Riverside Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8781 Lakeview Avenue, Riverside, California 92509
- CMS Provider Number
- 555330
- Inspections on file
- 116
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 97 (2 serious)
Citation history
Health deficiencies cited at Riverside Postacute Care during CMS and state inspections, most recent first.
The facility failed to provide required quarterly trust account statements to multiple residents and a responsible party whose personal funds were managed in facility-held trust accounts. Several alert and oriented residents reported not receiving any quarterly statements despite having active trust accounts, including residents with documented capacity to make decisions and one with a BIMS score indicating intact cognition. Another resident’s responsible party reported never receiving statements for her family member’s trust account, even though the resident had severe cognitive impairment and the RP was designated to manage finances. The BOM stated that statements were only provided upon request and that none had been issued since his employment began, while the ADM stated statements were supposed to be automatically mailed but acknowledged there was no procedure to ensure they were sent or received, and no relevant policies were produced when requested.
The facility improperly charged four residents’ trust accounts for private room and board during a month when each had documented Medi-Cal coverage. Business records showed that each resident’s trust account was debited the same substantial amount for private room and board while Eligibility Responses confirmed Medi-Cal benefits for that period, and payer setup information or billing practices reflected private pay status instead of Medi-Cal. The BOM acknowledged that these residents were switched from Medi-Cal to private pay despite having billable Medi-Cal benefits and that their trust funds should not have been charged, and the ADM confirmed residents are not supposed to be billed for Medi-Cal-covered services. The facility’s admission agreement also stated that a Medi-Cal-participating facility may not require a resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
The facility changed four residents from Medi-Cal coverage to private pay and debited $16,197.50 from each of their trust accounts for private room and board without obtaining consent from the residents or, where applicable, their responsible party. Business office records and eligibility responses showed that all four residents had billable Medi-Cal benefits for the month in question, yet payer setup documents reflected private pay billing for that period, followed by a later switch back to Medi-Cal-IEHP. The residents, who had diagnoses including dementia, schizophrenia, psychotic disorder, metabolic encephalopathy, and altered mental status, were either self-responsible or had a designated responsible party, but interviews revealed they were unaware of having a facility-managed account or of any large withdrawals, and one responsible party stated she did not know a trust balance existed. The Accounts Receivable Director, Business Office Manager, and Administrator acknowledged that the residents did not request the change to private pay, that the debits were made by facility decision despite Medi-Cal eligibility, that there was no documented consent for the withdrawals, and that residents are not supposed to be charged for Medi-Cal-covered benefits, while census records showed all four residents remained in three-bed rooms with roommates during the period they were charged for private room and board.
A resident with severe cognitive impairment had a trust account balance of over $14,000, far above the $2,000 threshold that staff, including the DAR and BOM, identified as placing Medicaid/SSI eligibility at risk. Although facility practice required notifying the resident or RP and arranging an IDT meeting to discuss spend down when a trust account exceeded this limit, there was no documentation that the RP was informed. The RP later stated she did not know a trust account existed, believed the resident’s Social Security income was used entirely for room and board, and had never been told about the balance or its impact on Medi-Cal/SSI eligibility. Requested policies on notification of account balances and benefit eligibility limits were not provided.
A resident with decision-making capacity and multiple chronic conditions was assessed and approved to self-administer only a specific bowel care medication, yet surveyors observed numerous additional OTC and supplement medications stored at the bedside and taken as needed by the resident without documentation. Nursing staff and the DON reported that residents are not permitted to keep or self-administer medications without physician orders and inclusion on a self-administration assessment, and that self-administered doses must be reported for MAR documentation. The DON confirmed that the medications found at the bedside were not ordered, not included on the self-administration assessment, and were not being tracked, contrary to the facility’s self-administration policy requiring IDT review, secure storage, and clear documentation processes.
A resident with significant neurologic and cognitive impairments, who was dependent on staff for mobility and incontinence care, activated the call light for a brief change and waited 31 minutes before staff responded. During this period, other staff entered the room but did not address the illuminated call light. The assigned CNA was on a meal break, while the TN and a housekeeper later confirmed that all staff are responsible for answering call lights, which facility policy states should be addressed and, if possible, completed within five minutes.
The facility failed to notify four residents and/or their responsible parties when their primary payor was changed from Medi-Cal IEHP to private pay, contrary to resident rights and the facility’s pay source conversion policy. Electronic census records showed that all four residents were converted to private pay effective the same date, but interviews with cognitively intact and moderately impaired residents revealed they were unaware they were paying privately or what the costs were, and a responsible party reported receiving no notification of the change. The BOM, ADM, and DOF gave conflicting accounts of responsibility and communication processes, with the BOM stating she was not informed of the corporate-initiated changes, the ADM stating the BOM should notify residents and report changes in meetings, and the DOF stating that facility leadership should explain and document payor changes, while also acknowledging the decision to convert these residents to private pay was made at the facility level without documented Medi-Cal direction.
A resident with a history of TIA and vascular dementia, documented as self-responsible and able to make decisions, authorized the LTCO in writing to obtain copies of the resident’s financial records, including trust account reports, representative payee documents, and a financial summary of coverage and share of cost. The LTCO emailed this request and the signed consent to the BOM, who stated she normally provides such financial information promptly and is expected to respond within 24 hours and fulfill requests by the next business day. Despite this, the BOM did not provide the requested records, and 12 days elapsed without fulfillment of the request, resulting in a failure to provide timely access to the resident’s financial records as required.
Two residents with significant cognitive impairment were not protected from abuse. In one case, a dependent resident with dementia and severe cognitive deficits was left unsupervised on a smoking patio, where a cognitively intact resident was witnessed by a CNA touching the resident’s breast and attempting to raise the resident’s shirt while the resident said "no." In the other case, a resident with traumatic brain injury, Parkinson’s disease, psychosis, and no decision-making capacity was heard screaming while a CNA stood over the resident and repeatedly told the resident to "shut up," as reported by another cognitively intact resident to an LVN. These events occurred despite facility policies stating residents must be free from sexual and verbal abuse and treated with respect and dignity.
Surveyors found that two residents who smoked were keeping cigarettes and lighters at their bedsides, despite staff statements and facility policy that residents were not allowed to have smoking materials and that only activities staff should control them. One resident, with nicotine dependence and decision-making capacity, was documented as a non-smoker and had no current smoking assessment reflecting his actual smoking status, yet was allowed to smoke without a valid assessment or supervision. Another resident, with COPD, diabetes, major depressive disorder, and fluctuating decision-making capacity, had a care plan requiring supervised smoking with all smoking materials kept in a smoking cart, but was observed with both cigarettes and a lighter in her nightstand. The DON confirmed that assessments and practices did not align with facility policy, which allowed independent smokers to keep cigarettes but prohibited residents from keeping lighters.
Staff failed to follow the facility’s hydration process and policy requiring NOC shift CNAs to replace and refill bedside water pitchers daily, resulting in two residents being observed on consecutive days with teal water pitchers only one-quarter full and not refilled. Both residents, who had conditions including DM, CKD, hypotension, lung CA, and a moderate cognitive deficit, reported that their pitchers had not been refilled for at least two days, despite care plans directing staff to encourage fluids, in-between snacks and fluids, and good nutrition and hydration to support skin health. A CNA acknowledged that the NOC shift appeared not to have refilled the pitchers, and the ADM stated that this failure could place residents at risk for dehydration.
An LVN entered the room of a COVID-19 positive resident posted with contact and droplet precaution signage wearing only a surgical mask, gown, and gloves to check blood sugar, despite facility policy and CDC guidance requiring an N95 respirator and eye protection for care in a COVID isolation area. The LVN acknowledged that an N95 and face shield should have been used, and both the IP nurse and DON confirmed that proper PPE for this situation included gown, gloves, N95 respirator, and face shield, in accordance with the facility’s written COVID-19 infection prevention and control policy.
A CNA placed a towel over a non-verbal, dependent resident's mouth during care while the resident was coughing, as the CNA was not wearing a mask. Another CNA witnessed and intervened, removing the towel. The resident was unharmed, and facility leadership confirmed this action violated abuse prevention policy.
A facility failed to report an allegation of physical abuse involving a resident with fluctuating decision-making capacity to CDPH within the required two-hour timeframe. A CNA witnessed another CNA place a towel over a resident's head and mouth but delayed reporting the incident, resulting in a two-day gap before authorities were notified, contrary to facility policy and federal requirements.
A resident with end stage renal disease and significant mobility limitations was transported to dialysis appointments via Uber instead of a wheelchair van, resulting in unsafe transfers, missed or delayed dialysis, and actual injury including a chest-wall hematoma and possible rib fractures. Staff and the resident reported the transportation was inappropriate and uncomfortable, and the facility did not conduct an interdisciplinary assessment of transportation needs prior to arranging Uber rides.
A resident with mobility limitations and recent foot surgery was transported to dialysis appointments in a standard vehicle instead of a wheelchair-accessible van after the facility changed transportation providers without updating the care plan or involving the resident and family. The care plan lacked interventions for safe transport, and the change led to missed treatments, hospitalization, and injury.
A resident with a history of playing loud music and verbally abusing others was not effectively managed, despite ongoing complaints and documentation of the behavior. Staff failed to implement or update care plans or interventions, resulting in another resident feeling threatened and verbally abused. The responsible resident was cognitively intact and refused offered interventions, but no further actions were taken to address the situation.
A resident with diabetes and peripheral vascular disease developed a new skin avulsion on the left second toe after podiatric treatment. The wound was not consistently evaluated or monitored as a change of condition, and required documentation and shift-to-shift monitoring were not completed, resulting in a deficiency in care.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident was re-admitted with open wounds and peripheral vascular disease, but did not receive wound treatment for three days due to the absence of physician orders and lack of documentation. Staff interviews confirmed that the admitting RN did not obtain or clarify treatment orders, and the facility's policy requiring prompt notification and treatment for skin breakdown was not followed.
A CNA was witnessed by two staff members roughly pushing a cognitively impaired resident multiple times to prevent the resident from getting up from bed. The resident, who had severe cognitive impairment and multiple mental health diagnoses, was found with redness and swelling on the face after the incident. Facility policy prohibits any form of abuse or rough handling.
A resident at high risk for pressure injuries was re-admitted with a blister on the right elbow that was not assessed, documented, or treated by nursing staff. The lack of assessment and intervention allowed the blister to worsen, resulting in a Stage 4 pressure injury with exposed bone, contrary to facility policy and standard nursing protocols.
A resident with dementia and moderate cognitive impairment reported being physically abused by a CNA. Although the administrator was notified, the required report to CDPH was not made within the mandated two-hour timeframe, as confirmed by staff interviews and documentation review.
A resident with a G-tube for dysphagia experienced a clogged tube, and an LVN attempted to clear the blockage using forceful and inappropriate techniques, including milking the tube and applying A&D ointment, which resulted in a tear in the tubing. Facility policy required gentle flushing with warm water and physician notification if unsuccessful, but these procedures were not followed, leading to the resident being sent to the hospital for tube replacement.
Two residents with intact decision-making capacity were transferred to a hospital for acute medical conditions without receiving written notice of the facility's bed hold policy at the time of transfer. Nursing staff did not complete the required bed hold consent forms, and interviews revealed confusion about the policy requirements, despite facility policy mandating written notification upon transfer.
The facility did not consistently offer or provide enough bedtime snacks to all residents, as confirmed by resident reports, staff interviews, and direct observation. A resident with diabetes was not provided with appropriate sugar-free snack options, and staff indicated that the available snacks were insufficient to meet resident needs, with shortages of preferred items like fruit and no snacks left for those who missed the initial distribution.
Trash, used gloves, and food residuals were found on the ground around the dumpsters and gate area outside the kitchen. Both the FNS Director and RD confirmed that the area should be kept clean to prevent pest attraction and infection control issues, in accordance with facility policy.
Multiple residents reported long waits for assistance with ADLs, call lights, and medication, while staff interviews confirmed significant staffing shortages, especially on night shifts. CNAs were assigned high numbers of residents, often exceeding recommended ratios, and were unable to complete care tasks efficiently. Facility records showed that required CNA care hours were not consistently met, leading to delays in care, residents being left in soiled conditions, and overall negative impacts on resident well-being.
Multiple residents experienced discomfort due to cold room temperatures, with several rooms recorded below the recommended range and staff also reporting feeling cold during night shifts. In addition, residents' personal clothing was not washed or distributed in a timely manner due to broken laundry equipment and insufficient laundry staff, leading to missing belongings and piles of unfolded clothes. The facility lacked proper documentation of equipment checks and did not have a policy for laundry services.
Surveyors identified multiple deficiencies in medication labeling and storage, including IV bags without beyond use dates, expired and discontinued medications stored with active stock, and insulin vials and pens lacking open dates or kept beyond recommended periods. Staff interviews confirmed that these practices did not follow facility policy or manufacturer instructions.
Surveyors found that dietary staff did not follow proper food safety and sanitation procedures, including incorrect use of Quat sanitizer, improper cleaning of meal carts, and lack of knowledge on thermometer calibration and required submersion times for kitchenware. These failures affected all residents receiving food from the kitchen.
Multiple failures occurred in food service, including not adding required margarine to fortified diets, lack of labeling to distinguish diet Jello for CCHO diets, and improper portioning of salad, meat, and cheese in meals. These actions resulted in residents not receiving meals as prescribed by their diet orders and facility policies.
Multiple residents reported that meals were frequently served cold, bland, and lacking variety, with some noting that hot foods were only warm and cold foods, such as ice cream, were sometimes melted. A test tray evaluation confirmed that food items were below required serving temperatures and that pureed foods did not have the correct texture. The Food and Nutrition Service Director and Registered Dietitian acknowledged these issues, which were not in line with facility policies for meal service and food preparation.
Several residents requiring pureed diets and nectar thick liquids were served food and beverages that did not meet prescribed texture and consistency requirements. Pureed meat was not smooth, thickened milk was lumpy or improperly mixed, and inappropriate items such as Jello and regular shakes were provided to residents with swallowing difficulties, contrary to physician orders and facility policy.
Surveyors identified multiple failures in food safety and sanitation, including dust accumulation in kitchen areas, unrestrained facial hair among staff, improper storage of open and expired food items, unsanitary kitchen equipment, and staff lacking knowledge of proper cleaning and sanitizing procedures. These deficiencies created conditions that could lead to food contamination and risk of foodborne illness for all residents receiving meals from the facility.
The facility did not have a written QAPI plan in place to address ongoing systemic issues with CNA staffing, dietary, and laundry services. Despite having a QAPI committee, the program did not identify or correct these deficiencies, resulting in multiple residents not receiving appropriate services in these areas.
Surveyors observed multiple infection control failures, including a resident's IV tubing coming into contact with food during a meal, laundry staff not monitoring or knowing required washer and dryer temperatures, and improper handling of clean linen—such as returning linen touched by a resident to an uncovered cart and using a floor-contaminated cover on clean linen. These actions did not follow facility policies or infection prevention standards.
Surveyors observed multiple pests, including bugs, a spider, and a house fly, in the kitchen's dry storage and food preparation areas. Staff interviews confirmed that pests should not be present due to the risk of cross contamination, and facility policies require ongoing pest control. Despite these requirements, pests were found in the kitchen.
Multiple deficiencies were identified in medication handling and administration, including improper disposal of a non-scheduled medication by an LPN, leaving medications unattended at a resident's bedside, and discrepancies in controlled medication documentation for two residents. Additionally, a resident did not receive scheduled narcotic pain medication due to pharmacy supply issues and lack of an emergency kit, resulting in missed doses and incomplete documentation.
Two residents were not served their meals at the same time as others at their tables, resulting in prolonged waiting and distress. Staff interviews revealed a lack of an organized meal delivery system, leading to confusion and delays. Both residents, who were cognitively intact and had relevant medical conditions, expressed discomfort and dissatisfaction with the experience, and facility policies regarding resident dignity and rights were not followed.
The facility did not obtain or renew informed consents for psychotropic medications as required by policy for two residents, resulting in administration of medications such as Melatonin, Diphenhydramine, and Depakote without proper documentation of consent. The DON confirmed the absence of current informed consents in the medical records, despite ongoing administration and policy requirements for biannual renewal.
A resident with a history of amputation, respiratory failure, and blindness reported her left leg prosthesis missing after a room change and did not receive feedback or follow-up from staff despite notifying multiple facility personnel. Staff interviews confirmed the loss was reported and some actions were taken, but the facility did not document or resolve the grievance as required by policy.
A resident with complex medical needs did not receive medications as ordered, including antihypertensives and insulin, on multiple occasions. Documentation was incomplete or missing for vital signs and blood sugar checks required before administration. Facility policy and physician orders were not consistently followed, as confirmed by the DON.
The Consultant Pharmacist did not identify or report duplicate medication orders for two residents, resulting in both receiving higher-than-intended doses of Vitamin D and Omeprazole, respectively. Additionally, a resident on routine opioid therapy did not have a bowel regimen in place, and this omission was not flagged by the pharmacist. The DON confirmed these issues, which were not detected during the monthly medication review as required by facility policy.
Two residents received duplicate doses of the same medications due to unreviewed and unclarified duplicate orders. One resident was administered double doses of Vitamin D, while another received up to four doses of Omeprazole daily. Nursing staff did not identify or clarify the duplicate orders, resulting in excessive medication administration.
A medication pass observation revealed that an LVN made four medication errors while administering medications to a resident, resulting in a 13.79% error rate. Errors included not administering scheduled azelastine nasal spray, giving an as-needed fluticasone nasal spray instead, administering a lower dose of Vitamin D3 than ordered, and omitting cyanocobalamin. The LVN confirmed the errors and lack of medication availability, and the DON stated that staff are expected to verify medications against the MAR and physician orders.
A resident with epilepsy did not receive a scheduled dose of phenobarbital, and there was no documentation or physician notification regarding the missed dose. The omission was confirmed by review of the MAR, CDR, and interviews with the DON and LVN, with the resident also reporting a history of seizures when medication was missed.
A resident with severe cognitive impairment and malnutrition experienced oral pain and a visible gum bump. Although a nurse notified the PCP and a dental consult was ordered, the resident was not seen by the facility dentist nor referred externally, leaving the dental issue unaddressed as required by facility policy.
The facility did not ensure the Food and Nutrition Services Director, a Certified Dietary Manager, completed the required six hours of in-service training on California dietary service regulations before starting full-time duties as dietetic services supervisor. This was confirmed through interviews and review of job qualifications.
Condensation ice buildup was found on the fans and a box of food inside a kitchen reach-in freezer. The FNS Director confirmed the freezer had not been working properly for about two weeks, and the EPD identified a defrost timer issue related to daylight saving time changes. No maintenance request had been submitted by dietary staff, despite the malfunction.
Failure to Provide Quarterly Trust Account Statements to Residents and Representatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required quarterly trust account statements to residents or their responsible parties (RPs) for resident funds managed by the facility. Surveyors interviewed multiple residents and an RP and reviewed medical and financial records. One resident, who was alert and oriented at the time of interview, stated he did not have a bank account or receive mail at the facility, but record review showed his trust account with the facility was opened on November 26, 2025, and his BIMS score indicated severe cognitive impairment. Another resident, alert and oriented, reported that her Social Security checks were sent directly to the facility and that she had a share-of-cost obligation, but she did not receive quarterly statements to track deposits and withdrawals; records showed her trust account was opened on August 1, 2024, and she had capacity to make decisions. A third resident, cognitively intact with a BIMS score of 14, stated he had not received quarterly statements for his trust account, which records showed was opened on November 30, 2018. A fourth resident, who had capacity to make decisions per the history and physical, stated he was unaware if he had a trust account and had not received a quarterly trust account statement, despite records indicating his trust account was opened on September 15, 2025. A fifth resident was alert but nonresponsive and could not be interviewed; her medical record showed severe cognitive impairment with a BIMS score of 0, and that her daughter was the RP. In a phone interview, the RP stated she had never received quarterly statements for this resident’s trust account, which had been opened on September 1, 2024. During a concurrent interview and record review, the Business Office Manager (BOM) stated that the facility’s process was to provide quarterly trust account statements only upon demand request by the resident or RP, and further stated that since his employment began on February 17, 2026, the business office had never provided quarterly trust account statements to residents or RPs. The Administrator later stated that quarterly statements were supposed to be automatically mailed from the business office, but acknowledged there was no procedure in place to ensure residents or RPs actually received the statements and confirmed with the corporate Director of Accounts Receivable that residents or RPs should have been receiving quarterly trust account statements. When policies related to resident trust accounts and quarterly statements were requested, the facility did not provide them.
Improper Charging of Resident Trust Funds for Medi-Cal-Covered Room and Board
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal funds from being charged for services covered by Medi-Cal. For four residents whose records were reviewed, the facility debited their trust accounts for private room and board charges for a month in which they had documented Medi-Cal coverage. Facility business records, including the Trust - Transaction History and Activity Reports, showed that each of these residents’ trust accounts was debited $16,197.50 for private room and board for the same month. Eligibility Response documents dated at the beginning of that month indicated that each of these residents had Medi-Cal covered benefits for that period. Resident 7 was re-admitted with diagnoses including dementia, schizophrenia, and bipolar disorder, and had a BIMS score indicating severe cognitive impairment. Despite an Eligibility Response showing Medi-Cal coverage for the month in question, the Payer Setup Information showed that this resident was billed as private pay, and the trust account was debited $16,197.50 for private room and board. Resident 10, admitted with dementia and a psychotic disorder and documented to have fluctuating capacity but a BIMS score indicating cognitive intactness, similarly had Medi-Cal coverage per the Eligibility Response, yet the Payer Setup Information listed private pay status and the trust account was debited the same amount for private room and board. Resident 11, re-admitted with metabolic encephalopathy and dementia and documented as having capacity to make decisions, also had a Trust - Transaction History showing a $16,197.50 debit for private room and board for the month, while an Eligibility Response confirmed Medi-Cal coverage for that same period. Resident 12, re-admitted with metabolic encephalopathy, dementia, and altered mental status, had severe cognitive impairment per BIMS and a daughter listed as the responsible party. This resident’s Trust - Transaction History and Care Activity Report showed a $16,197.50 debit for private room and board for the month, despite an Eligibility Response confirming Medi-Cal benefits and Payer Setup Information indicating the resident was billed as private pay. In interviews, the Business Office Manager explained that the facility’s process is to recommend residents enroll in Medi-Cal as secondary insurance to avoid private pay charges when Medicare coverage ends, and stated that residents are only transferred to private pay when they do not have secondary insurance. The Business Office Manager acknowledged that on the first day of the month in question, each of the four residents was switched from Medi-Cal to private pay despite documented evidence of billable Medi-Cal benefits for that month, and that their trust accounts should not have been charged $16,197.50 for private room and board. The Administrator similarly stated that residents are not supposed to be charged for Medi-Cal covered benefits and confirmed that these four residents should not have been switched to private pay to cover services that Medi-Cal would have covered. The facility’s standard admission agreement also stated that no Medi-Cal-participating facility may require any resident to remain in private pay status before converting to Medi-Cal coverage, and requested Medi-Cal billing policies were not provided.
Unauthorized Debiting of Resident Trust Funds for Private Pay Charges Despite Medi-Cal Eligibility
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ personal funds and prevent misappropriation when it unilaterally changed four residents from Medi-Cal coverage to private pay and debited $16,197.50 from each of their trust accounts for private room and board without their or their responsible parties’ consent. For Residents 7, 10, 11, and 12, business office records showed that on a specific date their trust accounts were each debited $16,197.50 for private room and board for a given month, despite documentation that all four residents had Medi-Cal-covered benefits for that same month. Payer setup and eligibility response documents confirmed that these residents were eligible for Medi-Cal (including Medi-Cal-IEHP) and that they were nonetheless billed as private pay for that month, with a later change back to Medi-Cal billing effective the following month. Resident 7 was re-admitted with dementia, schizophrenia, and bipolar disorder, and had a BIMS score of 7 indicating severe cognitive impairment, yet was listed as self-responsible. Facility trust transaction records showed a $16,197.50 debit from this resident’s trust account for private room and board for the month in question, even though an eligibility response documented Medi-Cal coverage for that month. There was no documented evidence that Resident 7 was notified of or consented to being changed to private pay or to the withdrawal from the trust account. During interview, Resident 7 stated he did not know he had a bank account with the facility and indicated that if someone withdrew a large amount of money without his knowledge, he would report it to the bank and law enforcement. Resident 10 was admitted with dementia and a psychotic disorder, had a history and physical noting fluctuating capacity to understand and make decisions, and had a BIMS score of 14 indicating cognitive intactness, and was also listed as self-responsible. Trust transaction records showed a $16,197.50 debit for private room and board for the same month, while eligibility responses documented Medi-Cal coverage for that month and the following month. Payer setup information showed the resident was billed as private pay for that month and then changed to Medi-Cal-IEHP the next month. There was no documented evidence that this resident was notified of or consented to the change to private pay or the trust account debit. In interview, the resident was unsure if he had a bank account with the facility and stated that if someone took his money without his knowledge it would anger him. Resident 11 was re-admitted with metabolic encephalopathy and dementia, was listed as self-responsible, and had a history and physical indicating capacity to make decisions. Trust transaction records showed a $16,197.50 debit for private room and board for the month in question, and an eligibility response documented Medi-Cal coverage for that month. The activity report confirmed the same debit amount and date. There was no documented evidence that this resident was notified of or consented to being changed to private pay or to the withdrawal from the trust account. In interview, the resident was unsure if he had a bank account with the facility and stated he would be upset if someone took money from his account. Resident 12 was re-admitted with metabolic encephalopathy, dementia, and altered mental status, had a BIMS score of 0 indicating severe cognitive impairment, and had a daughter identified as the responsible party. Trust transaction records showed a $16,197.50 debit for private room and board for the month in question, while eligibility responses documented Medi-Cal coverage for that month and the following month. Payer setup information showed the resident was billed as private pay for that month and then changed to Medi-Cal-IEHP the next month. The activity report confirmed the debit from the trust account. There was no documented evidence that the responsible party was notified of or consented to the change to private pay or to the trust account withdrawal. In a phone interview, the responsible party stated she did not know the resident’s trust account carried a balance, believed the resident’s Social Security income was being used for room and board, and reported she had never been notified of or consented to the change to private pay or the debit from the trust account. In interviews, the Accounts Receivable Director stated that Residents 10, 11, and 12 had billable Medi-Cal benefits for the month in question and confirmed that all four residents’ trust accounts were debited $16,197.50 for private room and board without documented notification to or consent from the residents or, for Resident 12, the responsible party. The Director further stated that none of the residents or the responsible party requested a change from Medi-Cal to private pay; the decision was made by the facility. The Business Office Manager stated that the facility’s process was to transfer a resident to private pay only when the resident did not have Medi-Cal as secondary insurance, and acknowledged that there was documented evidence that all four residents had billable Medi-Cal benefits for the month in question and that their trust accounts should not have been charged. The Administrator confirmed that residents are not supposed to be charged for Medi-Cal-covered benefits, that the residents should not have been switched to private pay to cover Medi-Cal-covered benefits, and that there was no documented evidence of consent to the private pay status or the trust account debits. Census records showed that during the relevant dates, all four residents were in three-bed rooms with two roommates, despite being charged for private room and board. The facility’s Abuse Prevention Program policy stated that residents have the right to be free from misappropriation of resident property and that administration will protect residents from abuse.
Failure to Notify Representative of Excess Resident Trust Account Balance
Penalty
Summary
The facility failed to notify a resident’s representative when the resident’s trust account balance exceeded the Supplemental Security Income (SSI) resource limit. The resident, who had diagnoses including metabolic encephalopathy, dementia, and altered mental status, had a BIMS score of 0, indicating severe cognitive impairment, and her daughter was documented as her representative and primary financial contact. A review of the facility’s trust transaction history showed that the resident’s trust account balance was $14,545.99. Interviews with the Director of Accounts Receivable (DAR) and the Business Office Manager (BOM) confirmed that the facility’s process requires notification to the resident or representative when a trust account exceeds $2,000 so that a spend down can be arranged to maintain Medicaid/SSI eligibility. Despite this established process, both the DAR and BOM acknowledged there was no documented evidence that the resident’s representative had been notified of the elevated trust account balance or the need for a spend down. The BOM stated that the usual procedure would include arranging an IDT meeting with the resident and/or representative to discuss the trust account balance, the reason for the spend down, and the amount required, but this did not occur for this resident. In a subsequent interview, the resident’s representative reported she was unaware that the resident had a trust account balance at all and believed the resident’s Social Security income was fully applied to room and board. She stated the facility had never informed her of the trust account balance or how it might affect the resident’s Medi-Cal and Social Security benefits. When policies related to notification of account balances and eligibility limits for Medi-Cal/Social Security were requested, the facility did not provide them.
Failure to Follow Self-Administration of Medication Policy for Bedside Medications
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy and procedure for self-administration of medications for one resident. The resident was admitted with multiple serious conditions, including acute and chronic respiratory failure, lumbar radiculopathy, chronic pain syndrome, acetonuria, and was receiving palliative care. A History and Physical indicated the resident had capacity to make decisions. A Quarterly Risk Assessment for Self-Administration of Medications dated February 3, 2026, documented that the resident requested to self-administer medications, that nursing recommended the resident could self-administer, and specifically listed only docusate sodium 100 mg as a bowel care medication to be self-administered as needed. During observation, surveyors found multiple medications stored at the resident’s bedside in two zippered cosmetic bags, including acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, docusate sodium 250 mg, potassium 99 mg, and Hair Skin and Nails vitamins. The resident stated she kept these medications at the bedside and took them as needed, reporting daily use of docusate sodium 250 mg for constipation and as-needed use of the other medications, including ZzzQuil Pure Zzzs Melatonin Gummies for sleep. The resident also stated she was not required to keep a record of, or inform nursing staff about, the medications she took. Interviews with LVNs, the RN, and the DON showed inconsistency between facility practice and the self-administration policy. Multiple nurses stated residents were not allowed to keep medications at the bedside or self-administer unless there was a physician’s order and a completed self-administration assessment, and that residents who self-administer must inform nursing so doses can be documented on the MAR. The DON confirmed there was a self-administration assessment for the resident but acknowledged that the medications found at the bedside were not on the assessment and not ordered by the physician, and confirmed that acetaminophen 500 mg, melatonin 10 mg, ZzzQuil PURE Zzzs Melatonin Gummies, mucus relief, diphenhydramine 25 mg, ibuprofen 200 mg, famotidine 10 mg, potassium 99 mg, and Hair Skin and Nails vitamins were not included on the Quarterly Risk Assessment. The facility’s written policy required IDT evaluation of appropriateness, safe and secure storage, determination and instruction regarding documentation responsibility, and removal of any unauthorized bedside medications, which was not followed in this case.
Delayed Call Light Response for Dependent Resident
Penalty
Summary
The facility failed to ensure a resident’s call light was answered in a timely manner, resulting in a 31‑minute delay in response to a request for incontinence care. The resident involved had multiple significant diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis affecting the right dominant side, muscle wasting and atrophy, major depressive disorder, bilateral ankle contractures, vascular dementia, epilepsy, bilateral foot drop, and schizophrenia. The resident reported using the call light when needing a brief change or assistance and stated he was unable to get out of bed without help. He also stated that call light response times were very slow and varied depending on which staff were working. During observation at the bedside, the resident pressed the call light at 11:06 a.m., illuminating the light in the room and above the doorway. While the call light remained on, a staff member entered the room and assisted the roommate, and a housekeeper entered the room but did not address the active call light. The call light was not answered until 11:37 a.m., when the Treatment Nurse entered and responded, confirming that a 31‑minute wait was unacceptable and that all staff were responsible for answering call lights. The CNA assigned to the resident stated she had been on lunch break during this time and that all staff were responsible for answering call lights, which should be answered within five minutes. The housekeeper stated she cleans resident rooms and can answer call lights. The facility’s “Answering the Call Light” policy indicated that staff should ensure timely responses, notify appropriate staff if another person is needed, and complete tasks within five minutes if possible.
Failure to Notify Residents and Families of Conversion From Medi-Cal to Private Pay
Penalty
Summary
The deficiency involves the facility’s failure to notify four residents and/or their responsible parties of changes in their primary payor status from Medi-Cal IEHP to private pay, as required by resident rights and the facility’s own policy. Record review showed that each of the four residents had Medi-Cal IEHP as the primary payor prior to January 1, 2026, and that their primary payor was changed to private pay effective January 1, 2026, in the PointClickCare (PCC) census records. The facility’s policy titled “Pay Source Conversion” states that Social Services is responsible for notifying the family of non-coverage and anticipated payment, and that the resident and/or responsible party must be informed of their financial obligations when there is a conversion from one primary pay source to another. Resident 2 was admitted with a history of transient ischemic attack and was documented as self-responsible, with an MDS indicating intact cognition. Resident 3 was admitted with dementia, also documented as self-responsible, and had an MDS indicating intact cognition. Resident 4 was admitted with dementia, had a responsible family member, and an MDS showing she was rarely/never understood with moderately impaired cognition. Resident 5 was admitted with metabolic encephalopathy and had an MDS indicating moderately impaired cognition. Despite these documented conditions and responsible party designations, interviews with Residents 2, 3, and 5 revealed that they were unaware they were currently paying privately for their stays, did not know the cost, and reported that no one had discussed these financial changes with them. Resident 4 was non-responsive at the time of attempted interview, and later her responsible party reported not receiving any notification of the payor change or information about the cost. Interviews with staff confirmed that required notifications were not provided. The Business Office Manager (BOM) stated that her department is responsible for notifying residents and responsible parties of payor changes via a notice of insurance change letter, but reported that the Director of Finance (DOF) at the corporate office initiated the payor changes on December 31, 2025, without informing her. The Accounts Receivable Director stated that the BOM, Administrator (ADM), or Social Services Director (SSD) should inform residents about becoming private pay. The Social Service Assistant stated that the BOM is responsible for payor changes and that she had never dealt with payor changes. The ADM stated the BOM is supposed to give notice of payor status changes to residents and report such changes in stand-up meetings, but he was not aware of the corporate-initiated changes and the BOM did not report any payor changes. The DOF stated that BOM, SSD, and sometimes ADM should explain payor changes and document their actions, and later clarified that no written Medi-Cal recommendation was received and that the decision to change the four residents to private pay was made at the facility level. These actions and inactions resulted in residents and responsible parties not being notified of the change from Medi-Cal to private pay and their resulting financial obligations.
Failure to Timely Provide Resident Financial Records Requested by Ombudsman
Penalty
Summary
The facility failed to provide copies of financial records within the required timeframe after a request was made on behalf of a resident by the Long-Term Care Ombudsman (LTCO). The resident involved was admitted with a history of transient ischemic attack and vascular dementia and was documented as self-responsible, with a Minimum Data Set indicating capacity to understand and make decisions. The LTCO emailed the Business Office Manager (BOM) requesting the resident’s trust account report, any representative payee documents from the last 12 months, and a financial summary of coverage and share of cost, and included a consent form signed by the resident authorizing release of this information. During an interview, the BOM stated that she typically provides requested financial information to residents or responsible parties within 10–15 minutes and that, for non-responsible parties, she obtains resident consent via a signed form. She acknowledged receiving the LTCO’s email request and consent form and stated that she is expected to respond to financial record requests within 24 hours and fulfill them by the next business day. The BOM further acknowledged that she should have responded and fulfilled this request by the next business day but had not done so, and that 12 days had elapsed since the request was made. The facility’s policy allowed up to 30 days for providing copies of personal or medical records but also recognized the right of the LTCO to examine resident records in accordance with state law. The failure to provide the requested financial records within two business days constituted a violation of the resident’s and the resident’s representative’s rights.
Failure to Prevent Sexual and Verbal Abuse of Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual abuse by another resident and verbal abuse by staff. In the first incident, a cognitively impaired resident with dementia, Alzheimer’s disease, major depressive disorder, and a BIMS score of 3 was involved. This resident had been assessed as lacking capacity to make decisions and was dependent on others for domestic tasks and safety awareness. On the date of the incident, the resident was on the smoking patio without staff supervision during a 4 p.m. smoke break. A CNA reported hearing this resident saying "no, no, no" and then observed a male resident touching the resident’s breast with one hand while attempting to raise the resident’s shirt with the other hand. The CNA noted that there were no other residents present and no staff supervising the smoking patio at that time. The male resident involved was cognitively intact, with a BIMS score of 15 and documented capacity to make decisions. In a subsequent interview, he stated that the cognitively impaired resident had held and kissed his hand and that he did not touch her breast or shirt, although a psychiatric note later documented that he stated he felt invited and began fondling her. The facility’s five-day follow-up report stated that staff witnessed the aggressor touching the victim’s breast and that evidence suggested the allegation of sexual abuse occurred. The DON acknowledged that the dependent resident required supervision and should not have been outside on the smoke patio without supervision. The second incident involved verbal abuse of another cognitively impaired resident with traumatic brain injury, Parkinson’s disease, psychosis, no decision-making capacity, and a BIMS score of 0, indicating the resident was rarely or never understood. Early in the morning, another resident with normal cognition reported to an LVN that he had seen a CNA hovering over this impaired resident and heard the CNA tell the resident to "shut up" while the resident was crying or screaming. The witness later described hearing screams that were not the resident’s normal screams, then observing the CNA standing over the resident and repeatedly saying "shut up" before leaving the room and going to the linen cabinet. The incident was documented in an SBAR as alleged verbal abuse, and an interdisciplinary post-event note recorded that the alleged perpetrator was sent home and the resident was assessed with no injury. The administrator stated that residents should be in a safe environment at all times and free from verbal abuse. Facility policies on Abuse Prevention and Resident Rights stated that residents have the right to be free from sexual and verbal abuse and to be treated with kindness, respect, and dignity.
Failure to Control Resident Smoking Materials and Maintain Accurate Smoking Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to resident smoking and smoking materials. During observation and interview, one resident was found sitting in bed with a sitter present and stated he was a smoker who kept his cigarettes and lighter in his jacket by the bedside. He produced a pack of cigarettes and a lighter from his jacket pocket and stated he only smoked on the smoking patio. Another resident, observed alert and oriented in a wheelchair at bedside, stated she was a smoker and kept her smoking materials in her nightstand drawer. She removed a lighter and a pack of cigarettes from the top nightstand drawer and also stated she only smoked on the smoking patio. When interviewed, the LVN stated residents were not allowed to have smoking materials and that only activities staff were supposed to have residents’ smoking materials. During this interview, the first resident again produced his cigarettes and lighter, and the LVN confirmed he should not have smoking materials with him. Record review for this resident showed a readmission with diagnoses including end stage renal disease, nicotine dependence, and an above-knee amputation, and a history and physical indicating he had capacity to make decisions. However, his smoking assessment documented him as a non-smoker and did not reflect his current smoking status as a smoker. There was no documented smoking assessment reflecting his current status until the concurrent observation and interview on the survey date, confirming he had been allowed to smoke without a valid smoking assessment and without supervision. For the second resident, record review showed admission diagnoses including COPD, diabetes mellitus, and major depressive disorder, with a history and physical indicating fluctuating capacity to understand and make decisions. Her quarterly smoking assessment documented that she was a smoker, a safe smoker, and independent. Her care plan stated she smoked cigarettes and was independent, with a goal that she would smoke safely with supervision, and interventions specifying that activity staff would keep all smoking materials in the smoking cart at all times, give one cigarette and light it for her, and supervise all residents. The DON stated that facility process required smoking assessments on admission and quarterly, that independent smokers could keep cigarettes but not lighters, and that residents were not allowed to have lighters. The DON acknowledged that the first resident’s assessment did not reflect his current smoking status and that he should not be smoking without an assessment or supervision, and that the second resident, although assessed as an independent safe smoker, should not have had a lighter at bedside under facility policy.
Failure to Provide Fresh Bedside Water and Hydration per Policy
Penalty
Summary
The facility failed to ensure bedside water pitchers were filled or that fresh water was offered daily for two residents, resulting in water pitchers remaining only one-quarter full over multiple days. On two consecutive mornings, one resident was observed alert and oriented in a wheelchair with a teal bedside water pitcher that was one-quarter full; the resident reported that CNAs usually refilled his water but that it had not been done that morning, and later stated the pitcher had not been refilled either the previous day or that day. A CNA later confirmed, in the resident’s presence, that the NOC shift appeared not to have refilled this resident’s water pitcher for two days. This resident’s records showed diagnoses including diabetes mellitus, chronic kidney disease, and hypotension, and care plans directing staff to encourage fluids during the day to promote prompted voiding, assist and encourage in-between fluids and snacks due to risk for protein malnutrition, and encourage hydration related to hyperglycemia and skin integrity. Another resident was observed on two consecutive days with a teal water pitcher on the nightstand that was one-quarter full, first while alert, oriented, dressed, and eating lunch, and later with the water level unchanged from the prior day. This resident stated that CNAs usually refilled her water pitcher but that it had not been filled that day, and later reported it had not been filled the previous day or that day. In a subsequent observation with a CNA present, the CNA stated that the NOC shift is responsible for filling all residents’ water pitchers daily before the end of shift and acknowledged that it appeared the NOC shift did not refill this resident’s pitcher. This resident’s records indicated diagnoses including chronic kidney disease and lung cancer, a BIMS score of 11 indicating a moderate problem with thinking, and a care plan intervention to encourage good nutrition and hydration to promote healthier skin. The Administrator stated that the facility’s process is for NOC shift CNAs to replace and refill residents’ water pitchers with fresh water daily toward the end of each shift and acknowledged that failure to refill pitchers could place a resident at risk for dehydration. The facility’s policy on Resident Hydration and Prevention of Dehydration stated that nurses’ aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
Failure to Use Required PPE for COVID-19 Isolation Resident
Penalty
Summary
The deficiency involves a failure to implement appropriate infection prevention and control practices for a resident with confirmed COVID-19. On January 8, 2026, signage posted outside the resident’s room clearly indicated both contact and droplet precautions, instructing that everyone must clean their hands before entering and when leaving the room, and that providers and staff must put on gloves and a gown before room entry. The droplet precaution sign further required that eyes, nose, and mouth be fully covered before entering. The resident’s admission record, dated January 9, 2026, documented a diagnosis of COVID-19. The facility’s written policy on Infection Prevention and Control for COVID-19 Infection, dated June 2023, required all staff to wear fit-tested NIOSH-approved N95 respirators in any indoor space where there are residents in isolation, and specified that eye protection is required when caring for residents in the COVID isolation area. Despite these posted precautions and written policies, on January 8, 2026, at 12:25 p.m., an LVN preparing to check the COVID-positive resident’s blood sugar level was observed donning only a surgical mask, gown, and gloves before entering the room. During a concurrent interview, the LVN acknowledged that the contact and droplet precaution signs were posted to be followed to avoid transmitting bacteria and confirmed that the resident had COVID-19. The LVN further stated she was wearing a surgical mask, gown, and gloves when she entered the room and acknowledged she should have worn an N95 mask and a face shield. In subsequent interviews, the Infection Preventionist Nurse and the Director of Nursing both stated that the LVN should have worn the proper PPE—gown, gloves, N95 respirator, and face shield—before entering the isolation room. CDC Infection Control Guidance for SARS-CoV-2, cited in the report, recommends that healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection use an NIOSH-approved N95 or higher-level respirator, gown, gloves, and eye protection.
Resident's Mouth Covered with Towel by CNA
Penalty
Summary
A Certified Nursing Assistant (CNA) placed a towel over the mouth of a resident who was non-verbal, dependent for activities of daily living, and had severely impaired decision-making capacity due to a cerebral infarction. The incident occurred while the CNA was providing care and the resident began coughing. The CNA, not wearing a mask at the time, covered the resident's mouth with a towel for at least one minute, reportedly to protect herself from the resident's cough. Another CNA witnessed the event, removed the towel, and advised the CNA that such actions were inappropriate. The resident was assessed following the incident and was found to have no injuries and was calm and in no distress. Interviews with staff and facility leadership confirmed that placing a towel over a resident's mouth is not acceptable practice and is contrary to the facility's abuse prevention policy, which prohibits physical abuse. The facility's policy emphasizes residents' rights to be free from abuse, including physical abuse.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported to the California Department of Public Health (CDPH) within the required two-hour timeframe after the allegation was made. The incident involved a Certified Nursing Assistant (CNA) placing a towel over the resident's head and mouth and telling the resident to be quiet. Another CNA witnessed the event but did not immediately report it to a supervisor, instead choosing to wait and report it directly to the Director of Staff Development (DSD) two days later. The facility's policy and federal requirements mandate immediate reporting of such allegations, but the CNA misunderstood the reporting timeframe and delayed notification. The resident involved had a history of cerebral infarction and fluctuating decision-making capacity. Following the incident, the resident was assessed and found to have no injuries or distress, and the physician was notified. Interviews with facility staff confirmed that the expectation was for immediate reporting of abuse allegations, but the delay resulted in the incident not being reported to CDPH until two days after it occurred. Documentation showed that the CNA had previously acknowledged understanding the mandatory reporting requirements.
Failure to Provide Safe and Appropriate Transportation for Dialysis
Penalty
Summary
The facility failed to ensure that a resident received necessary care and services in accordance with her comprehensive assessment and professional standards of practice by not conducting a comprehensive interdisciplinary assessment of her transportation needs for dialysis appointments. The resident, who had end stage renal disease, type 2 diabetes, and a recent amputation of two toes, required substantial to maximal assistance with transfers and was dependent on a wheelchair for mobility. Despite these needs, the facility arranged for her to be transported to dialysis appointments via Uber, which required unsafe and uncomfortable transfers from her wheelchair to a standard vehicle three times a week. Documentation and interviews revealed that the resident missed or experienced delays in dialysis appointments due to transportation issues, including the facility's failure to pay for appropriate wheelchair van services and the subsequent use of Uber. The resident expressed discomfort and fear regarding the Uber transportation, stating that the cars were difficult to enter and exit, and that she was transferred by staff in a manner that was physically challenging and unsafe. Staff, including CNAs and nurses, reported difficulties in transferring the resident and acknowledged that Uber was not an appropriate mode of transportation for her condition. The facility's own rehabilitation department was not consulted to assess the resident's transportation needs prior to the decision to use Uber. As a result of these actions and inactions, the resident sustained actual harm, including a right chest-wall hematoma, soft-tissue swelling, and possible rib fractures after being transported in a standard vehicle. The unsafe transportation practice continued even after the injury, with the resident being exposed to further risk of harm. The facility's failure to provide safe and appropriate transportation, as well as the lack of interdisciplinary assessment and communication, directly led to the resident's injuries and missed or delayed dialysis treatments.
Removal Plan
- Resident 1 was assessed by assigned licensed nurse for any adverse effects of being transferred to dialysis using Uber Health transportation.
- Resident 1 was assessed by PT to determine whether Resident 1 can tolerate the car or wheelchair van transportation.
- The Care Plan was updated to reflect current transportation information for dialysis.
- A new contract for wheelchair transport was drawn up by the ADM.
- An ad hoc QAPI Committee meeting was held to discuss changes in contracted dialysis transportation services.
- Inservice training was conducted by DON and/or DSD with licensed staff regarding use of contracted dialysis transportation.
Failure to Update Care Plan for Dialysis Transportation Needs
Penalty
Summary
The facility failed to develop and revise a comprehensive, person-centered care plan to address the transportation needs of a resident who required dialysis. After the resident's transportation method was changed from a wheelchair-accessible van to a standard vehicle (Uber), there was no interdisciplinary assessment or update to the care plan to reflect this significant change. The change in transportation was made without discussion or involvement of the resident or her family, and there was no documentation of their participation in the care planning process. The care plan did not include interventions for transportation to dialysis, transfer assistance, or mobility safety, and was not revised after the transportation method changed or after the resident sustained an injury. The resident had a history of foot surgery and was not supposed to put pressure on her feet, requiring a lifted van for safe wheelchair transfer. Despite this, the facility arranged for transportation via Uber, which did not accommodate her functional limitations. The decision to switch transportation providers was made by the corporate office due to payment issues, and the staff responsible for social services and case management did not communicate this change to the resident or her family. As a result, the resident was transported in an inappropriate vehicle, leading to missed dialysis treatments, hospitalization, and physical injury.
Failure to Prevent Resident-to-Resident Verbal Abuse and Address Ongoing Disruptive Behavior
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in the affected resident feeling threatened. Specifically, one resident repeatedly played loud music in his room, which disturbed others. When another resident requested that the music be turned down, the first resident responded with verbal threats and derogatory language. This behavior was ongoing for months, as noted in interviews and progress notes, and was not effectively addressed by staff. The resident responsible for the loud music and verbal abuse was cognitively intact and had a diagnosis of bipolar disorder, but refused interventions such as headphones when offered. Despite multiple complaints and documentation of the disruptive behavior, the facility did not implement or update care plans or interventions to address the ongoing issue. Staff interviews revealed that the only action taken in response to a previous grievance was to move a different resident out of the room, rather than addressing the root cause. The Director of Nursing and other staff acknowledged that the behavior should have been care planned and that interventions were lacking, which contributed to the escalation of the situation and the resulting verbal abuse.
Failure to Monitor and Document New Wound Following Podiatric Procedure
Penalty
Summary
The facility failed to complete appropriate monitoring and documentation for a resident who experienced a new skin avulsion on the left second toe following podiatric treatment. The resident, who had diagnoses of diabetes mellitus and peripheral vascular disease, was noted to have a new wound on August 18, 2025, as documented in the skin check. However, subsequent skilled evaluations on August 19 and August 21, 2025, did not identify any skin issues, indicating inconsistent evaluation of the wound. The Treatment Nurse confirmed that the skin avulsion was a new finding and should have been treated as a change of condition, requiring documentation and ongoing monitoring to track the wound's progress. Interviews with facility staff, including the DON, revealed that the wound was not monitored every shift for three days as required by facility policy for a change of condition. The facility's policy states that significant changes in a resident's condition require interdisciplinary review and thorough documentation. The lack of consistent monitoring and documentation for the resident's new wound resulted in a deficiency related to the facility's failure to provide care and treatment according to orders, resident preferences, and goals.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Provide Timely Wound Treatment Upon Admission
Penalty
Summary
The facility failed to provide wound treatment for a resident's left lower extremity open wound for three days following admission. Upon review, the resident was re-admitted with diagnoses including a non-pressure ulcer of the left foot and ankle and peripheral vascular disease. Hospital discharge documents and progress notes indicated the presence of open wounds on the resident's left lower and posterior leg and left foot. The skilled nursing facility's admission assessment also documented a skin breakdown on the left lower leg, and a Braden Skin Risk Assessment classified the resident as mild risk for pressure ulcers. However, there was no physician's order for wound treatment from the date of admission through the following three days, and the Treatment Administration Record showed no documentation of wound care being provided during this period. Interviews with facility staff revealed that the admitting RN did not obtain or clarify treatment orders for the resident's wounds, nor was the wound described in the medical records. The Quality Assurance Nurse and Assistant Director of Nursing confirmed that the expected process was for the admitting nurse to conduct a full body assessment, notify the physician, and secure treatment orders, with follow-up and shift endorsement if clarification was needed. The facility's policy required licensed nurses to notify the practitioner for any skin breakdown requiring treatment upon admission, but this was not followed, resulting in a lack of timely wound care for the resident.
Failure to Prevent Physical Abuse of a Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA 1) was observed by two other staff members to have roughly pushed a resident with severe cognitive impairment multiple times to prevent the resident from getting up from bed. The resident, who had diagnoses including psychosis, anxiety, Parkinson's disease, schizoaffective disorder, depression, and a cognitive communication deficit, was noted to have a BIMS score of 1, indicating severe cognitive impairment. The care plan for this resident included interventions to interact in a peaceful manner due to a history of anxiety and wandering. On the evening of the incident, two CNAs witnessed CNA 1 push the resident down by the shoulders, causing the resident to fall back onto the bed. Both CNAs reported seeing redness and swelling on the resident's face, and one heard slapping noises, though did not see slapping. The resident was heard yelling for help and to stop. The Registered Nurse assessed the resident and confirmed redness and swelling on the left cheek. Facility policy prohibits any form of abuse or rough handling of residents.
Failure to Assess and Treat Blister Led to Stage 4 Pressure Injury
Penalty
Summary
The facility failed to properly assess and treat a blister on the right elbow of a resident who was re-admitted with a history of chronic wounds and high risk for pressure injuries, as indicated by a Braden Scale score of 12. Upon re-admission, the resident's right elbow was wrapped with a bandage, and a blister the size of a ping-pong ball was present, but this was not documented, assessed, or reported to the physician. No treatment order was obtained for the blister at that time, and the presence of the bandage was not investigated further by the admitting nurse. Subsequent interviews and record reviews revealed that the licensed nurses did not perform or document a head-to-toe skin assessment upon re-admission, as required by facility policy. The wound was not unwrapped or measured, and the physician was not notified. The lack of assessment and documentation meant that no care plan or treatment was initiated for the blister, despite the resident's high risk for skin breakdown and pressure injuries. As a result of these failures, the blister on the resident's right elbow worsened and progressed to a Stage 4 pressure injury, with full-thickness skin loss and exposed bone. Staff interviews confirmed that the expected protocol was not followed, and the facility's own policies required immediate assessment, documentation, and intervention for any skin issues identified upon admission or re-admission.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident with dementia and moderate cognitive impairment was reported to the California Department of Public Health (CDPH) within the required timeframe. The resident reported being punched by a Certified Nurse Assistant (CNA) on the evening of March 5, 2025. Documentation shows that the administrator was notified of the allegation, but there was no evidence that CDPH was notified immediately or within two hours as required by both regulation and the facility's own policy. Interviews with staff confirmed that the required report to CDPH was not made. The Registered Nurse (RN) involved stated she did not fax or call the report to CDPH and could not recall the reason for this omission. The administrator acknowledged that CDPH should have been notified no later than two hours after the facility became aware of the allegation. The facility's policy clearly outlines the requirement for immediate reporting of abuse allegations to the appropriate authorities.
Improper G-Tube Unclogging Procedure Results in Tube Damage
Penalty
Summary
A deficiency occurred when a licensed nurse failed to follow proper procedures for unclogging a resident's gastrostomy (G-) tube. The resident, who had dysphagia and a G-tube for feeding, experienced a clogged tube as indicated by an alarm on the G-tube pump. The nurse attempted to flush the tube with warm water, which was unsuccessful, and then applied A&D ointment and used a milking technique to try to clear the blockage. During this process, a bubble formed and burst in the tubing, resulting in a tear. The nurse then clamped the tube and notified the RN, who assessed the situation and arranged for the resident to be sent to the hospital for a replacement tube. Interviews with other nursing staff and review of facility policy revealed that the correct procedure for addressing a clogged G-tube is to flush with warm water using a gentle back-and-forth motion, without using force, massaging the tube, or applying ointments. If the clog cannot be cleared, staff are to notify the physician and follow further orders. The nurse's actions deviated from these procedures, as force and inappropriate techniques were used, leading to damage of the G-tube and necessitating hospital transfer for the resident.
Failure to Provide Written Bed Hold Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to two residents who were transferred to a general acute care hospital. In both cases, the residents had intact decision-making capacity and were transferred for acute medical issues—one for bacterial pneumonia and the other for chest pain. Upon review, there was no documented evidence that either resident received a written notice of the bed hold policy at the time of their transfer, as required by facility policy. Interviews with nursing staff revealed a lack of understanding regarding the requirement to complete the bed hold consent form upon transfer, with one nurse believing that discussing the policy at admission or including it in the physician's order was sufficient. The Assistant Director of Nursing and the Administrator both confirmed that the expectation was for nurses to notify residents and their families of the bed hold policy and to complete the necessary documentation at the time of transfer. Facility policy specified that written information about the bed hold option should be provided upon admission and at the time of transfer to a hospital. The absence of this documentation for both residents indicated a failure to follow established procedures for informing residents of their rights regarding bed holds during hospitalizations.
Failure to Provide Sufficient and Appropriate Bedtime Snacks
Penalty
Summary
The facility failed to ensure that bedtime snacks were routinely offered and were sufficient for all residents who received food from the kitchen. During a confidential resident council meeting, half of the residents present reported that bedtime snacks were not offered or were insufficient. One resident with diabetes specifically stated that sugar-free or diabetic-appropriate evening snacks were not available to her. Observations in the kitchen revealed a limited supply of snacks, including a small number of sandwiches, crackers, fruits, and desserts, which were distributed by activity staff in the evening. Interviews with activity staff confirmed that the quantity of snacks provided was not enough to meet resident demand, with many residents requesting more than one snack and a particular shortage of fruit. Staff also reported that there were no snacks left for residents who missed the initial distribution time. The registered dietician noted that the lack of adequate bedtime snacks could negatively impact residents' sense of comfort and satisfaction. A review of the facility's own policy indicated that nourishing bedtime snacks should be routinely offered to all residents unless contraindicated.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed trash, used gloves, and food residuals on the ground surrounding the dumpsters and gate area outside the back kitchen. These findings were made during a concurrent observation and interview with the Food and Nutrition Services Director, who acknowledged that the area needed to be kept clean to prevent bacterial growth and pest attraction, and identified the situation as an infection control issue. A subsequent interview with the Registered Dietician confirmed that the area should be kept clean and that the presence of trash, used gloves, and food residuals could attract pests and create an infection control problem. Review of the facility's policy indicated that garbage and trash cans must be inspected daily to ensure no debris is on the ground or surrounding area, and that the trash collection area must be kept clean to prevent it from becoming a feeding ground for vermin and rodents.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident complaints and staff interviews. Several residents reported long wait times for assistance with activities of daily living (ADLs), such as toileting, bathing, and receiving medications. Residents described waiting 20 to 30 minutes or more for call lights to be answered, being left in soiled conditions, and experiencing delays in receiving food and pain medication. These issues were corroborated by resident council meeting minutes, which documented ongoing concerns about untimely responses to call lights and lack of teamwork among CNAs. Staff interviews further confirmed the staffing shortages, particularly on the night shift, where CNAs were responsible for as many as 23 to 32 residents each, and sometimes up to 52 residents. CNAs reported being unable to complete their assignments efficiently, being pulled away from resident care for other tasks, and working frequent double shifts due to lack of coverage. The Assistant Director of Staff Development and the DON acknowledged that the facility was not consistently meeting the required Nursing Hours Per Patient Day (NHPPD), with documented shortfalls on several days. The DON also confirmed awareness of residents being left in urine and stool and stated that the facility had not been safely or sufficiently staffed in recent months. Record reviews showed that the facility's actual CNA direct care hours per patient day fell below the required minimum on multiple occasions, and staff assignment sheets indicated that CNAs were regularly assigned more residents than recommended. Facility policies required prompt response to call lights and sufficient staffing to meet resident needs, but these standards were not met. The deficiency resulted in negative resident experiences, including frustration, anger, and compromised quality of care, as directly stated in the report.
Failure to Maintain Comfortable Temperatures and Timely Laundry Services
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents by not ensuring comfortable temperature levels in multiple resident rooms and by not providing timely laundry services. Several residents reported feeling cold, especially at night, and were observed using multiple blankets and additional clothing to keep warm. Temperature readings taken in various rooms were found to be below the normal range of 71 to 81 degrees Fahrenheit, with some rooms as low as 67.3 degrees Fahrenheit. Staff members, including LVNs and CNAs, also reported feeling cold during nighttime shifts and noted that residents frequently requested extra blankets. The Maintenance Director was using an incorrect temperature range for monitoring and only checked a few rooms daily, with logs showing temperatures consistently below the recommended range. Additionally, the facility did not maintain proper documentation of weekly checks on laundry equipment, and there was insufficient laundry staff to ensure residents' personal clothing was washed and distributed in a timely manner. One resident reported missing clothing and attributed it to a broken washing machine, which had led to a backlog of laundry and misplaced belongings. Observations confirmed that some laundry equipment was not operational for extended periods, and piles of residents' clothing remained unfolded and undistributed for days. The Housekeeping and Laundry Supervisor confirmed ongoing issues with laundry equipment and staffing, and the Maintenance Director did not keep regular logs of equipment checks, only documenting issues when they occurred. A review of facility records and interviews with staff revealed that previous corrective actions regarding laundry services had not been sustained, as equipment remained out of service and additional staff were not consistently scheduled. The Administrator confirmed the lack of weekly documentation for laundry equipment checks and acknowledged the absence of a policy and procedure related to laundry services. These failures resulted in residents not receiving their personal belongings in a timely manner and experiencing discomfort due to inadequate room temperatures.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications in accordance with its policies, procedures, and manufacturer instructions. Surveyors observed that IV Mini-bag plus containers were removed from or stored in opened manufacturer's overwraps without being marked with beyond use dates, and these were found in multiple medication carts. Additionally, a medication card for fenofibrate was found with the expiration date cut off, and the nurse administering it did not verify the expiration date prior to administration. Insulin vials and pens were also found without open dates or stored beyond their recommended use period, and staff were unable to confirm when these medications were removed from refrigeration or first opened. Expired medications were found stored in various medication and treatment carts, including an opened package of sterile wound dressing and an expired box of omeprazole tablets. Staff interviews confirmed that these items should have been discarded after opening or upon expiration, but they remained accessible in the carts. The facility's policies require immediate removal and disposal of outdated, contaminated, or deteriorated medications, but these procedures were not followed. A discontinued medication was also found stored alongside active medications in a medication cart. Staff acknowledged that discontinued medications should be removed and destroyed if not eligible for return to the pharmacy. The presence of these expired, improperly labeled, and discontinued medications in accessible storage areas demonstrated a failure to adhere to established protocols for medication management, as confirmed by staff interviews and policy reviews.
Dietary Staff Lacked Knowledge and Adherence to Food Safety and Sanitation Procedures
Penalty
Summary
The facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services, as evidenced by multiple observed deficiencies in food safety practices. Food service workers did not follow the manufacturer's guidelines for testing the Quaternary (Quat) sanitizer, with staff dipping test strips for incorrect durations and being unable to accurately read or state the required sanitizer concentration. Several dietary aides and cooks demonstrated a lack of knowledge regarding the correct concentration range for the sanitizer, with most staff incorrectly stating the acceptable parts per million (ppm) range, despite clear manufacturer instructions and posted guidelines. Further deficiencies were observed in cleaning and sanitizing procedures. Some dietary aides were unable to demonstrate the proper steps for cleaning dirty meal carts, with one aide using only sanitizer and omitting the required wash and rinse steps. Staff also showed a lack of understanding regarding the calibration of food thermometers, with incorrect target temperatures cited during demonstrations. Additionally, dietary aides were unable to state or demonstrate the correct submersion time for kitchenware in the sanitizer sink, as required by posted manufacturer guidelines. These failures were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The deficiencies had the potential to affect all 153 residents who received food from the kitchen, as improper sanitation and food safety practices could compromise the effectiveness of infection control measures in the dietary department.
Failure to Follow Prescribed Diets and Portion Control in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served according to prescribed recipes and diet orders, as observed during multiple meal services. During a lunch meal, several residents with physician orders for a fortified diet did not receive the required margarine on their vegetables, as specified in the facility's Fortified Menu Plan and confirmed by both a Certified Nurse Aide and the Registered Dietitian. The absence of margarine meant these residents did not receive the additional calories intended to support their nutritional status. Additionally, food service workers did not have a system to distinguish between diet and regular Jello for residents on a Controlled Carbohydrate Diet (CCHO). Multiple residents on CCHO diets were served red Jello that was not labeled as diet, and the dietary aide could not differentiate between the two types without labeling. The Registered Dietitian confirmed that CCHO diet residents should receive diet Jello per the menu plan, and the lack of labeling created a risk of serving the incorrect product. Further deficiencies were observed in portion control and recipe adherence. The wrong scoop size was used to serve both salad and meat portions, resulting in residents receiving either less or more than the planned serving sizes. In another instance, a diet aide prepared cheese quesadillas without measuring the amount of shredded cheese, and was unable to locate the recipe. These actions were inconsistent with the facility's policies and procedures, which require standardized recipes and portion control to meet residents' nutritional needs.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food was served at appropriate temperatures, was palatable, and offered variety according to residents' preferences and facility policy. Multiple residents reported that their food was frequently served cold or not at the correct temperature, with some stating that hot foods were only warm and cold foods, such as ice cream, were sometimes melted. Several residents also described the food as bland, lacking taste, and repetitive, with one resident specifically noting that breakfast was always served cold. During a test tray evaluation, food items for both regular and pureed diets were found to be below the facility's required serving temperatures, and the pureed beef teriyaki did not have the correct texture, with visible beef fibers remaining. The Food and Nutrition Service Director acknowledged these issues, including overcooked vegetables and tough meat, and admitted that the mashed potatoes tasted unpleasant. The Registered Dietitian confirmed that serving cold and unpalatable food could lead to decreased meal intake, which may result in residents not receiving proper nutrition. Facility policies reviewed indicated that meals should be served at specific temperatures and prepared to conserve flavor, appearance, and nutritive value, with staff required to sample food for satisfactory flavor and consistency. However, observations and interviews demonstrated that these procedures were not consistently followed, resulting in food that did not meet the established standards for temperature, palatability, and variety.
Failure to Provide Proper Food and Liquid Consistencies for Residents with Special Dietary Needs
Penalty
Summary
The facility failed to provide food and liquids in the appropriate texture and consistency as ordered for residents with special dietary needs. During dinner service, 13 residents on pureed diets were served pureed meat that was not smooth, with visible meat fibers still intact. The Food and Nutrition Services Director confirmed that the pureed beef did not meet the required smooth, mashed potato-like texture, and stated that the food should have been blended longer to achieve the correct consistency. Facility documentation confirmed that these residents had physician orders for pureed diets, and the facility's own guidelines specified that pureed foods should be smooth and moist. Additionally, a resident with a physician order for nectar thick liquids was served milk with undissolved thickener at the bottom of the cup and a regular shake instead of a nectar thick shake. Both the LVN and CNA acknowledged that the milk was not properly mixed and that the resident received the incorrect shake consistency. The Registered Dietitian confirmed that the resident should have received a nectar thick shake and that improperly thickened liquids could discourage fluid intake. Another resident with an order for nectar thick liquids was observed receiving Jello and milk with a pudding-like consistency. The LVN stated that Jello was not appropriate for this resident, as it could melt and become a thin liquid, and that the pudding consistency milk could discourage the resident from drinking. The Registered Dietitian also confirmed that Jello should not be served to residents on nectar thick liquids and that incorrect consistencies could negatively impact fluid intake. Facility policies and procedures required that diet orders be followed and that thickened liquids be prepared to the prescribed consistency.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. Surveyors observed dust accumulation in multiple areas of the kitchen, including the dry storage room and back door frame, which was confirmed by the Food and Nutrition Services Director (FNS) and Registered Dietitian (RD) as a potential source of cross contamination. Staff members, including a Dietary Aide and the Engineering Plant Director, were observed working in food preparation areas with unrestrained facial hair, contrary to facility policy and professional standards. Additionally, open bags of frozen vegetables were found exposed to air in the walk-in freezer, and the refrigerator gasket had black grime buildup, both of which were acknowledged by staff as risks for cross contamination. Further deficiencies included improper storage and handling of food and kitchenware. Three baking pans of pizza were stored near a sanitizer bucket with an air gap, and wilted produce was found in the walk-in refrigerator. The cabinet used to store kitchenware had chipped wood, and two hot waterspouts had calcium buildup. Unsanitary practices were also observed, such as ice bags placed on the floor of the facility lobby, a dirty rag on a clean coffee cart, and eight expired boxes of English muffins in the dry storage pantry. Staff interviews confirmed a lack of knowledge regarding proper cleaning and sanitizing procedures, including the correct use and testing of Quaternary (Quat) sanitizer, the appropriate concentration for sanitizing solutions, and the correct steps for cleaning meal carts and calibrating food thermometers. The survey also revealed that staff were unable to demonstrate or articulate the required procedures for submerging kitchenware in sanitizer, as per manufacturer guidelines. These failures were corroborated by interviews with the FNS and RD, who confirmed that the observed practices did not align with facility policies or professional standards. The cumulative effect of these deficiencies had the potential to result in the contamination of food and food contact surfaces, posing a risk of foodborne illness to all residents receiving food from the kitchen, all of whom were medically compromised.
Failure to Implement QAPI Plan for Staffing, Dietary, and Laundry Deficiencies
Penalty
Summary
The facility failed to maintain a written Quality Assurance Performance Improvement (QAPI) plan to address systemic process issues related to CNA staffing, dietary, and laundry services. During the recertification survey, surveyors identified ongoing deficiencies in these areas, as referenced under F725 (nursing staff), F804 (food services), and F584 (laundry services). An interview and record review with the Administrator revealed that, although a QAPI committee was in place with representation from key facility leadership and departments, the committee did not have a program that identified, corrected, or improved the issues affecting CNA staffing, dietary, and laundry services. As a result of these failures, multiple residents did not receive appropriate services in the areas of CNA staffing, dietary, and laundry. The lack of a comprehensive and data-driven QAPI plan meant that the facility did not systematically address or monitor these deficiencies, which affected the quality of care and services provided to residents. The facility's own policy required the QAPI committee to develop, implement, and monitor corrective actions for identified quality issues, but this process was not followed for the cited areas.
Infection Control Failures in IV Care, Laundry Practices, and Linen Handling
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several observed instances. During a lunch meal service, a resident with an intravenous (IV) access had loose IV tubing without an end cap, which was observed touching the food on her plate. The nurse responsible for taping the IV tubing confirmed that the tubing should have been secured to prevent contamination, and the Infection Preventionist agreed that the tubing should have been taped and possibly netted to avoid contact with food, as per facility policy. In the laundry department, staff were unable to state or monitor the required washer and dryer temperatures necessary for effective disinfection of linens and clothing. Laundry staff reported that they did not check temperatures, were unaware of the required standards, and did not keep logs of temperature checks. The Maintenance Director used an infrared gun to check equipment temperatures but did not document the results. The Infection Preventionist stated that staff should be aware of and track these temperatures to prevent the spread of infectious microorganisms, as supported by equipment manuals and federal guidelines. Additionally, improper handling of clean linen was observed. A staff member placed linen that had been touched by a resident back into an uncovered clean linen cart and later covered clean linen with a cover that had been in contact with the floor. The staff member acknowledged these actions were incorrect, and the Infection Preventionist confirmed that such practices could lead to contamination of clean linens. Facility policy requires clean linen to be loaded onto a covered cart and transported appropriately, which was not followed in these instances.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by the observation of four bugs, one spider, and one house fly in food storage and preparation areas. During a walkthrough of the dry storage room, four brown bugs with wings and a spider were seen on the ceiling, and the Food and Nutrition Services Director acknowledged that pests should not be present in the kitchen due to the risk of cross contamination of stored foods. Additionally, a house fly was observed landing on a window near the steamtable, further indicating the presence of pests in food service areas. Interviews with facility staff, including the Food and Nutrition Services Director and the Registered Dietician, confirmed that the kitchen is expected to be free of pests to prevent cross contamination and infection control issues. A review of the facility's pest control policy and procedures indicated that the facility is required to maintain an ongoing pest control program to keep the premises free of insects, rodents, and other pests, specifically noting the importance of fly and vermin control in the Food & Nutrition Services Department. Despite these policies, the presence of pests in the kitchen was directly observed.
Deficiencies in Medication Handling, Administration, and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of four residents, as evidenced by multiple deficiencies in medication handling, administration, and documentation. In one instance, a licensed nurse discarded a non-scheduled medication (Ipratropium/Albuterol inhalation solution) into a regular trash bin after dropping it on the floor, rather than using the designated medication disposal bin and documenting the destruction as required by facility policy. The nurse later acknowledged this error during an interview, and the Director of Nursing confirmed the expectation for proper disposal and documentation. During medication administration, the same nurse left several medications unattended on a resident's bedside table while leaving the room to obtain supplies. This included pills, a liquid oral solution, and an inhalation solution. The nurse admitted that medications should not be left unattended, as this could result in them being taken by the wrong person or discarded by the resident. The DON reiterated that medications should always remain with the nurse until administration is complete, in accordance with facility policy. A review of controlled medication records for two residents revealed discrepancies between the narcotic count sheets and the electronic Medication Administration Records (eMAR). Medications were signed out on the count sheets but not documented as administered on the eMAR, resulting in unaccounted doses of Norco and Tramadol. Additionally, another resident did not receive scheduled doses of Norco due to the medication being out of stock and pending pharmacy delivery, as documented in progress notes and confirmed by inventory records. The facility did not have an emergency kit for hospice residents, and the pharmacy supplied only limited quantities of the medication, leading to missed doses. The DON verified these findings and acknowledged the lack of specific pain management policies for hospice residents.
Failure to Serve Meals Concurrently Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that meals were served to all residents at the same time, resulting in two residents not receiving their meals concurrently with others at their tables. On March 17, 2025, one resident was observed sitting in a wheelchair at a dining table with three other residents. While the other residents received their meals, this resident was left waiting and had to ask staff about his food. He remained without his meal for nearly an hour, only receiving it after the others had finished eating. Staff interviews revealed there was no organized system for meal service, leading to confusion and delays in serving certain residents. Another resident experienced similar issues on two occasions. On March 17, 2025, he was observed waiting for his lunch while others at his table were already eating. The following day, he waited approximately 20 minutes for his dinner tray while another resident at his table had already been served. This resident expressed unhappiness and frustration at being left out. Staff, including a CNA and an RN, acknowledged the lack of organization in meal delivery and recognized the negative impact on residents' dignity and well-being. Both residents involved were cognitively intact, with one having a history of diabetes mellitus and the other with diagnoses including depression, diabetes mellitus, and malnutrition. Facility policy reviews confirmed that residents' rights to dignity and equal treatment were not upheld during these incidents, as staff failed to provide meals in a manner that respected their self-esteem and individuality.
Failure to Obtain and Renew Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents prior to the initiation and administration of psychotropic medications for two residents, as required by its own policy and procedure. For one resident with diagnoses including insomnia, depression, anxiety, dementia, and seizure, medical records showed that Melatonin and Diphenhydramine were administered at bedtime since early September 2024 without any documented informed consent. The Director of Nursing (DON) confirmed during record review that no informed consents were present in the electronic medical records for these medications. For another resident with diagnoses of psychotic disorder with delusions, anxiety, and dementia, Depakote was ordered and administered for labile mood, but the last documented informed consent for this medication was from September 2023. The DON verified that no updated informed consent had been obtained for Depakote since that time, despite the facility's policy requiring renewal every six months. The facility's policy specifies that informed consent must be obtained in writing prior to administration of psychoactive medications and renewed biannually, but this process was not followed for the residents in question.
Failure to Address Resident Grievance Regarding Missing Prosthesis
Penalty
Summary
The facility failed to address a resident's grievance regarding a missing left below-the-knee prosthetic leg. The resident, who had a history of respiratory failure with hypoxia, left leg amputation, and blindness in both eyes, reported the prosthesis missing after a room change approximately seven months prior. The resident stated she notified the charge nurse, administrator, DON, and Social Service Assistant but did not receive any feedback or follow-up. The resident expressed distress over the loss, stating she could no longer get out of bed or walk with her walker, and felt herself getting weaker due to lack of use of the prosthesis. Interviews with facility staff confirmed the prosthesis was reported missing and that searches and insurance contacts were made, but there was no documentation or evidence of prompt resolution or communication with the resident regarding the status of her grievance. The facility's policy required investigation, reporting, and documentation of lost items, as well as safeguarding and replacement of resident property, but these procedures were not followed in this case.
Failure to Administer and Document Medications per Physician Orders
Penalty
Summary
The facility failed to administer medications according to physician orders for one resident with multiple diagnoses, including hypertensive heart disease, diabetes mellitus, and bradycardia. Review of the resident's records showed that clonidine, hydralazine, and Lantus were not administered as ordered on several occasions. Specifically, clonidine was missed on multiple dates and times, and was sometimes signed as administered without documented blood pressure and pulse readings. Hydralazine was not given as ordered, with some doses missed or administered without proper documentation of vital signs, and in some cases, given when the resident's blood pressure or pulse was below the parameters set by the physician. Lantus was also not administered as ordered on several dates, and there was no documented evidence that blood sugar was checked prior to administration during the review period. During an interview and record review, the DON confirmed that medications should be administered and documented according to physician orders, including recording vital signs and blood sugar checks as required. Facility policy requires that all medications administered be documented on the MAR, including reasons for withholding or not administering medications, and that the person administering the medication sign the record. The review found multiple instances where these requirements were not met, resulting in a failure to provide care and treatment according to orders and established protocols.
Failure to Identify and Report Medication Therapy Irregularities During Monthly Pharmacist Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication therapy irregularities during the monthly Medication Regimen Review (MRR) for three residents. For one resident with a history of myocardial infarction, duplicate Vitamin D orders with the same strength, frequency, and indication were present, resulting in the resident receiving double the intended dose daily for nearly a month. The CP did not identify or report this duplication during the MRR, and the Director of Nursing (DON) confirmed the error upon review. Another resident with a diagnosis of malnutrition was found to have duplicate orders for Omeprazole 20 mg, both with the same strength, frequency, and indication. This led to the resident receiving four doses daily instead of the intended two, as documented in the Medication Administration Record (MAR) over a month-long period. The DON verified the duplication and inappropriate administration, and the CP acknowledged missing this irregularity during the MRR. A third resident, admitted with multiple chronic conditions including chronic pain syndrome and Alzheimer's disease, was on a routine opioid regimen (Percocet) without a corresponding bowel management plan, despite the known risk of opioid-induced constipation. The absence of a bowel regimen was not identified or addressed by the CP during the MRR, and the DON confirmed that no such regimen had been ordered since the initiation of opioid therapy. Facility policies required monitoring for adverse consequences of medications, including constipation from opioids, and mandated the CP to identify such irregularities.
Failure to Prevent Duplicate Medication Administration
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications by allowing duplicate medication orders to be administered without review or clarification. For one resident, two separate orders for Vitamin D at the same strength, frequency, and indication were active, resulting in the resident receiving double the intended dose each day over a period of several weeks. The duplicate orders were not identified or clarified by nursing staff, and both were administered as scheduled. Another resident had two active orders for Omeprazole 20 mg, both prescribed for similar gastrointestinal indications and scheduled at overlapping times. This led to the resident receiving up to four doses of Omeprazole daily, rather than the intended two. The DON confirmed that the duplicate orders were not clarified with the physician, and nursing staff continued to administer the medication according to both orders. The facility's policy required nurses to check for correct dosage schedules and clarify any questionable orders with the pharmacy or prescriber prior to administration, but this was not followed in these cases.
Medication Error Rate Exceeds Acceptable Threshold During Medication Pass
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a cumulative error rate of 13.79%. During the observation, a licensed vocational nurse (LVN) administered medications to a resident and made four errors out of 29 opportunities. Specifically, the LVN did not administer the scheduled azelastine nasal spray and instead gave an as-needed fluticasone nasal spray. Additionally, the LVN administered a lower dose of Vitamin D3 (2000 IU) instead of the prescribed 5000 IU, and failed to administer cyanocobalamin (Vitamin B12) as ordered. These errors were confirmed through review of the resident's medical records and the Medication Administration Record (MAR), which showed missing documentation for the omitted medications and incorrect documentation for the administered medications. During interviews, the LVN acknowledged the errors, stating that the correct medications were not available in the medication cart and would need to be reordered. The Director of Nursing (DON) confirmed that the expectation was for nurses to check the MAR and medication labels against physician orders before administration. Facility policy required medications to be administered according to written orders and for the MAR to be reviewed at the end of each medication pass to ensure all necessary doses were given and documented.
Failure to Administer and Document Seizure Medication
Penalty
Summary
A significant medication error occurred when a resident with a diagnosis of epilepsy did not receive a prescribed dose of phenobarbital, a medication used to control seizures. The resident's physician had ordered phenobarbital 32.4 mg, seven tablets by mouth at bedtime, but review of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for March showed that the dose was not administered on March 11, and there was no documentation in the MAR or nursing progress notes explaining the omission or indicating that the physician was notified. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) confirmed the absence of documentation and were unaware of the missed dose until it was brought to their attention during the survey. The facility's policy requires that all medication administrations and omissions be documented, and that the physician be notified if a dose is missed. The resident reported a history of experiencing seizures when not receiving phenobarbital and stated that he had previously informed staff to reorder his medication. The Consultant Pharmacist confirmed that missing a dose of phenobarbital could result in a seizure and that any missing administration should be reported immediately. The facility's failure to administer and document the prescribed medication, as well as to notify the physician and document the reason for the omission, resulted in the resident not being free from significant medication errors.
Failure to Provide Timely Dental Consultation
Penalty
Summary
The facility failed to ensure that a dental consultation was provided for a resident who was experiencing oral pain and had a visible bump on her lower gum. The resident, who had severe cognitive impairment and a diagnosis of protein-calorie malnutrition, reported pain when touching the affected area and discomfort while eating. Documentation showed that on March 4, a nurse observed the bump and notified the primary care physician, who then ordered a dental consult. The resident's care plan was updated to coordinate dental care as ordered. Despite these actions, the resident was not seen by the facility dentist during the dentist's visit, nor was an outside dental appointment arranged. Staff interviews confirmed that the dental consult was not completed, and the resident was not included on the list for the facility dentist. The facility's policy required social services to coordinate such referrals, but this was not carried out, resulting in the resident's dental needs remaining unaddressed.
Dietary Supervisor Lacked Required In-Service Training Prior to Full-Time Duties
Penalty
Summary
The facility failed to ensure that the Food and Nutrition Services Director, who is a Certified Dietary Manager, completed the required six hours of in-service training specific to California dietary service requirements as outlined in Title 22 of the California Code of Regulations before assuming full-time duties as the dietetic services supervisor. During an interview, the Food and Nutrition Services Director stated she was unaware of the requirement to complete this training prior to starting her role. The Registered Dietitian confirmed knowledge of the requirement but was not aware that the Director had not completed the necessary training hours. A review of the facility's job description indicated that the Food and Nutrition Services Director must meet state and federal regulatory qualifications. State regulations require that if a registered dietitian is not employed full-time, a full-time dietetic services supervisor must have completed at least six hours of in-service training on California dietary service requirements before assuming the position. The lack of this required training by the supervisor was identified through interviews and record review.
Failure to Maintain Kitchen Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition when condensation ice buildup was observed on the two fans inside the reach-in freezer, along with a puddle of ice on a box of cut corn on the second shelf. The Food and Nutrition Services Director acknowledged that the freezer was not functioning properly and that condensation ice buildup had occurred intermittently over the past two weeks. The Engineering Plant Director explained that the defrost timer had been affected by the daylight saving time change, leading to temperature fluctuations, condensation, and ice formation, which could impact food quality. No verbal or written work order had been submitted by the dietary department regarding the malfunction. Facility policy requires all equipment to be maintained in good repair.
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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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