with a broken plastic rim was hung with clean prep items, and a green cutting board with yellow debris and deep marring was stored with clean equipment. The DM confirmed each issue and referenced facility policy requiring dented cans to be set aside and cutting boards to be cleaned and sanitized after each use.
Two cognitively intact residents, each admitted with fractures, reported that a CNA provided rough physical care and used foul language during personal care, causing distress. One resident informed a CNA on the next shift, who notified an LVN and obtained a written statement from both residents, then followed a CC’s direction to place the statement under the DSD’s door. Despite this, the allegation was not brought to Social Services or the abuse coordinator (the Administrator) until several days later, and CDPH was notified by fax only after that delay, contrary to the facility’s policy requiring immediate, but no later than 2-hour, reporting of alleged abuse.
Self-Administration of Unassessed Medications: A resident with muscular dystrophy was observed keeping Biotin, Vitamin K2, Vitamin D3, Vitamin E, and Magnesium Glycinate at bedside and stated she took them independently each day. An LVN confirmed the resident was self-administering the supplements, but the IDT had only determined self-administration was appropriate for Vitamin D, with a physician order for that medication only. The IDT had not completed the required assessment for Biotin, Vitamin E, or Magnesium Glycinate, and there were no corresponding self-administration orders or MAR documentation for those supplements.
A resident with CHF was transferred to the ED after developing SOB, low O2 sat, and edema, but the facility had no documented evidence that a written bed-hold notification was given to the resident or his representative at the time of transfer. The BOM confirmed there was no record of a Bed Reservation Notification or other documentation showing the resident and/or representative were informed of bed-hold rights.
A resident with Type 2 DM and poor chewing ability had a physician-ordered soft and bite sized diet, but the care plan still listed a regular texture diet. The resident said he had only two bottom teeth and needed his food cut up. The CM confirmed the care plan was not updated to match the current diet order, and the DON stated care plans were expected to reflect current orders.
Unsecured treatment cart keys were left at the nursing station and later identified as belonging to an open cart with wound care supplies. In addition, a resident with muscular dystrophy had self-administered supplements, including Biotin, Vitamin K, Vitamin E, and Magnesium Glycinate, stored unsecured on an open shelf in a shared room; an LVN confirmed the medications were not locked or secured, and the DON stated medications should be kept in a locked box accessible to the resident.
Infection control PPE was not followed for two residents. A resident on contact precautions for C. diff had staff enter the room without the required gown, and another staff member entered without gown and gloves while interacting with the resident and meal tray. In a separate event, an LVN entered a resident’s EBP room without a gown and administered meds through a G-tube while her clothing contacted the bed and bedside table; the ICP stated gown use was required for this task.
A resident with fractures after a fall did not receive a STAT X-ray in a timely manner when the contract vendor failed to arrive and staff did not follow up, resulting in imaging being completed much later at an outside hospital. Another resident with dementia and chronic back pain received PRN acetaminophen for pain rated above the ordered mild-pain range, and the LVN did not notify the MD to clarify the order or reassess pain management.
Surveyors found multiple failures in kitchen sanitation and food storage, including dirty equipment, expired and unlabeled food items, improper storage of bulk ingredients, and unclean food-contact surfaces. The kitchen environment was not maintained, with grease and debris on cooking equipment, dirty drains, and unsealed flooring, creating conditions that could lead to food contamination.
A resident with a history of hemiplegia and dysphagia requiring a GT received medications through the tube without the LVN verifying tube placement as required by medical orders and facility policy. The LVN admitted to not checking placement before administering medications, and the DON confirmed that verification should occur before each use.
The facility failed to follow the recipe for preparing pureed chopped beef steak for 11 residents on a pureed diet. A staff member did not measure the ingredients as per the recipe, which was acknowledged during an interview. The Dietary Director and RD noted that this could dilute the nutritional value of the food. Interviews with facility leadership confirmed the expectation that recipes should be followed.
A resident admitted with hearing aids did not have this need documented in their baseline care plan, contrary to facility policy. Staff interviews confirmed the oversight, and both the DON and Administrator acknowledged the requirement to include such information in the care plan.
A resident at high risk for falls did not have a documented fall prevention intervention implemented, as staff were unaware of the care plan directive to place a floor/landing pad next to the bed. Despite the resident's need for substantial assistance and moderate cognitive impairment, the intervention was not consistently applied, indicating a communication breakdown among staff.
Food Storage and Equipment Sanitation Deficiencies
Penalty
Summary
Food service safety and sanitation requirements were not followed when a 7-pound can of cherry pie filling with a dent near the top was observed in dry storage with regular cans instead of in the designated dented can area. During the observation, the Dietary Manager confirmed the can was dented and stated it did not belong with the regular cans and should have been placed in the designated dented can area. The facility policy stated that dented cans will not be served and will be labeled and set aside in a designated area for return. Food preparation equipment was also found stored with clean items despite being damaged or soiled. A cheese grater with a broken red plastic rim and separated plastic was observed hanging with clean food preparation items, and the Dietary Manager confirmed it should not have been stored for use and stated it should have been discarded because it could lead to an infection control issue. In addition, a green cutting board stored with clean equipment had yellow debris on it and deep marring on one side; the Dietary Manager confirmed the debris and marring and stated it should have been replaced to prevent bacteria growth. The facility policy stated cutting boards are to be cleaned and sanitized after each use.
Failure to Timely Report Alleged Rough Care and Verbal Abuse to CDPH
Penalty
Summary
The facility failed to timely report an allegation of abuse to the California Department of Public Health (CDPH) within the required two hours for two cognitively intact residents. One resident, admitted with a right talus fracture and with a BIMS score of 13, reported that on a PM shift a CNA provided rough care while cleaning her after a bowel movement, continued despite her complaints of pain, and used foul language while providing care to her roommate, who became very upset. The following morning, the resident informed a CNA on the AM shift about the rough and rude care provided to both her and her roommate. The CNA who received the report stated she informed an LVN, who instructed her to obtain a written statement from both residents. After obtaining the shared statement, the CNA asked the Clinical Coordinator what to do with it and was told to slide it under the DSD’s door, which she did during the same AM shift. The DSD later stated that the CNA, LVN, and Clinical Coordinator were aware of the allegation on that date, but it was not reported to Social Services or to him until five days later, at which time Social Services notified CDPH. The Administrator, identified as the abuse coordinator, confirmed that rough care by a CNA is considered an allegation of abuse and that the allegation involving the two residents was not reported to CDPH within two hours, contrary to the facility’s abuse investigation and reporting policy requiring immediate reporting, but no later than two hours, for alleged abuse or incidents resulting in serious bodily injury.
Self-Administration of Unassessed Medications
Penalty
Summary
The facility failed to follow its policy and procedure for self-administration of medications for one sampled resident with muscular dystrophy. During observation, the resident was seen in bed with bottles of Biotin, Vitamin K2, Vitamin D3, Vitamin E, and Magnesium Glycinate stored on a shelf next to the bedside, and the resident stated she took the supplements independently every day. An LVN confirmed the resident had medications at bedside and was self-administering them in her room. The case manager stated the interdisciplinary team had determined it was clinically appropriate for the resident to self-administer Vitamin D and a physician order existed for that medication, but the team had not determined whether it was appropriate for the resident to self-administer Biotin, Vitamin E, or Magnesium Glycinate, and there was no physician order for those supplements. The self-administration medication safety screen indicated the assessment should be completed before self-administration begins and with medication changes, but the resident was not screened for Biotin, Vitamin E, or Magnesium Glycinate. The order summary and MAR also did not show self-administration orders or documentation for those medications.
Failure to Provide Bed-Hold Notification at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold notification to Resident 142 and/or his representative when the resident was transferred to an acute care hospital on 1/21/2026. Resident 142’s admission record showed a diagnosis of congestive heart failure. On 1/21/2026 at 3:59 p.m., progress notes documented shortness of breath, a respiratory rate of 21-22, oxygen saturation of 83 percent, and edema, and the resident was then sent to the hospital. Transfer orders dated 1/21/2026 indicated transfer to the emergency department. A review of the clinical record found no documented evidence that a bed-hold notification was provided to Resident 142 and/or his representative at the time of transfer. During an interview on 4/22/2026 at 2:56 p.m., the Business Office Manager stated there was no documented evidence of a written Bed Reservation Notification or any documentation showing that Resident 142 and/or his representative were informed of the bed-hold upon transfer to the hospital. The facility policy titled Bed-Holds and Returns stated residents and/or representatives are to receive written information about bed-hold policies at least twice, including at the time of transfer or within 24 hours if the transfer is an emergency.
Care plan not updated to match current diet order
Penalty
Summary
The facility failed to update the nursing care plan for one resident with Type 2 Diabetes Mellitus and a physician-ordered soft and bite sized texture diet. The resident’s admission record dated 4/21/2026 identified the diabetes diagnosis, and the physician’s orders dated 4/19/2026 showed the resident was on a soft and bite sized diet. During interview, the resident stated he was on a regular diet, showed that he had only two bottom teeth, and said he could not chew well and needed his food cut up. During concurrent interview and record review on 4/22/2026, the resident’s At Risk for Altered Nutritional Status care plan, last revised 4/10/2026, was reviewed and found to still indicate a regular texture diet. The CM stated the altered nutritional care plan was not updated to match the current physician’s diet order and that the care plan should match the current diet order to avoid confusion. The DON stated the expectation was for the care plan to be updated to reflect residents’ current orders. The facility policy on care plans stated that assessments are ongoing and care plans are revised as residents’ conditions change.
Unsecured treatment cart keys and resident self-administered medications
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when a set of keys for a treatment cart was left unattended and unsecured at Nursing Station 1. During a concurrent observation and interview, an LVN retrieved the keys from a black binder on top of the counter and identified them as the keys for an open treatment cart containing ointments, creams, and wound care supplies. The DON stated the expectation was for treatment cart keys to be held by nurses at all times. Self-administration medications for Resident 44 were also not stored in a locked compartment. Resident 44, who was admitted with muscular dystrophy, had Biotin, Vitamin K2 and D3, Vitamin E, and Magnesium Glycinate observed unsecured on an open shelf next to the bedside in a shared room. Resident 44 stated the supplements were taken every day and stored on the shelf. An LVN confirmed the medications were not locked or secured, and the DON stated all medications should be stored in a locked box accessible by the self-administering resident. The facility policy stated self-administered medications are to be stored in a safe and secure place not accessible by other residents.
Infection Control PPE Not Followed for Contact Precautions and EBP
Penalty
Summary
The facility failed to follow infection control practices for two residents. Resident 150 had a diagnosis of a displaced intertrochanteric fracture of the left femur and was placed on contact precautions for pending C. diff test results, with later laboratory results showing C. diff positive. A contact precautions sign was posted at the room entrance directing visitors and personnel to perform hand hygiene before entering, wear a gown and gloves, and wash hands with soap and water before leaving the room. During observation, a Maintenance Assistant entered Resident 150’s room to fix the television while wearing gloves and a face mask but no gown. In a separate observation, a CNA entered the room without a gown and gloves, spoke with the resident, moved items on the meal tray, and then sanitized her hands before leaving. In interviews, the Maintenance Assistant stated he should have worn a gown, and the CNA stated she believed PPE was only needed for direct care such as changing an incontinent brief. The Infection Control Preventionist stated both staff members should have worn the appropriate PPE, including a gown, before entering the room and that staff should wash hands with soap and water before leaving a room on contact precautions for C. diff. Resident 8 was admitted with esophageal obstruction and had an order for Enhanced Barrier Precautions related to enteral feeding, with instructions to perform hand hygiene and apply PPE including gloves, gown, and/or goggles/face shield. During observation, an EBP sign was posted at the doorway indicating gown and glove use. An LVN entered the room with water and morning medications, donned gloves but no gown, and accessed the resident’s G-tube to administer medications while her clothing contacted the bed and bedside table. The LVN stated she did not think a gown was required for medication administration in an EBP room, while the Infection Control Preventionist stated gowns should be worn when medications are administered through a G-tube and that not wearing a gown created a risk for transmitting MDROs to the resident.
Failure to Timely Complete STAT Imaging and Follow PRN Pain Order
Penalty
Summary
A STAT X-ray ordered for a resident after a fall was not implemented in a timely manner. The resident had diagnoses including muscular dystrophy and fractures of the first and second thoracic vertebrae, and had an intact BIMS score. After the resident fell during therapy, the provider ordered an immediate X-ray at 1:17 p.m. on 1/30/2026. The X-ray was not completed until 5:40 p.m. on 1/31/2026, and the resident was transferred to an outside hospital for the imaging after the contract vendor did not show up and the facility did not follow up with the vendor. A second resident with diagnoses including lumbosacral spondylosis and unspecified dementia had PRN acetaminophen ordered for mild pain only, 1-4 on the pain scale. The resident had a BIMS score of 4 and was observed in a wheelchair complaining of low back pain. The resident and his son stated he had frequent back pain and was not sure he had received pain medication. The MAR showed acetaminophen was given when the resident reported pain rated at 6, and the LVN confirmed the medication was administered despite the pain level being above the ordered range. The DON confirmed the resident had five April 2026 occurrences of pain higher than 4 and received acetaminophen, and stated staff should have notified the physician to clarify the order and have the resident re-evaluated for pain management before administering the medication. The facility policy stated diagnostic services should be promptly carried out as ordered and pain medication should be implemented as ordered, with ongoing communication between the prescriber and staff for optimal use of pain medications.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and kitchen sanitation standards, as evidenced by multiple observations of unsanitary conditions and improper food handling. Surveyors observed that the ice machine floor drain was dirty and covered in black film and debris, and the two-compartment sink used for food preparation had a build-up of food and debris. Food items in the walk-in refrigerator and pantry were found to be stored beyond their use-by dates, and many items lacked proper labeling, including use-by or expiration dates. Additionally, an open jar of mayonnaise was left unrefrigerated, and a large box of thickener was left unsealed and exposed, contrary to facility policy and USDA recommendations. Kitchenware and food-contact surfaces were found in poor condition and not properly cleaned. Multiple pans, trays, and utensils had grease build-up, metal flakes, and visible food residue, while some equipment, such as the can opener, blender, and food processor, were not cleaned after use and had accumulated food particles and debris. The food processor was also broken, with dried debris in the damaged area. Drawers used to store utensils contained food particles and dirty equipment, and some utensils were visibly dirty or in disrepair, with melted handles and substances that could not be removed by wiping. The physical environment of the kitchen was also not maintained in a clean and safe manner. The stove and oven had significant grease and food residue build-up, and a kitchen oven mitt was found on the stove top, contrary to facility policy. The dishwashing area had a dirty grease trap, black slimy build-up in the drain, and a floor with accumulated sludge and an unsealed gap between the tile and wall. These conditions were confirmed by both the Certified Dietician and the Director of Maintenance, who acknowledged that such uncleanliness could lead to illness and attract pests. The report documents that these failures had the potential to result in contamination of food and foodborne illness for all residents in the facility.
Failure to Verify Feeding Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to verify the placement of a gastrointestinal tube (GT) prior to administering medications to a resident. The resident, who had a history of hemiplegia and dysphagia resulting in GT placement, was observed receiving two crushed medications diluted in water through the GT without confirmation of proper tube placement. The LVN attached a syringe to the feeding tube, flushed it with water, and administered the medications using gravity flow, but did not check the GT position immediately before the procedure. The resident's medical orders specifically required verification of GT placement before administering feedings or medications. During interviews, the LVN acknowledged not checking the GT placement before the medication administration and stated that she typically only checked placement at 8 a.m. before the first water flush. The Director of Nursing confirmed that GT placement should be verified before each administration of medication or feeding. Facility policy and national guidelines also require verification of tube placement prior to administering medications or feedings.
Failure to Follow Recipe for Pureed Diets
Penalty
Summary
The facility failed to adhere to the recipe for preparing pureed chopped beef steak for 11 residents who were on a pureed diet. The facility's policy on Texture and Consistency Modified Diets mandates that the food and nutrition services department is responsible for preparing and serving food and beverages in the correct consistency as ordered. However, during the preparation of pureed beef, a staff member did not measure the amount of water and beef base added to the ground beef, nor did they follow the specified recipe instructions. This deviation from the recipe was acknowledged by the staff member when questioned about the correct amounts of broth and beef to be used. Interviews with the Dietary Director, Registered Dietitian (RD), Director of Nursing, and the Administrator revealed a consensus that the cooks were expected to follow recipes when preparing pureed foods. The RD highlighted that adding too much liquid could dilute the nutritional value of the food, which was a concern shared by the Dietary Director. The deficiency was observed through a combination of document reviews, interviews, and direct observation, indicating a systemic issue in the preparation of pureed diets for the affected residents.
Failure to Document Hearing Aid Use in Baseline Care Plan
Penalty
Summary
The facility failed to include a resident's use of hearing aids in the baseline care plan within 48 hours of admission, as required by their policy. The resident, who was admitted with hearing aids, did not have this need documented in their care plan. This oversight was identified during a review of the resident's admission records and baseline care plan tool, which showed no indication of the need for hearing aids, despite the resident being admitted with them. Interviews with facility staff, including a Certified Nurse Aide and a Licensed Vocational Nurse, confirmed that the resident used hearing aids and that this was not reflected in the care plan. The Director of Nursing and the Administrator both acknowledged that the facility's policy required the inclusion of such information in the care plan, indicating a lapse in adherence to established procedures.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a documented fall intervention for a resident identified as being at high risk for falls. The resident, who was readmitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, required substantial assistance with transfers and had moderate cognitive impairment. The care plan, revised upon readmission, included an intervention to place a floor/landing pad next to the resident's bed to prevent falls. However, observations on multiple occasions revealed that the floor/landing pad was not in place while the resident was in bed. Interviews with staff members, including a Licensed Vocational Nurse (LVN) and a Certified Nurse Aide (CNA), indicated a lack of awareness regarding the intervention to place a floor/landing pad next to the resident's bed. The charge nurse and CNA assigned to the resident were not informed of this specific intervention, and the LVN who implemented the intervention expected it to be consistently in place. The facility administrator expressed an expectation for staff to adhere to the policy and procedure, highlighting a communication breakdown in ensuring the intervention was consistently applied.
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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