Royal Palms Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, California.
- Location
- 630 W. Broadway, Glendale, California 91204
- CMS Provider Number
- 055899
- Inspections on file
- 65
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Royal Palms Post Acute during CMS and state inspections, most recent first.
A resident with a history of left femur fracture, COPD, and right hip osteoarthritis had documented lower extremity ROM impairment and required substantial/maximal assistance with transfers. Admission orders and care plans called for PT, OT, and ST evaluation and treatment, including PT for gait training, posture correction, and strengthening, and a post-fall rehab screen noted lower extremity weakness and indicated the resident was on rehab services. However, facility staff could not produce any PT evaluation or treatment documentation after the resident’s readmission, and the resident reported not receiving leg therapy for ambulation. The MDS nurse, OTA, and RN supervisor all confirmed the absence of PT records, despite facility policies requiring appropriate mobility services and rehabilitative care based on MDS findings.
Improper garbage and refuse disposal was observed when one of four dumpsters was overflowing and not completely closed, and a trash can in the kitchen prep area was left uncovered when not in use. The DS and MS stated the containers should be kept closed to prevent flies, pests, and contamination, and facility policy and the Food Code required covered receptacles.
Incomplete Advance Directive Acknowledgment Forms were found for three residents. The forms were left blank and did not show whether each resident had executed an advance directive. The residents had diagnoses including metabolic encephalopathy, and MDS findings showed two residents were cognitively intact while one was moderately cognitively impaired. The SSD confirmed the forms were incomplete, and the facility policy stated residents must be asked whether they have executed any advance directives.
Puree diet cream of rice was observed flat on the plate and not holding its shape, with the item later mixed with slurry but still spreading and touching other foods. RD and DS stated the recipe was not followed and the item had too much water, while puree bread was used as a substitute because it was considered safer. The diet manual and standardized recipe required IDDSI Level 4 foods to be thick, cohesive, and hold shape.
Surveyors found widespread kitchen sanitation and food handling failures, including dirt and debris in freezers, storage areas, drawers, and equipment; missing freezer log entries and no corrective action; unlabeled sandwiches; dented cans stored with regular stock; and cracked or chipped resident trays. Staff were also observed with improper hand hygiene, incomplete beard coverage, soiled towels in prep areas, a dirty coffee scoop and container, chewing gum on trayline, a nose ring in the kitchen, and wet pans stacked in storage.
The facility failed to provide a designated refrigerator for residents’ leftovers or food brought in from outside sources. The DS, ADM, DON, ADON, and RD stated the facility either did not store outside food, expected residents to eat it immediately, or told families to take leftovers home. Staff also reported confusion about the policy and location of any resident refrigerator, while reviewed policies referenced storing outside food in a designated or facility refrigerator and labeling it appropriately.
A CNA provided bed bath and brief change care to a resident on EBP without wearing an isolation gown, despite posted signage and care plan directions requiring gowns and gloves for high-contact activities. The resident had multiple vascular ulcers on the left foot and needed substantial to maximal assistance with ADLs. The CNA stated she was not aware a gown was required, and the IPN and DON confirmed gown use was required for close contact care such as bathing and changing briefs.
Two CNAs worked a scheduled overnight shift after five of seven CNAs failed to report, leaving one CNA and one other CNA to care for all residents. Residents reported waiting 1.5 to 2 hours for ADL assistance, including brief changes, and one resident remained in a soiled brief for about 1.5 hours. A resident with DM, COPD, and endocarditis, another with cirrhosis and insomnia, a resident with COPD and DM, a resident with hemiplegia/hemiparesis and DM, and a resident with hemiplegia/hemiparesis and HTN were among those affected.
Failure to Maintain Resident Dignity During Personal Care and Feeding: A resident with a urinary drainage container was observed with the bag left uncovered, and the resident stated it was embarrassing and should be covered. In a separate event, a CNA assisted another resident with meals while standing rather than positioning at eye level during feeding. Facility leadership acknowledged both situations were inconsistent with dignity expectations and policy.
Failure to Obtain Informed Consent for Psychotropic Medication: A resident with encephalopathy, dementia, and schizoaffective disorder had orders for Zyprexa, but the EHR and consent binders contained no documentation of informed consent from the prescriber. The resident was severely cognitively impaired and nonresponsive during observation, and the SSD, ADON, and DON all confirmed the consent was missing.
A resident with dementia, severe cognitive impairment, and high fall risk was observed in bed with multiple pillows placed under the sheets on both sides, creating a barrier that restricted movement and prevented independent repositioning. Staff stated the pillows were being used to keep the resident from getting out of bed, and the DON/ADON confirmed this would be considered a restraint. No physician order or care plan was documented for this use of pillows.
A facility failed to develop and implement individualized care plans for two residents. One resident with epilepsy had a seizure CP that only stated to keep the area safe and hazard free without specific measures such as padded bedrails or a low bed, and staff observed the bed not kept low and were unsure how to provide seizure safety. Another resident with dementia and severe cognitive impairment had a wandering CP that used general reorientation and redirection interventions even though the resident continued to wander repeatedly throughout the facility and staff acknowledged the plan was not individualized or effective.
Incorrect ID Band Attached to Resident’s Bed Rail: An ADON observed an incorrect ID band attached to a resident’s bed rail, and confirmed it belonged to another resident. The resident had hemiplegia, encephalopathy, epilepsy, severe cognitive impairment, and was dependent on staff for all ADLs. The DON stated the wrong ID band could confuse staff and lead to wrong care, while the facility policy states photo and/or wristband ID are used for meds and treatments.
A resident with DM, anemia, and adult failure to thrive had limited ROM in the left 4th and 5th fingers, but the decline was not documented in nursing notes or identified in the care plan. A CNA noticed the stiffness but did not promptly report it to licensed staff, and the LVN stated she did not properly assess the resident’s fingers because she thought the position was normal. The resident reported pain and stiffness for months and said only pain medication was provided, with no MD evaluation or therapy.
Failure to Maintain Safe Seizure Precautions: A resident with epilepsy had care plans and a physician order to keep the area safe and monitor seizures, but the plans did not specify the precautions to use. During observation, the resident’s bed was not in the lowest position, there were no bedrails, and nearby equipment was positioned around the bed. CNA staff said they were not familiar with the resident’s injury risk or instructed on seizure safety, and an RN stated the resident should have had padded bedrails, a floor mat, and the bed in the lowest position.
Failure to Follow Up on Dental Referral and Denture Process: A resident with DM, anemia, and adult failure to thrive had missing teeth and requested new dentures, but social services did not document follow-up on dental X-ray results, medical clearance, or the denture/extraction process. The resident said he needed dentures to chew preferred foods and felt ignored after not receiving updates for more than 2 months. The SSD confirmed the follow-up and resident updates were not completed, and the issue was not discussed in IDT meetings.
A resident with DM, anemia, and adult failure to thrive had signs and symptoms of UTI, and the physician ordered in and out urine collection for UA and C&S along with empiric Bactrim pending results. The LVN could not locate any UA/C&S results in the EHR or paper chart, and the IPN stated he did not know whether the catheterization was completed or follow up on whether the specimen was sent to the lab or the results were received. The DON stated nursing staff and the IPN were supposed to follow up to confirm the UTI diagnosis and guide antibiotic treatment.
Food was served at improper temperatures and was not palatable. During a test tray observation, the DS found hot items such as pork chop, rice, and vegetables below the facility’s stated hot-food standard, and stated the pork chop was dry and overcooked. A resident with COPD, metabolic encephalopathy, and upper lung cancer reported meals arrived cold and were not reheated; during observation, the resident said the meat was cold and the rice would not be eaten.
Inaccurate documentation of Wander Guard function testing was found for a resident with metabolic encephalopathy, bipolar disorder, and dementia who used an elopement alarm daily. The MAR showed an LPN signed for the resident’s Wander Guard checks on multiple shifts, but the LPN stated she did not perform the test, was not familiar with the device, and signed without completing the check herself; the DON stated staff should only sign their own assigned residents’ MAR entries.
Failure to Track UA/C&S and Perform Antibiotic Timeout: A resident with DM, anemia, and adult failure to thrive was started on empiric Bactrim DS for a suspected UTI after a UA/C&S was ordered by the MD. The MAR showed the antibiotic was given for four consecutive days, but there was no documentation that the urine specimen was collected or sent to the lab, no UA/C&S results were found, and no Antibiotic Timeout was documented at the 48-72 hour mark. The IPN stated he did not follow up on the specimen or lab results even though he was responsible for monitoring antibiotic stewardship and infection surveillance.
Call Lights Not Accessible to Two Residents: The facility failed to ensure two residents could use their call lights. One resident with metabolic encephalopathy, epilepsy, and TIA had the call light placed out of reach while in bed, and another resident with hemiplegia, hemiparesis, dysarthria, and moderate cognitive impairment could not physically activate the call light with either hand. The IPN, LVN, and DON all acknowledged the residents’ inability to access or use the call system as observed.
A resident on warfarin for chronic PE refused PT/INR blood draws for several consecutive days and missed warfarin doses, but staff did not promptly notify the MD of the refusals or the missed medication. The resident said the blood draws were painful because the phlebotomist pulled and twisted her arm, and the ADON, LVN, and DON confirmed the lack of timely physician notification despite the facility policy requiring immediate reporting of high-risk refusals and changes in condition.
A resident with DM, a left BKA, and on dialysis, who required substantial assistance with ADLs and was cognitively intact, was assessed as high risk for falls based on a fall risk evaluation. Despite this, no fall risk care plan was developed or implemented. The resident later called for help and was found on the floor in a kneeling position by the bed with severe left hip pain, and was subsequently diagnosed with a left intertrochanteric femur fracture. The MDSC acknowledged the fall risk assessment had been wrongly coded and that a high fall risk care plan should have been initiated, and the DON confirmed that a fall risk care plan should have been completed in accordance with facility policy.
A resident with advanced dementia, severe cognitive impairment, and a low BIMS score was known by staff to be profoundly confused, disoriented, and frequently wandering into other residents’ rooms, including both female and male rooms, requiring frequent redirection. Despite an altercation in which the resident entered a roommate’s personal space at the bedside and was struck, and despite complaints from other residents, RNs and the SSD reported there were no specific care plan interventions or assigned staff monitoring to address the wandering behavior. The MDS did not code the resident as significantly intrusive wandering, and the MDS coordinator confirmed that no individualized, person-centered care plan had been developed to manage the resident’s behavior, contrary to facility policy requiring comprehensive care plans with measurable objectives and timetables.
A resident with UTI, pneumonia, sepsis, multiple pressure injuries, impaired skin integrity, and an indwelling urinary catheter had physician-ordered Enhanced Barrier Precautions (EBP) and care plan interventions requiring staff to use gowns and gloves for high-contact care. Surveyors found that no EBP signage or PPE was placed outside the resident’s room, and a CNA provided hands-on care, including handling the Foley catheter bag and bedding, without PPE, stating they were unaware EBP was required. An RN and the Infection Preventionist confirmed that EBP should have been implemented per the physician’s order and facility infection control policy, but it was not.
The facility failed to implement its IPCP for suspected scabies by not initiating a line list for affected residents and staff, not updating infection surveillance logs to include residents with suspicious rashes treated with Permethrin, and not performing skin scrape tests before prophylactic scabies treatment. A resident with neuropathy and DM developed a rash and was treated with Permethrin months earlier without a skin scrape or surveillance tracking, and later experienced a recurrent generalized rash that was again treated before testing. Three additional residents with multiple comorbidities developed generalized rashes, were placed on contact precautions, and received Permethrin (and for some, Ivermectin and Hibiclens) before skin scrapes were obtained, with specimens left at the front desk for two days before lab pickup. Despite multiple symptomatic residents and reports of staff rashes, the IP did not maintain a current surveillance log or line list and delayed reporting a suspected scabies outbreak to public health until several days after multiple residents were already on contact precautions.
Surveyors found that staff failed to follow facility policy for timely medication administration and documentation for three residents. Multiple medications scheduled for a specific morning time were documented as given outside the required one-hour window, and an LVN admitted she had pre-signed the MARs before actually administering the medications and was late giving them. The affected residents had conditions including alcoholic cirrhosis with ascites, diabetes, heart disease, and sequela of cerebral infarction, with varying levels of cognitive function and ADL dependence. One resident reported that medications were sometimes not given on time, especially on the night shift. A supervising RN confirmed that facility policy required medications to be given within one hour of the ordered time and documented immediately after administration. The report states that this practice resulted in delayed medication administration and had the potential to compromise residents’ health.
Three residents at high risk for falls were not adequately supervised or provided a hazard-free environment. One resident with cognitive impairment and mobility deficits was left unsupervised in the bathroom and suffered a head injury after a fall. Another resident's bed was not kept in the lowest position as required, and a third resident was found on the floor with the call light out of reach while the assigned CNA was on break and had not arranged for coverage. These deficiencies resulted in actual harm and placed all three residents at risk for serious injury.
A resident who was fully dependent for ADLs and had severe cognitive and physical impairments was left in a wet and soiled incontinence brief for several hours, contrary to their care plan. The CNA responsible had not checked or changed the resident since the morning, resulting in observed skin irritation. Facility staff acknowledged that incontinence care should have been provided more frequently.
A resident with ESRD, diabetes, and dementia was discharged as 'against medical advice' after failing to return from a scheduled dialysis appointment, without proper documentation, care planning, or evidence of communication with the resident or their contacts. The facility did not follow its own policies for discharge preparation or documentation, and there was no physician discharge order or interdisciplinary review.
A resident with end stage renal disease, diabetes, and dementia repeatedly left the facility without permission and missed dialysis appointments, yet the facility did not implement or document behavioral interventions, care plan revisions, or interdisciplinary team involvement as required. The facility also failed to communicate with the resident's family or emergency contacts and did not initiate a psychiatric evaluation as ordered.
A resident diagnosed with impetigo was not placed on contact isolation after a physician's order for hospital transfer, and two roommates exposed to the infection were also not placed on isolation or enhanced barrier precautions. Staff did not post isolation signage or use PPE, and no care plans or physician orders for isolation were initiated, contrary to facility policy and CDC guidelines.
A resident tested positive for CRAB, a rare multidrug-resistant organism, but the facility did not promptly initiate surveillance, notify CDPH, or inform the primary and attending physicians of the affected and exposed residents. The DON delayed recommended screenings and failed to document the exposure or notify medical staff, contrary to facility policy.
The facility failed to properly dispose of garbage, with one dumpster found without a lid and overflowing, and the garbage area littered with waste and rubbish. The DON, HKS, MS, and DSS acknowledged the oversight, which could attract pests and spread infection. Facility policy requires food waste to be contained and dumpsters to be closed, which was not followed.
A resident's call light was found inaccessible, stuck behind the bed and on the floor, preventing the resident from calling for assistance. The resident, with conditions including difficulty in walking and muscle weakness, was unable to reach the call light, as confirmed by staff and the Director of Nursing. The facility's policy requires call lights to be accessible and functioning at all times.
A resident with mental health diagnoses was not referred for a required PASRR Level II evaluation after a positive Level I screening. The facility's oversight was discovered during a record review, revealing no documentation of the necessary referral. Staff interviews confirmed the lapse in following up on the PASRR requirement, highlighting the absence of a system to ensure compliance.
A resident with quadriplegia developed a Stage 1 pressure injury due to the facility's failure to update the care plan. Despite existing care plans for skin integrity, the plan was not revised when the injury was identified, as confirmed by staff interviews. The DON acknowledged the oversight, which left the resident at risk for further complications.
A resident's care plan was not updated to include Febuxostat, a medication prescribed for gout, despite being on the medication since late 2024. This oversight was confirmed by facility staff, who acknowledged the importance of updating care plans to monitor treatment effectiveness. The facility's policy requires care plans to be revised with new resident information, which was not followed in this case.
A facility failed to provide a communication tool for a resident with dementia and Alzheimer's who did not speak the facility's formal language. The resident, with severely impaired cognition and dependent on care, lacked translation materials in their room, hindering communication with staff. A CNA and the DON acknowledged the absence and necessity of such tools, contrary to the facility's policy on language access.
A resident with communication difficulties and at risk for falls did not have their call light within reach, as observed during a room visit. Facility staff confirmed the importance of call light accessibility for timely assistance, as per facility policies. The deficiency had the potential to prevent the resident from receiving necessary care.
Two residents in a facility experienced deficiencies in pressure ulcer care and prevention. One resident's low air loss mattress was not set to their correct weight, contrary to guidelines, risking skin breakdown. Another resident developed a Stage 1 pressure injury that progressed to Stage 2 due to the care plan not being updated with necessary interventions. These failures in adhering to facility policies and procedures resulted in inadequate care and increased risk for the residents.
Two residents in an LTC facility experienced deficiencies in oxygen administration. One resident, with a history of respiratory issues, was found with their nasal cannula on the floor, not receiving prescribed oxygen. Another resident was administered oxygen without a physician's order, contrary to facility policy. These lapses in following protocols had the potential to impact the residents' health.
A resident with benign prostatic hyperplasia did not receive their prescribed Finasteride due to the facility's failure to reorder the medication in a timely manner. The LVN responsible did not document the refill request, and the medication was unavailable during a scheduled administration. The DON confirmed that the facility's policy requires timely reordering and documentation of medication orders.
The facility failed to ensure that two residents signed their POLST forms before placing them in their medical charts. Despite having intact cognition, the residents' POLST forms were prepared but not signed, leading to incomplete documentation. Staff interviews revealed a lack of adherence to the process for completing and filing POLST forms, with signed forms not being placed in the residents' charts as required.
The facility failed to maintain a safe and clean environment in two bathrooms, where paint was peeling, and grout was discolored, posing potential infection risks. The Maintenance Supervisor confirmed these issues, which contradicted the facility's policy for a homelike environment.
Two residents with cognitive impairments were found with cigarette lighters, violating the facility's smoking policy. Despite requiring supervision, staff failed to enforce the policy, posing a fire risk, especially with oxygen present. Interviews revealed staff were unaware of the residents' possession of lighters, highlighting a lapse in safety practices.
The facility failed to meet the required square footage for 40 out of 54 resident rooms, with 5 two-bedroom and 35 three-bedroom configurations not providing the minimum space per resident. Despite this, residents reported adequate space for mobility and care, and no deficits in care or safety were observed during the survey.
A facility failed to notify a resident's representative of a diabetic ulcer, violating the policy requiring prompt notification of changes in medical condition. The resident, with severe cognitive impairment and type 2 diabetes, had a documented ulcer upon readmission, but the representative was not informed, preventing timely medical intervention. Interviews revealed the representative was unaware of the ulcer until the resident's transfer to a hospital, and the Social Services Director confirmed the lack of documentation of communication.
A facility failed to develop a person-centered care plan for a resident's Prevalon boots, lacking instructions on cleaning and maintenance. The resident, with conditions like encephalopathy and diabetes, had a care plan mentioning the boots but no maintenance guidance. Staff interviews revealed a lack of documentation and understanding of boot care, posing an infection risk. The facility's policy required care plans to maintain resident well-being, but this was not followed, leading to potential infection control issues.
A resident with end-stage renal disease and severely impaired cognition repeatedly refused medications and supplements, but the LTC facility failed to develop a comprehensive care plan or inform the responsible party. Despite requests for an IDT meeting, none was held, leading to the resident's hospitalization due to severe weakness and abnormal lab values.
Failure to Implement Ordered PT Services for Resident With Impaired Mobility
Penalty
Summary
The facility failed to implement physician orders for PT for one resident with impaired lower extremity mobility. The resident had been originally admitted and later readmitted with a displaced intertrochanteric fracture of the left femur, COPD, and osteoarthritis of the right hip. An MDS assessment showed impaired range of motion in one lower extremity and a need for substantial/maximal assistance with sit-to-stand, sit-to-lying, and bed/chair transfers. The Order Summary Report contained an admission order for PT, OT, and ST evaluation and treatment. The resident’s care plans for fall risk and unsafe device use/body alignment included interventions for PT to evaluate and treat, and to provide gait training, posture correction, and strength exercises. A Rehab Post Fall Screen following a fall identified lower extremity weakness and indicated the resident was currently on rehab services. Despite these orders and care plan interventions, there was no documentation that PT services were ever initiated or provided after the resident’s readmission. During interviews and record reviews, the MDS nurse confirmed there were OT clarification orders and that OT was discharged, but she did not find any PT orders beyond the initial admission order. The OTA could not locate a PT evaluation after readmission and acknowledged she had not documented informing the prior DOR that the resident had not been seen by PT. The RN supervisor also could not find documentation of PT and stated she was responsible for reviewing care plans and ensuring the resident received PT. The resident reported feeling upset and frustrated, stating he had not received therapy for leg training for ambulation since returning from the hospital. The DON stated that after rehab orders are entered, nursing staff must follow up and communicate with rehab when ordered therapy is not provided. Facility policies on resident mobility and specialized rehabilitative services required that residents with limited mobility receive appropriate services and that rehabilitative services be provided as indicated by the MDS, but these were not followed for this resident.
Improper Garbage and Refuse Disposal
Penalty
Summary
Garbage and refuse were not properly disposed of when one of four dumpsters in the dumpster area was observed overflowing with trash and not completely closed while not actively in use. During the observation, the Dietary Supervisor stated the dumpster was not completely closed and that staff could have used the other three dumpsters, which were not full, to avoid overflowing. The Maintenance Supervisor later stated the dumpster should not be overflowing and should always be closed to prevent flies and pests, and noted that flies could contaminate food and cause residents to get sick. In the kitchen preparation area, a trash can was observed not completely covered when it was not actively being used. The Dietary Supervisor stated the lid was not closed while dietary staff were not using it and explained that keeping the lid closed was important to prevent bugs and flies, pest droppings, and contamination of food. Facility policy required garbage and refuse containers to have tight-fitting lids or covers and to be kept covered when stored or not in continuous use, and the Food Code cited in the report also required outside receptacles to be kept covered with tight-fitting lids or doors.
Incomplete Advance Directive Acknowledgment Forms
Penalty
Summary
The facility failed to complete the Advance Directive Acknowledgment Form for three sampled residents, leaving the section blank that should indicate whether each resident had executed an advance directive. Resident 7 was admitted with diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, and the MDS dated 3/23/2026 indicated the resident’s functional and cognitive status was intact. Resident 9 was admitted with metabolic encephalopathy, and the MDS indicated the resident’s functional and cognitive status was intact. Resident 87 was admitted with metabolic encephalopathy, and the MDS indicated the resident was moderately cognitively impaired. The Advance Directive Acknowledgment Form for Resident 7, dated 12/23/2025, was blank and did not indicate whether an advance directive had been executed. The form for Resident 9, dated 1/22/2026, was also blank and did not indicate whether an advance directive had been executed. The form for Resident 87, dated 12/18/2025, was blank and did not indicate whether an advance directive had been executed. During interviews, the Social Services Designee stated the forms for Residents 7, 9, and 87 were incomplete, and stated that if residents do not have an advance directive, their care may not be aligned with their wishes and there is a risk of providing unwanted care. The facility policy titled Advance Directives stated the facility shall ask residents whether they have executed any advance directives.
Puree Diet Cream of Rice Not Prepared to Required Texture
Penalty
Summary
The facility failed to prepare food in a form designed to meet individual needs when pureed cream of rice served on the puree diet was observed flat on the plate and not holding its shape. The deficiency involved residents on puree diet/IDDSI Level 4, and the report stated that 15 of 15 residents on puree diet were potentially affected. During tray line observation with the Registered Dietitian, the herbed cream of rice was seen flat on the plate, and the dietitian stated it would be fixed and replaced because it was flat. During a later observation, the Registered Dietitian was seen adding slurry and mixing the puree cream of rice with a whisk. When the item was observed again, it was still flat and touching other food items on the plate. The Registered Dietitian stated puree bread was used as a substitute because the cream of rice was too watery and puree bread was safer to serve. The Dietary Supervisor stated the puree cream of rice had too much water, did not follow the recipe, and was spreading out on the plate instead of holding its shape. The facility’s diet manual stated IDDSI Level 4 foods must be extremely thick, smooth, lump free, moist, cohesive, and not liquid, and the standardized recipe required staff to follow the recipe exactly as written. The recipe for herbed cream of rice directed staff to measure water, bring it to a boil, stir in the cereal, cook for 1 minute, cover and remove from heat, then stir in margarine, spices, and seasonings. The report also noted that IDDSI Level 4 food should hold shape on a spoon and on the plate, and that the texture testing method included the spoon tilt test and fork drip test.
Unsafe Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary kitchen conditions during multiple observations in the dietary department. Surveyors observed dirt, dust, food debris, cardboard boxes, and trash in and around kitchen equipment and storage areas, including the bottom shelves of reach-in freezers, the dry storage floor corner, the kitchen utensils drawer, the pots and pans storage area, and the resident refrigerator in the activity room. The attached freezer in the activity room had ice buildup and no thermometer, and the reach-in freezer temperature log had missing entries and no corrective action documented. The Dietary Supervisor acknowledged several of these conditions and stated the areas should be cleaned daily or weekly as applicable. Surveyors also observed multiple food handling and sanitation practices that were not followed during food preparation and service. A dietary aide did not fully cover his beard while preparing food, staff touched towel dispenser knobs after handwashing and then continued food preparation, one staff member touched the garbage can lid and then handled utensils without washing hands, and another dietary aide handled soiled dishes and then clean dishes without changing gloves or washing hands. A soiled towel was left in the food preparation area, a coffee scoop had debris and was not washed after use, and a blue coffee scoop container was cracked with dirt and coffee residue touching the lip. During lunch trayline, a cook was chewing gum, and a dietary aide was wearing a nose ring in the kitchen. The survey also identified food storage and equipment issues. Two trays of sandwiches were not labeled and dated, two dented cans were stored with non-dented cans despite a designated dented-can area, and 60 of 65 resident trays were cracked and chipped. Pans were stacked wet in storage, and the Dietary Supervisor stated they should not be stacked wet because they could grow mildew. The report states these failures had the potential to result in harmful bacterial growth and cross-contamination that could lead to foodborne illness in 124 of 127 medically compromised residents who received food and ice from the kitchen.
No Designated Refrigerator for Residents’ Outside Food
Penalty
Summary
The facility failed to provide a safe designated refrigerator for residents’ leftovers or food brought in from outside sources for 124 of 127 residents. During interview, the Dietary Supervisor stated the facility did not store residents’ food from home because the refrigerators had been removed, and staff expected residents to consume the food right away with any leftovers discarded. During observation of the refrigerator in the activities room, a sign on the door stated that patients’ food was not allowed in that fridge, and the Dietary Supervisor stated this may have been the refrigerator used for outside food. The Administrator stated the facility did not have any designated storage for residents’ food brought from outside and that residents needed to eat the food immediately or have family take it back home. The DON stated residents were not allowed to bring food from home and was unfamiliar with the facility’s policies, while also stating the facility had a designated resident refrigerator but did not know its location. The ADON stated families often brought large quantities of home-cooked meals, especially during holidays, and staff asked them to take excess food back home. The Registered Dietitian stated the facility did not have a refrigerator designated for residents bringing food from outside and did not have a clear, structured policy about storing food or leftovers. Facility policies reviewed stated that outside food could be brought in for resident consumption and, in some versions, should be stored in a designated or facility refrigerator when refrigerated, labeled with the resident’s name and date received; another policy stated only small quantities for immediate consumption should be brought in and any leftovers discarded.
Failure to Use Required Gown During EBP Care
Penalty
Summary
The facility failed to ensure CNA 1 wore an isolation gown while providing high-contact care to a resident placed on Enhanced Barrier Precautions (EBP). Resident 84 was admitted with diagnoses including right side hemiplegia, muscle wasting, peripheral vascular disease, and reduced mobility. The resident’s Minimum Data Set indicated substantial to maximal assistance was needed with bathing, toileting, personal hygiene, and dressing, and the care plan identified infection prevention interventions related to multiple wounds on the left foot, including use of gowns and gloves for high-contact activities such as bathing, hygiene, changing linens, changing briefs, and wound care. Resident 84 had physician-ordered wound treatments for multiple vascular ulcers on the left foot, including the left lateral malleolus, left midfoot, and left plantar area. On the day of the observation, EBP signage was posted at the resident’s door indicating gloves and gown were required for high-contact care, including bathing and changing briefs. During observation, CNA 1 was providing personal care inside the room without wearing an isolation gown. In a concurrent interview, CNA 1 stated she gave the resident a bed bath and changed his briefs without wearing an isolation gown because she was not aware it was required for his care. The Infection Preventionist Nurse stated CNA 1 should have worn a gown during close contact care such as bed bathing and changing briefs because of the resident’s multiple vascular ulcers on the left foot. The DON also stated the resident required EBP and staff needed to wear PPE such as an isolation gown when providing close contact care, including bathing and changing briefs. The facility policy on Enhanced Barrier Precautions stated gowns and gloves are to be used during high-contact resident care activities, including bathing and changing briefs.
Insufficient CNA Staffing Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs during the 11PM-7AM shift when only two CNAs reported to work out of seven scheduled. Five CNAs were no call/no show, and the facility did not have enough staff available to provide timely assistance to residents throughout the building. The report states that this staffing shortage affected five sampled residents and resulted in delays with activities of daily living care, including toileting and brief changes. Resident 10 had diagnoses including type 2 DM, COPD, and endocarditis, and the MDS showed intact cognition with moderate assistance needed for ADLs such as oral hygiene, toileting hygiene, showering/bathing, and dressing. Resident 43 had cirrhosis and insomnia, had capacity to understand and make decisions, and was assessed as cognitively intact with supervision needed for ADLs. Resident 44 had COPD and type 2 DM, had capacity to understand and make decisions, and required substantial/maximal assistance with ADLs. Resident 46 had hemiplegia and hemiparesis affecting the right dominant side and type 2 DM, had capacity to understand and make decisions, and required substantial/maximal assistance with ADLs. Resident 106 had hemiplegia and hemiparesis affecting the left dominant side and hypertension, had fluctuating capacity to understand and make decisions, and was cognitively moderately impaired with substantial/maximal assistance needed for ADLs. During interviews, residents reported waiting approximately 1 hour and 15 minutes to 2 hours for care, and one resident reported remaining in a soiled brief for about 1.5 hours before receiving assistance. Staff interviews confirmed that seven CNAs were scheduled, five did not report, and the facility did not have enough CNA staff on the shift to meet resident care needs. The DSD stated she was not notified in time to come in and assist, and the ADON stated the staffing shortage delayed resident care and increased the risk for adverse outcomes, including falls, injuries, and skin breakdown.
Failure to Maintain Resident Dignity During Personal Care and Feeding
Penalty
Summary
The facility failed to maintain resident dignity for two residents by not ensuring privacy and respectful positioning during care. One resident, who had diagnoses including metabolic encephalopathy, neuromuscular dysfunction of the bladder, and paraplegia, was documented as cognitively intact and able to make decisions. During observation, the resident’s urinary drainage container was left uncovered, and the resident stated that the bag should be covered because it looked bad and was embarrassing. A LVN and the DSD both observed the uncovered drainage container and acknowledged that a privacy cover should have been in place to maintain dignity. The facility also failed to maintain dignity during meal assistance for another resident with quadriplegia and anxiety disorder who was documented as able to make decisions for ADLs and cognitively intact. During multiple observations, a CNA assisted the resident with feeding while standing and not positioned at the resident’s eye level. The CNA stated she understood the expectation to position herself at eye level during feeding and acknowledged that she did not offer or attempt to sit at the resident’s eye level while providing feeding assistance. The facility’s policy on dignity stated that each resident shall be cared for in a manner that promotes and enhances self-worth and self-esteem, that demeaning practices compromising dignity are prohibited, and that urinary drainage bags or containers are to be kept covered to promote and maintain resident dignity. The DSD stated that staff are expected to position themselves at the resident’s eye level during feeding and that the CNA did not promote resident dignity while providing feeding assistance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for Zyprexa, a psychotropic/psychotherapeutic medication, for one sampled resident who had diagnoses including encephalopathy, dementia, and schizoaffective disorder with severe mood swings. The resident’s MDS dated 3/16/2026 indicated severely impaired cognitive status, and the resident required supervision with eating and was dependent for bathing, toileting, personal hygiene, and dressing. The resident’s OSR dated 4/7/2026 showed physician orders for Zyprexa 2.5 mg twice daily and Zyprexa 10 mg at bedtime. During observation on 4/7/2026, the resident was in bed, did not respond to interview, and had a flat affect. A concurrent review of the EHR with the SSD and ADON found no documentation that informed consent for Zyprexa had been obtained by the prescriber, and both staff members also checked consent binders without finding any consent documentation. The DON stated the facility did not have informed consent for the resident’s Zyprexa and explained that informed consent from the resident or RP was important so reasons, benefits, risks, and alternatives could be disclosed and an informed decision made.
Unnecessary Physical Restraint Used Without Order
Penalty
Summary
The facility failed to ensure one sampled resident was free from unnecessary physical restraints. Resident 30, who was admitted with dementia, a history of falls, and adult failure to thrive, had severe cognitive impairment on the MDS and required total dependence for activities of daily living, with maximal assistance needed for rolling left and right. The resident was also identified as a high fall risk on the nursing fall risk assessment. During observation, Resident 30 was found lying in bed on her right side with multiple pillows placed on both sides under the sheets, creating a concave surface and a barrier along each side of the bed. The resident’s legs were dangling off the right side of the bed, and she repeatedly attempted to raise her head and upper body to reposition herself but was unable to do so, falling back onto the bed each time. This continued for approximately 24 minutes while the resident remained without staff assistance. Staff interviews confirmed the pillows were being used to prevent the resident from getting out of bed. A CNA stated the pillows were already in place when she came on duty and that she was instructed to leave them because the resident attempted to get out of bed. The DSD stated the pillows appeared to be used to prevent the resident from getting out of bed and that, if used for repositioning, they would not be placed in that manner. The ADON stated pillows used in a way that restricts movement would be considered a restraint, and the facility’s restraint policy required a physician’s order and consent, which were not documented for this use of pillows.
Incomplete Care Plans for Seizure Safety and Wandering
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two sampled residents. For one resident with a history of epilepsy, metabolic encephalopathy, and end stage renal disease, the record showed a physician order to monitor seizure episodes and keep the place safe and hazard free. The care plan for seizure disorder included general interventions to keep the place safe and hazard free and to protect the resident from injury, but it did not specify how staff were to carry out those measures, including the use of padded side rails or keeping the bed in the lowest position. During observation, the resident’s bed was not in the lowest position, and a CNA stated the bed was not kept at the lowest position and that she was not familiar with the resident’s risk for injury or instructed by licensed nursing staff on how to keep the place safe during a seizure episode. Later observation showed the resident lying in bed with no bedrails on, a BiPap machine on the bedside cabinet next to the resident’s head, an IV pole with a feeding pump on the left side, and the bed positioned approximately at the waist level of the RN. The RN stated the resident should have been provided protection in case a seizure occurred, such as padded bedrails and the bed placed at the lowest position. For the other resident, who had dementia, psychosis, insomnia, fluctuating capacity, and severely impaired cognition, the care plan identified high risk for wandering and included interventions such as reorientation, reassuring redirection, and monitoring whereabouts. Nursing notes documented repeated wandering episodes, including being redirected back to the room multiple times during shifts. Staff interviews confirmed the resident continued to wander throughout the facility despite redirection, and one CNA stated staffing was insufficient to adequately supervise the resident. RN and ADON interviews acknowledged that the interventions were too general, were not effective, and did not adequately address the resident’s individualized wandering behaviors and needs.
Incorrect ID Band Attached to Resident’s Bed Rail
Penalty
Summary
The facility failed to ensure that Resident 17 had a correct identification band that was not attached to the right-side bed rail. Resident 17’s face sheet showed diagnoses including hemiplegia, encephalopathy, and epilepsy. The MDS dated 7/2/2022 indicated the resident had severe cognitive impairment and was dependent on staff for all activities of daily living. During a concurrent observation and interview on 4/7/2026 at 10:49 a.m., the resident was observed lying in bed with the head elevated at a 45-degree angle, and an incorrect ID band was attached to the right-side bed rail. The ADON stated that the ID band belonged to a different resident and that having the incorrect ID band could result in the resident receiving the wrong medication, the wrong diet, and overall incorrect care. The DON later stated that having the wrong ID band on a resident’s bed rail could confuse staff and potentially result in the resident receiving the wrong care. The facility policy on Resident Identification System stated that photo and/or wristband identification are used by nursing service personnel when administering medications and treatments.
Failure to Identify and Report Declining ROM in a Resident’s Fingers
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM, and/or mobility, unless a decline is for a medical reason, was not met for one sampled resident with limited ROM in the left fourth and fifth fingers. The resident had diagnoses including diabetes mellitus, anemia, and adult failure to thrive, and had an order allowing participation in restorative nursing care. The resident’s MDS indicated assistance needs with eating and dressing, but did not identify functional limitation in ROM in either upper extremity. The resident’s care plan included interventions to observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in ROM, and withdrawal or resistance to care. However, nursing progress notes from 10/1/2025 through 4/6/2026 contained no documented evidence that the resident’s left fourth and fifth fingers with limited ROM were identified. During observation, the resident showed the surveyor that the left fourth and fifth fingers were bending inward toward the palm and could not be fully straightened, and the resident stated the fingers had been painful and stiff for a couple of months. The resident also stated the issue had been reported to the nurse, but only pain medication was provided and the resident was never seen by a doctor or received therapy. A CNA stated he noticed the stiffness a while ago and was supposed to report it to licensed nursing staff immediately when noticed. The LVN stated the resident did not have restorative nursing services for the left fourth and fifth fingers and that the CNA or any CNA was supposed to observe the resident’s functional mobility decline and notify her. The LVN also stated she did not properly assess the resident to recognize the ROM decline because she thought it was just how the resident’s fingers looked when holding things. The DON stated nursing staff were responsible to assess the resident daily and report concerns, and that not assessing and reporting the resident’s stiff and contracted fingers placed the resident at high risk for further decline and irreversible loss of mobility.
Failure to Maintain Safe Seizure Precautions
Penalty
Summary
The facility failed to provide a hazard-free environment for one sampled resident with a history of epilepsy, metabolic encephalopathy, and end stage renal disease. The resident’s care plan for seizure disorder, dated 1/20/2026, included interventions to keep the place safe and hazard free and to protect the resident from injury, but it did not specify how those measures were to be carried out. A later care plan addressing altered cognitive status and risk for falls and injury identified goals to maintain the highest possible level of cognitive function and remain free from injury, with interventions to implement safety and fall precautions, but it also did not specify what precautions staff were to follow. The resident’s MDS dated 3/22/2026 indicated the resident was taking anticonvulsant medication and was cognitively modified independent in daily decision making. The OSR dated 4/2/2026 included a physician order for staff to monitor seizure episodes and keep the place safe and hazard free. During observation on 4/8/2026, the resident’s bed was not at the lowest position, and CNA 8 stated the bed was not kept at the lowest position and that she was not familiar with the resident’s risk for injury or instructed by licensed nursing staff on how to keep the place safe during a seizure episode. Later that day, the resident was observed lying in bed with no bedrails, a BiPap machine on the bedside cabinet next to the resident’s head, an IV pole with a feeding pump on the left side, and the bed positioned approximately at the waist level of RN 2. RN 2 stated the resident should have had protection in case of seizure, such as padded bedrails, a floor mat, and the bed should have been in the lowest position for safety. RN 2 also stated that if the resident had a seizure, the resident could fall from bed and hit nearby equipment, which could lead to injury. The DON stated the care plan should have been individualized and resident-centered to specify seizure precautions and padding devices, and that RN supervisors were supposed to include high-risk residents such as those on seizure precautions during daily huddles and ensure CNAs were aware of the interventions to keep the resident safe.
Failure to Follow Up on Dental Referral and Denture Process
Penalty
Summary
The facility failed to provide medically-related social services for one sampled resident who had missing teeth and requested new dentures. The resident had diagnoses including DM, anemia, and adult failure to thrive, and his diet order included consistent carbohydrate with soft and bite-size texture. Dental notes documented that 14 PA X-rays were taken, and later notes indicated multiple missing teeth with recommendations for new dentures/partials and teeth extractions. The record showed that the resident’s dental treatment process was not followed through by social services. Documentation indicated that the resident’s treatment was approved and medical clearance was requested, and a dental medical order form later authorized full upper and lower dentures and multiple extractions, but the physician’s medical order release section was not completed. The social services quarterly evaluation documented the dental X-ray but did not show follow-up to obtain X-ray results, confirm Medi-Cal authorization, or contact the primary physician for medical clearance. Social services progress notes from 10/1/2025 through 4/7/2026 did not show documented attempts to follow up with the dental clinic regarding treatment approval, X-ray results, or medical clearance for the extraction and denture fabrication process. During interview, the resident stated he needed dentures to chew and enjoy preferred foods and said he had spoken to social services but had not received responses for more than 2 months, feeling ignored. The Social Service Director confirmed awareness of the need for dentures, stated that follow-up with the dentist and updates to the resident were their responsibility, and acknowledged that no updates, X-ray follow-up, medical clearance follow-up, or IDT discussion occurred.
Failure to Obtain Ordered Urine Specimen and Lab Results
Penalty
Summary
The facility failed to ensure timely laboratory services for one sampled resident who had signs and symptoms of a UTI. Resident 11 was admitted and readmitted with diagnoses including DM, anemia, and adult failure to thrive. The physician ordered in and out urine collection for UA and C&S on 4/4/2026, and the MAR showed Bactrim DS 800-160 mg orally twice daily for 10 days for UTI pending UA/CS, starting on the same date. During record review and interviews, the LVN could not locate any UA and C&S results in the EHR or the paper chart binder. The IPN stated he did not know whether the ordered in and out catheterization had been completed, and he did not follow up to ensure the specimen was sent to laboratory services. He also stated he did not check on the results, even though he said UA results usually returned in one or two days. The DON stated nursing staff and the IPN were supposed to follow up on the urine specimen to ensure results were available to confirm the UTI diagnosis and timely adjust antibiotic treatment if needed.
Food Served at Improper Temperature and Poor Palatability
Penalty
Summary
Food and drink were not prepared and served at a palatable, attractive, and safe temperature when hot foods were observed below the facility’s stated temperature standards. During a test tray observation, the Dietary Supervisor took temperatures of the meal and found the pork chop at 127 degrees F, herbed rice at 110 degrees F, and mixed vegetables at 107 degrees F. The Dietary Supervisor stated the hot foods were low in temperature, the pork chop was dry and overcooked, and that hot foods are expected to be served hot because residents would not eat food that was not palatable. The Dietary Supervisor also stated the facility’s service wares were not insulated and the facility did not have plate warmers. Resident 2 was admitted with diagnoses including metabolic encephalopathy, COPD, and malignant neoplasm of the upper lung. The resident’s MDS indicated the resident was cognitively intact and required only verbal cues for activities of daily living. The resident stated the food was cold by the time the tray arrived and the facility would not reheat it. During the meal observation, the resident assessed the tray and stated the vegetables were slightly warm, the meat was cold, and the rice was not palatable and would not be eaten. The Dietary Supervisor stated that food at those temperatures was cold and not palatable, and that if a tray is cold, a new tray or alternative meal should be provided.
Inaccurate Documentation of Wander Guard Function Testing
Penalty
Summary
The facility failed to ensure accurate documentation of Wander Guard function testing for one resident who was at risk for elopement. The resident was admitted and readmitted with diagnoses including metabolic encephalopathy, bipolar disorder, and dementia. The resident’s MDS dated 1/19/2026 indicated the resident required supervision or touching assistance for transfers and walking 50 feet with two turns, and also used a wander/elopement alarm daily. The resident’s orders directed staff to apply the Wander Guard every shift for safety and to monitor Wander Guard functioning every shift. Review of the MAR from 4/1/2026 to 4/9/2026 showed that the 7-3 shift entries for monitoring Wander Guard functioning on 4/2/2026, 4/3/2026, and 4/9/2026 were signed by LVN 2. During interview, LVN 3 stated the resident was assigned to LVN 3 but that LVN 2 signed the MAR for her, and explained that sometimes another nurse with the test device would check all residents with a Wander Guard on behalf of other nurses. LVN 2 stated she did not perform the Wander Guard function test for the resident on 4/9/2026, was not familiar with the device, did not know how to perform the test, and signed for 4/2/2026, 4/3/2026, and 4/9/2026 without performing the test herself. The DON stated staff should check and sign their assigned residents’ MARs on their own and should never sign on behalf of someone else because it is not appropriate and not legal.
Failure to Track UA/C&S and Perform Antibiotic Timeout
Penalty
Summary
The facility failed to implement its antibiotic stewardship program for a resident who was prescribed Bactrim DS for a suspected UTI. The resident’s record showed diagnoses including DM, anemia, and adult failure to thrive. On 4/4/2026, the physician ordered a urine specimen for UA and C&S by in-and-out catheterization and ordered Bactrim DS 800-160 mg twice daily for 10 days pending the UA/C&S results. The resident’s infection note documented that the facility started an empiric course of Bactrim DS on 4/4/2026 for a suspected healthcare-associated infection. The infection note stated that an Antibiotic Timeout should have occurred at the 48-72 hour mark after the initial dose to review culture results, consider de-escalation, check duration, and monitor for side effects. The care plan for suspected UTI also included monitoring the lab portal for UA/C&S results and conducting a clinical review at 48-72 hours to discuss de-escalation, switching to a narrow-spectrum agent, or discontinuation with the physician. However, the MAR showed Bactrim DS was administered for eight doses over four consecutive days, and the progress notes from 4/6/2026 to 4/7/2026 did not document that an Antibiotic Timeout occurred. There was also no documented evidence that the urine specimen was collected, sent to the laboratory, or that the IPN followed up on the lab results. During interview and record review, LVN 4 stated she could not find the UA and C&S results and there was no hard copy of the lab order in the nursing station binder, indicating the order was not received by the lab. The IPN stated he did not know whether the in-and-out catheterization had been completed and did not follow up to ensure the specimen was sent out or check for results, even though he stated he was responsible for monitoring the Antibiotic Stewardship Program, tracking infections, and ensuring lab results were obtained and reported to the physician.
Call Lights Not Accessible to Two Residents
Penalty
Summary
The facility failed to ensure that two sampled residents were able to use their call lights. Resident 122’s face sheet showed diagnoses including metabolic encephalopathy, epilepsy, and transient ischemic attack, and the MDS dated 3/3/2025 indicated moderate cognitive impairment. During a 4/6/2026 observation in Resident 122’s room, the resident was lying in bed with the head elevated at a 45-degree angle, and the call light was behind the resident on the right side of the dresser, out of reach. The IPN stated the call light should always be within the resident’s reach so the resident can request assistance. Resident 135’s face sheet showed diagnoses including hemiplegia, hemiparesis, and dysarthria, and the MDS indicated moderate cognitive impairment and dependence on staff for all ADLs. During a 4/6/2026 observation and interview in Resident 135’s room, the resident demonstrated that he could not extend his hands to activate the call light and stated he was unable to call for assistance because he did not have the strength to press the call light pad with either hand. LVN 3 later stated Resident 135 could benefit from an alternative call light that could be activated using his head instead of his hands. The DON stated that residents who are unable to use their call lights would be unable to seek assistance during an emergency, and the facility policy stated residents are to be able to return the demonstration of using the call light and that it is to be accessible when in bed.
Failure to Notify Physician of Refused PT/INR Draws and Missed Warfarin Doses
Penalty
Summary
The facility failed to notify the primary physician of a significant change in condition for one resident who refused PT/INR blood draws for three consecutive days while receiving warfarin for chronic pulmonary embolism. The resident was admitted with diagnoses including chronic respiratory failure, COPD, severe obesity, and chronic pulmonary embolism, and the MDS dated 4/2/2026 indicated the resident’s cognitive status was intact. The resident required supervision or touching assistance with eating and substantial to maximal assistance with toileting, personal hygiene, and dressing. The resident’s MAR did not show warfarin administration on 4/1/2026 and 4/2/2026. The OSR included an order dated 3/29/2026 for PT and INR to be drawn on 3/31/2026 and another order dated 4/2/2026 for a stat PT and INR. During observation and interview, the resident stated she was not given warfarin a few days earlier and reported refusing blood draws because the phlebotomist pulled and twisted her arm, which she had told nurses about. The resident also stated she had voiced concern about her health to the nurses. During interview and record review, the ADON confirmed the resident did not receive two doses of warfarin and refused blood draws on 3/31/2026, 4/1/2026, and 4/2/2026. The ADON stated there was no documentation that the primary physician was informed of the refusals or that warfarin was not given until 4/2/2026 at 1:46 PM. The LVN stated he did not notify the physician because he thought the supervisor had already reported it. The DON stated the refusal of PT/INR blood draws should have been reported immediately and a change of condition initiated, especially since the resident did not receive warfarin as ordered. The facility policy required immediate physician notification for high-risk refusals and prompt notification of changes in resident condition.
Failure to Develop and Implement Fall Risk Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing fall risk for a resident who was at high risk for falls. The resident was admitted with diagnoses including diabetes mellitus, a left below-knee amputation, and was receiving dialysis. An MDS dated 3/3/2026 showed the resident was cognitively intact with a BIMS score of 15, and required substantial/maximal assistance for personal hygiene, dressing, toileting hygiene, and putting on/taking off footwear, and partial/moderate assistance with oral hygiene and eating. A Fall Risk Evaluation dated 2/20/2026 was completed, but the MDS Coordinator later stated it was wrongly coded and that the resident was actually at high risk for falls. The DON also stated that the fall risk evaluation showed a high-risk fall score of 16. On 2/20/2026 at approximately 9:00 PM, the resident called for help and staff found the resident on the floor in a kneeling position next to the end of the bed, facing the bathroom, unable to get up without assistance and reporting severe left hip pain. A Change of Condition Evaluation documented this event at 10:03 PM. A subsequent hospital orthopedic surgery history and physical dated 2/22/2026 indicated the resident had sustained a left intertrochanteric femur fracture after the injury on 2/20/2026. During interviews, the MDS Coordinator confirmed that no fall risk care plan had been completed for this resident despite the high fall risk, and the DON confirmed that a care plan for risk of falls should have been completed. The facility’s policy on comprehensive person-centered care stated that care plan interventions are to be based on thorough assessment and are intended to prevent or reduce decline in residents’ functional level.
Failure to Care Plan for Resident Wandering and Room Intrusions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with specific, measurable interventions to address a resident’s wandering behavior, particularly entering other residents’ rooms. The resident was originally admitted with dementia with behavioral disturbance, anxiety disorder, vascular dementia, and confusional arousals. An MDS dated 1/22/2026 documented severely impaired cognitive skills and a need for moderate assistance with ADLs, but did not code the resident as wandering in a manner that significantly intruded on others. An IDT note dated 02/09/2026 described an altercation on 02/08/2026 in which the cognitively impaired, disoriented resident independently ambulated to a roommate’s bedside, attempted to pull up the roommate’s blanket, and entered the roommate’s personal space, leading the roommate to become verbally upset and strike the resident in the left eye. A psychiatric assessment dated 02/12/2026 documented that the resident was profoundly confused, severely disoriented, had limited insight, functioned at an extremely low cognitive level consistent with advanced dementia, and did not understand boundaries or the seriousness of certain behaviors. The Social Services Director reported that the resident had a low BIMS score, could not answer simple questions such as name and time, and required staff redirection because the resident always wandered into other residents’ rooms. RN staff confirmed the resident was very confused, wandered into both female and male residents’ rooms, and required redirection, and also stated there were no care plan interventions or specific interventions in place to address this wandering behavior and no staff member assigned to monitor it, despite complaints from female residents. The MDS coordinator confirmed that no care plan had been developed to address the resident’s wandering into other residents’ rooms and that there were no individualized interventions in place, contrary to the facility’s policy requiring a comprehensive, person-centered care plan with measurable objectives and timetables to meet residents’ needs.
Failure to Implement Physician-Ordered Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered Enhanced Barrier Precautions (EBP) for a resident with multiple infection risks. The resident was readmitted with diagnoses including a UTI, pneumonia, and sepsis, and had multiple lower pressure injuries, impaired skin integrity, and an indwelling urinary catheter. The resident’s care plan identified risks for infection, catheter-associated UTI, and transmission of MDROs, and included goals and interventions requiring compliance with EBP, including the use of clean gowns and gloves during all high-contact care activities. A physician’s order dated 11/18/2025 directed continuation of EBP for infection control. Surveyors’ review of records and interviews with staff confirmed that the EBP order and related care plan interventions were not implemented. On review of the resident’s order summary with an LVN, it was confirmed that EBP should have been in place, including posting of an EBP sign and provision of PPE for staff. The LVN stated that implementing physician orders was important so residents and visitors would know what protective equipment to wear to limit infection transmission. The care plan for risk of healthcare-associated infection, dated 11/20/2025, specified that all direct care staff were to demonstrate and document 100% compliance with EBP protocols, but this was not carried out in practice. Direct observations showed that staff were providing hands-on care without PPE and without any visible indication that EBP was required. A CNA was observed touching the resident’s blanket, repositioning the Foley catheter bag, and assisting the resident without wearing any PPE, and the CNA stated they did not know the resident required PPE under EBP. On a separate observation, there was no EBP signage or PPE available outside the resident’s room. An RN verified that no EBP sign was posted and no PPE was available, despite acknowledging that EBP had been ordered by the physician to decrease infection transmission. The Infection Preventionist also stated that the resident should have been placed on EBP with appropriate PPE available and that the physician’s order should have been implemented. The facility’s infection prevention and control policy required implementation of appropriate enhanced barrier and transmission-based precautions when necessary, consistent with CDC guidelines, but these were not followed for this resident.
Failure to Implement Scabies Surveillance and Timely Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program (IPCP) and follow county scabies guidelines for four residents with suspected scabies. The Infection Preventionist (IP) did not initiate or maintain a line list for residents or staff with suspected scabies, despite multiple residents and some staff developing generalized rashes and being placed on contact precautions. The IP acknowledged that some staff reported rashes and concern for scabies but stated he did not create a list and was unsure how many staff were affected. Infection surveillance logs from 10/2025 to 1/2026 did not include residents with suspicious rashes treated with Permethrin, including a resident who was suspected of having scabies and treated with Permethrin cream in 10/2025. The IP stated he did not consider rashes treated with Permethrin as infections requiring monitoring and only tracked infections requiring antibiotics. One resident, admitted with neuropathy and diabetes mellitus, complained of mild itchiness and localized rash in 10/2025. The IP documented that the rash was of unknown etiology with potential for transmission, and the resident and roommates were placed on contact isolation and treated with Permethrin cream, Hydroxyzine, and Hydrocortisone. However, no skin scrape test was performed at that time to rule out scabies, and this episode was not entered into the infection surveillance log. The same resident later developed a generalized rash again in 2/2026, was placed on contact precautions, and was prophylactically treated with Permethrin before a skin scrape was performed. The IP and a licensed nurse confirmed that the skin scrape for this resident was done after Permethrin treatment, and the IP stated that residents should have been tested with a skin scrape prior to treatment. In early 2/2026, three additional residents with significant comorbidities (including COPD, CHF, Parkinson’s disease, CVA, hemiplegia, DM, adult failure to thrive, and kidney stones) were identified with generalized body rashes. Dermatology consultations were obtained, and all four residents were placed on contact precautions, had environmental cleaning measures implemented, and were prophylactically treated with Permethrin cream; two residents also received oral Ivermectin and Hibiclens. Physician orders for skin scraping were written for these residents, but the scrapes were performed only after Permethrin treatment and after the arrival of collection kits. The IP’s notes show that skin scrape specimens for multiple residents were completed and then left at the front desk until picked up by the lab two days later. Despite having at least four residents on contact precautions for suspicious rashes and staff reporting rashes, the IP did not maintain an updated infection surveillance log for 2/2026 and did not prepare a line list of symptomatic residents and staff. The facility also failed to recognize and timely report a suspected scabies outbreak to the local public health department. The county guidance available in the facility defined an outbreak as two or more clinically suspected or confirmed cases of scabies in residents, healthcare workers, volunteers, or visitors within a six-week period and directed facilities to report healthcare-associated scabies outbreaks. The IP stated he did not report a potential outbreak when the four residents were placed on contact precautions and tested for scabies because skin scrape results were still pending, and he chose to wait until a positive result was obtained. A fax to the county department of public health reporting a possible scabies outbreak was not sent until eight days after the residents were placed on contact precautions. The IP later acknowledged that, based on the county guideline, he should have reported a potential outbreak earlier and that he should have recommended scabies testing before Permethrin treatment from an infection prevention standpoint.
Failure to Administer and Document Medications per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for timely medication administration and proper documentation for three of five sampled residents. The facility’s policies required medications to be administered within one hour before or after the scheduled time and documentation to occur immediately after, and never before, administration. Review of the Medication Administration Audit Reports showed that multiple medications scheduled for 9:00 AM for three residents were documented as given at times outside the required one-hour window, and a nurse later admitted to pre-signing the MARs before actually administering the medications. One resident with alcoholic cirrhosis with ascites and diabetes, cognitively intact but dependent for most ADLs, had several 9:00 AM medications (including metolazone, furosemide, gabapentin, lactulose, rifaximin, midodrine, and spironolactone) documented as administered between 9:38 AM and 9:41 AM. Another cognitively intact resident with diabetes and heart disease, requiring maximal assistance with dressing and toileting hygiene, had 9:00 AM medications (ferrous sulfate, diltiazem, metoprolol, and hydralazine) documented as administered between 9:30 AM and 9:31 AM. A third resident with sequela of cerebral infarction and moderately impaired cognition, requiring supervision for most ADLs, had 9:00 AM medications (amlodipine and clopidogrel) documented as administered at 9:27 AM and 9:28 AM. During observation and interviews, an LVN was seen at the medication cart well after the scheduled 9:00 AM medication time and stated that the 9:00 AM medications for the three residents in the same room had not yet been administered. The LVN later confirmed that on that date she was late in administering the medications and had pre-signed the MARs for those residents before actually giving the medications, acknowledging that this was not the facility’s practice. A resident also reported that medications were sometimes not administered on time and that this depended on which nurse was working, noting that medications were especially late on the night shift. A registered nurse confirmed that the standard was to “pour, pass, and sign,” and that medications must be given as ordered within the one-hour before/after window, consistent with the written policies reviewed by surveyors. The report states that this deficient practice resulted in delayed medication administration for the three residents and had the potential for residents’ health to be compromised.
Failure to Prevent Falls and Maintain Safe Environment for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and maintain a hazard-free environment for three residents at risk for falls. One resident with a history of metabolic encephalopathy, hemiplegia, and hemiparesis following a stroke was left unsupervised in the bathroom by an RN, despite care plan interventions requiring frequent visual checks due to poor decision-making and inability to use the call light. This resident subsequently fell, sustaining a 4 cm hematoma on the right forehead and was diagnosed with a non-traumatic intracranial hemorrhage after transfer to an acute care hospital. Another resident, also with hemiplegia and hemiparesis following a cerebral infarction and classified as high risk for falls, was observed with their bed in a high position, contrary to care plan instructions and staff knowledge that the bed should be kept in the lowest position to prevent falls. The resident was not informed by staff about the risks associated with the bed's position and was not reminded to keep it low, despite documentation in nursing progress notes indicating this requirement. A third resident, with diagnoses including hemiplegia, hemiparesis, metabolic encephalopathy, and dementia, required total dependence for mobility and was at high risk for falls. This resident was found on the floor with the call light out of reach while the assigned CNA was on break and had not endorsed coverage to another staff member. The care plan required the call light to be within reach and frequent visual checks, but these interventions were not followed, and the resident was not monitored during the CNA's absence.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was unable to perform activities of daily living (ADLs) independently was not assessed or changed in a timely manner for a wet and soiled incontinence brief, as required by the resident's care plan. The resident, who had diagnoses including hemiplegia, hemiparesis following a stroke, metabolic encephalopathy, and dementia, was observed at 2 PM with a brief soaked in urine and feces. The certified nurse assistant (CNA) responsible stated the last incontinence check and change had occurred at 8 AM, and was unsure when the resident had last had a bowel movement. The CNA acknowledged that the resident should have been checked more frequently and that care was not provided as needed. Further observation and interviews revealed that the resident was dependent on staff for nearly all ADLs, including toileting hygiene. A registered nurse (RN) noted the presence of blanchable redness near the resident's left medial buttock and sacrococcyx, which could have resulted from prolonged exposure to urine and feces. The director of nursing (DON) confirmed the importance of timely incontinence and perineal care, stating that failure to maintain good hygiene could lead to skin breakdown and other complications. Review of facility policy indicated that residents unable to perform ADLs independently should receive necessary support and assistance with elimination in accordance with their care plan.
Failure to Ensure Accurate Discharge Documentation and Resident Preparation
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate discharge procedures for a resident who was assessed as cognitively intact and capable of making decisions. The resident, who had diagnoses including end stage renal disease, diabetes, dementia, and dependence on renal dialysis, was admitted with orders for regular dialysis and a limited out-on-pass privilege. On the day of the incident, the resident was observed leaving for a scheduled dialysis appointment but did not arrive at the dialysis center. The facility was notified by the dialysis center that the resident was missing, and subsequent attempts to contact the resident were unsuccessful. The police were notified later that evening, and a missing person report was filed. Despite the resident's absence, the facility documented the discharge as 'against medical advice' (AMA) without evidence of a physician discharge order, care plan, interdisciplinary team documentation, or any indication that the resident was informed of or participated in a planned discharge. The facility's policy required detailed documentation and communication for transfers or discharges, including preparation of a post-discharge plan and notification of the resident and their representative. None of these steps were documented in the resident's medical record. Interviews with facility staff and the physician revealed that the decision to discharge AMA was based on the resident exceeding the out-on-pass time limit, but there was no formal documentation of behavioral concerns, care plan interventions, or interdisciplinary review regarding the resident's history of leaving without notice. The resident was later found by a security guard at a local hotel and returned to the facility, after which the facility arranged for transfer to an acute care hospital for missed dialysis treatments. The resident was subsequently readmitted to the facility. Throughout the incident, there was a lack of documentation regarding the basis for discharge, communication with the resident or their emergency contacts, and adherence to facility policies and procedures for safe and appropriate discharge planning.
Failure to Implement Behavioral Health Interventions and Care Planning for Resident with Repeated Unauthorized Absences
Penalty
Summary
The facility failed to develop and implement resident-centered care plan interventions and involve the interdisciplinary team (IDT) for a resident with a known history of leaving the facility without permission and failing to return from out on pass, as required by physician's orders. Despite repeated incidents where the resident left the facility without authorization, there was no evidence that behavioral interventions were initiated or that strategies were documented to address the resident's non-compliance and unsafe behaviors. The facility also did not document the resident's status upon return after these episodes, nor did they ensure timely notification of the physician regarding missed dialysis appointments and the resident's whereabouts. The resident in question had multiple complex medical diagnoses, including end stage renal disease requiring regular dialysis, diabetes, and dementia, but was assessed as cognitively intact and able to make decisions. The resident had physician orders specifying dialysis schedules and limitations on out-on-pass privileges, which required accompaniment by a family member and a maximum duration of four hours. However, the facility did not document the rationale for these restrictions, nor did they involve or communicate with the resident's family or emergency contacts as indicated in the orders. Additionally, a psychiatric evaluation was ordered but not initiated or scheduled, and there was no documentation explaining the reason for the psychiatric referral. Multiple progress notes and interviews revealed that the resident missed scheduled dialysis appointments after leaving the facility without permission, and the facility was often unaware of the resident's whereabouts until notified by external parties such as the dialysis center or police. The facility's own policy required behavioral health assessments, individualized interventions, and IDT involvement, but these steps were not documented or implemented. Staff interviews confirmed a lack of formal care planning, IDT review, or revision of privileges in response to the resident's repeated behaviors, and there was no evidence of family involvement in care planning as required.
Failure to Implement Infection Control Precautions for Residents Exposed to Impetigo
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for three residents who shared a room, following a physician's diagnosis of impetigo in one of the residents. After the diagnosis, the resident with impetigo was not immediately placed on contact isolation, despite a physician order for transfer to a hospital and a text message from the Infection Preventionist indicating the need for isolation. The resident remained in the shared room for approximately eight hours after the need for isolation was identified, without any isolation signage or precautions in place. The two roommates who were exposed to the resident with impetigo were also not placed on isolation or enhanced barrier precautions during or after the exposure. Staff interviews revealed that neither the Director of Nursing nor the assigned nurses and CNAs were aware of the need to implement isolation or enhanced barrier precautions for the exposed residents. No isolation signage was posted outside the room, and staff did not use personal protective equipment (PPE) when providing care to any of the three residents during the period of exposure. Record reviews confirmed that there were no physician orders or care plans initiated for isolation or contact precautions for the affected residents. The facility's own policies, as well as CDC guidelines, require contact precautions for suspected or confirmed cases of impetigo to prevent transmission. The Infection Preventionist and Director of Nursing acknowledged during interviews that the facility did not follow these guidelines or their own policies, and that the necessary precautions were not implemented in a timely manner.
Failure to Implement Infection Control Program and Timely Notification for CRAB Exposure
Penalty
Summary
The facility failed to implement its Infection Prevention and Control Program (IPCP) for 27 residents following notification from the Local Health Officer's Public Health Nurse (PHN) that a resident tested positive for Carbapenem-Resistant Acinetobacter baumannii (CRAB) Tier 2, a rare and communicable multidrug-resistant organism. Despite receiving an email with recommendations from the PHN, the Director of Nursing (DON) did not initiate surveillance tracking or interventions for the 26 potentially exposed residents, nor did the facility notify the California Department of Public Health (CDPH) within the required 24-hour period. The DON acknowledged being too busy and covering for the infection preventionist at the time, resulting in a delay of 11 days before screening exposed residents was initiated. Additionally, the facility did not notify the primary medical doctor of the resident who tested positive for CRAB, nor did it notify or coordinate with the attending physicians of the 26 other residents who were potentially exposed and recommended for rectal swab screening. There was no documentation in the affected residents' medical records regarding the exposure, the positive CRAB result, or the recommended screenings. The infection preventionist, who started after the initial notification, confirmed that attending physicians were not informed and that there was no documentation or change of condition forms completed for the exposed residents. The facility's own policies and procedures require immediate notification of attending physicians for significant changes in condition, surveillance and data reporting for infection control, and reporting of unusual occurrences to appropriate agencies within 24 hours. These policies were not followed, as evidenced by the lack of timely surveillance, physician notification, and reporting to CDPH. Interviews with facility staff and the PHN confirmed these failures, and the DON admitted that the lack of action could have allowed the communicable disease to spread and prevented residents from receiving appropriate medical recommendations.
Improper Garbage Disposal and Overflowing Dumpster
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. One of the four metal dumpsters was found without a lid and overflowing with boxes, while the garbage area was littered with food waste and various rubbish, including dirty crates, broken chairs, carts, and shelves. This situation was identified during an observation with the Director of Nurses (DON), who acknowledged the issue and stated she was unaware of the missing lid. The DON recognized the potential for attracting pests and spreading infection due to the improper disposal of waste. Interviews with the Housekeeping Supervisor (HKS), Maintenance Supervisor (MS), and Dietary Service Supervisor (DSS) revealed that they were responsible for ensuring the trash bins were covered and the area was clean. However, they admitted to missing this oversight. The HKS and MS acknowledged the environmental concerns associated with uncovered and overflowing trash, which could lead to infestations and infections. The DSS also stated that the dietary staff used the trash bin for food waste and was unaware of the overflowing condition. The facility's policy on food-related garbage and refuse disposal emphasized the importance of keeping food waste in containers and ensuring dumpsters are closed and free of surrounding litter, which was not adhered to in this instance.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to accommodate the needs of a resident by not ensuring the resident's call light was within reach, as required by the resident's care plan. The resident, who was admitted with diagnoses including difficulty in walking, muscle weakness, and diabetes type 2, was observed unable to reach the call light, which was stuck behind the bed and on the floor. This was confirmed during an interview with the resident, who stated he needed help but could not find the call light. Further observations and interviews with the facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the call light was not accessible to the resident. The facility's policy and procedure on answering call lights, revised in September 2022, mandates that call lights must be accessible to residents and functioning at all times. The failure to ensure the call light was within reach could potentially prevent the resident from asking for assistance, leading to accidents such as falls.
Failure to Follow Up on PASRR Level II Evaluation
Penalty
Summary
The facility failed to follow up on a Preadmission Screening and Resident Review (PASRR) Level II evaluation for a resident who had a positive Level I screening indicating the need for further mental health evaluation. The resident, who was originally admitted in 2021 and readmitted later, had diagnoses including psychotic disorder and schizoaffective disorder. Despite the positive PASRR Level I screening on 11/15/2023, which required a Level II evaluation, the facility did not refer the resident for this necessary assessment. This oversight was identified during a review of the resident's records, which showed no documentation of a Level II referral. The resident's medical records indicated significant assistance needs with daily activities and ongoing treatment for mental health conditions, including medications for schizoaffective disorder and depression. Interviews with facility staff, including the MDS Nurse and Assistant Director of Nurses, revealed that the responsibility for following up on the PASRR Level II requirement was missed. The Director of Nurses acknowledged the lack of a system to ensure PASRR II follow-ups, emphasizing the importance of such evaluations to meet the resident's comprehensive care needs.
Failure to Update Care Plan for Pressure Injury
Penalty
Summary
The facility failed to update and implement a resident-centered care plan for a resident who developed a Stage 1 pressure injury on the left upper buttock. The resident was readmitted to the facility with diagnoses including quadriplegia and contractures of the lower extremities, and was dependent on care for various activities of daily living. Despite having a care plan in place to prevent skin breakdown, the plan was not updated when the pressure injury was identified. Interviews with facility staff, including a Treatment Nurse and a Registered Nurse, confirmed that the care plan was not revised to address the new pressure injury. The Director of Nursing acknowledged that the care plan for skin breakdown was not updated, which could have prevented the development of the pressure injury. The facility's policy and procedure for comprehensive, person-centered care plans require the identification of problem areas and the development of interventions, which was not adhered to in this case. The lack of an updated care plan left the resident at risk for further complications, such as infection, due to the pressure injury.
Failure to Update Care Plan for Gout Medication
Penalty
Summary
The facility failed to update and revise the care plan for a resident, identified as Resident 11, to include the use of Febuxostat, a medication prescribed to manage gout. Despite the resident being on Febuxostat since December 31, 2024, the care plan, initiated on November 12, 2024, did not reflect this medication as part of the interventions for managing the resident's pain related to gout. This oversight was identified during a review of the resident's records, which showed that the care plan had not been updated to include the medication, potentially affecting the monitoring of the medication's effectiveness. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the care plan should have been revised to include the new medication. The staff acknowledged that care plans are essential for monitoring the effectiveness of treatments and ensuring that the resident's goals and needs are met. The facility's policy on care plans, revised in March 2022, mandates that care plans be updated as new information about the resident's condition becomes available, highlighting a lapse in adherence to this policy.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or device for a resident who did not speak the formal language used in the facility. This deficiency was identified for a resident who was readmitted with diagnoses of dementia and Alzheimer's disease, and whose primary language was different from the facility's formal language. The resident's cognitive abilities were severely impaired, and they were dependent on care for eating and toileting hygiene. Despite these needs, there was no communication tool or translation material available in the resident's room to facilitate communication with the staff. Observations and interviews revealed that the lack of communication tools prevented the resident from effectively communicating their needs, which could delay the provision of appropriate care and treatment. A Certified Nursing Assistant (CNA) confirmed the absence of translation materials in the resident's living area and emphasized the importance of such tools for residents who do not speak English. The Director of Nursing (DON) acknowledged the necessity of communication tools for residents who speak a different language and confirmed that the resident required such a tool to communicate their needs. The facility's policy on translation and interpretation services, last revised in 2017, indicated that individuals with limited English proficiency should have meaningful access to information and services, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide necessary care and services to a resident who was dependent on staff for activities of daily living (ADL). The resident, who had communication problems due to slurred speech and was at risk for falls, did not have their call light within reach. This deficiency was observed during a room visit where the call light was found wrapped around the bottom of the right siderail, out of the resident's reach. The resident was noted to be frowning and attempting to pull the string for the overhead light, indicating a need for assistance. Interviews with facility staff, including a CNA, RN, and the Director of Nurses, confirmed that the call light should always be within reach to ensure the resident can request assistance, especially in emergencies. The facility's policies on ADLs and answering call lights emphasize the importance of accessibility and timely response to residents' needs. The failure to ensure the call light was within reach had the potential to prevent the resident from receiving timely care and assistance.
Deficient Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident 9, who had a history of pressure injuries and was using a low air loss (LAL) mattress, did not have the mattress settings adjusted to their current weight of 117 pounds, as required by the manufacturer's guidelines. This oversight was confirmed through observations and interviews with the treatment nurse, licensed vocational nurse, registered nurse, and director of nursing, all of whom acknowledged the importance of setting the LAL mattress correctly to prevent pressure injuries. The facility's policy and procedure, as well as the manufacturer's guidelines, emphasized the need for proper mattress settings to prevent skin breakdown. Resident 29, who was admitted without any pressure injuries, developed a Stage 1 pressure injury on the left upper buttock, which progressed to a Stage 2 injury within two days. The care plan for Resident 29 was not updated to address the new pressure injury, and the necessary interventions were not implemented in a timely manner. Interviews with the treatment nurse and registered nurse revealed that the care plan and treatments were not adjusted when the Stage 1 pressure injury was identified, contributing to its progression to Stage 2. The director of nursing acknowledged that the lack of timely updates and interventions in the care plan could have prevented the progression of the injury. The facility's failure to adhere to its policies and procedures for pressure ulcer prevention and management resulted in inadequate care for both residents. The lack of proper mattress settings for Resident 9 and the failure to update and implement interventions for Resident 29's pressure injury highlight deficiencies in the facility's care practices. These deficiencies placed both residents at risk for further skin breakdown and complications, as noted in the facility's policies and procedures for pressure ulcer risk assessment and management.
Deficiencies in Oxygen Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen administration. Resident 116, who had a history of pneumonia, sleep apnea, heart failure, and respiratory failure, was found with their nasal cannula on the floor, not receiving the prescribed oxygen treatment. The resident required substantial assistance for self-care and moderate assistance for mobility. During an observation, it was noted that the nasal cannula was not in place, and the resident was not receiving oxygen, which could have caused difficulty in breathing. The facility's policy required staff to ensure the nasal cannula was correctly placed and to periodically check on the resident, which was not adhered to. Resident 69, diagnosed with Huntington's disease, atherosclerotic heart disease, and diabetes, was administered oxygen without a physician's order. The resident's cognitive status was moderately impaired, and they required supervision or assistance with daily activities. During an observation, the resident was receiving oxygen at 3 liters per minute without an order, and the electronic health records did not indicate any physician's order for oxygen. The facility's policy required a physician's order before administering oxygen, which was not followed, leading to the potential risk of oxygen toxicity. The facility's policies on oxygen administration and physician orders were not followed in both cases. The Director of Nursing and other staff acknowledged the lapses in ensuring the nasal cannula was correctly placed for Resident 116 and the lack of a physician's order for Resident 69. These deficiencies in following established protocols for oxygen administration had the potential to adversely affect the residents' health and safety.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to implement its policy on Transmitting Medication Orders by not reordering a scheduled medication, Finasteride, in a timely manner for a resident with benign prostatic hyperplasia (BPH). The resident was initially admitted on 11/10/2022 and readmitted on 9/23/2024, with a physician's order to administer Finasteride 5 mg daily. On 2/26/2025, during a medication pass observation, the medication was not available in the cart, and the resident did not receive the prescribed dose. LVN 1, responsible for administering the medication, stated that the last dose was given the previous day, and a refill request was made to the pharmacy, but no documentation was provided to confirm this action. The Director of Nursing (DON) confirmed that licensed nurses should request medication refills when only three doses remain, as per the facility's policy. The facility's policy also requires nurses to reorder medications when a three to five-day supply remains and to document the order details in the resident's medical record. The failure to reorder Finasteride in a timely manner resulted in the medication not being available for administration, potentially compromising the resident's health.
Failure to Obtain Resident Signatures on POLST Forms
Penalty
Summary
The facility failed to implement its policy and procedure on charting and documentation by not ensuring that the POLST forms for two residents were signed by the residents before being placed in their medical charts. Resident 24, who was admitted with peripheral vascular disease, and Resident 179, who was admitted with type 2 diabetes and a foot ulcer, both had intact cognition according to their Minimum Data Set assessments. Despite this, the facility prepared the POLST forms for these residents but did not obtain their signatures before filing them in their charts. Interviews with facility staff revealed a lack of adherence to the process for completing and filing POLST forms. The Medical Records Director and Social Services Director indicated that the admission nurse was responsible for offering the POLST to residents, and the Medical Records Assistant maintained a binder with signed POLST forms. However, the signed forms were not placed in the residents' charts as required. The Director of Nursing emphasized the importance of having a complete and accurate POLST in the resident's chart to prevent delays in treatment during emergencies. The facility's policy on charting and documentation mandates that medical records be complete and accurate, which was not followed in these instances.
Deficient Maintenance of Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and clean homelike environment in two observed bathrooms. During observations, it was noted that the paint was bubbling and peeling off the walls behind the sinks in both bathrooms. Additionally, there was a light brown discoloration on the grout sealer around the sinks and a white residue around the faucet heads. These conditions were observed on February 27, 2025, at 9:31 AM and 9:39 AM, respectively. During a concurrent observation and interview with the Maintenance Supervisor at 11:30 AM, it was confirmed that the paint was indeed bubbling and peeling in both bathrooms. The Maintenance Supervisor acknowledged that these conditions posed a potential source for infection control issues, as the peeling paint and discolored grout could come into contact with residents' hands during handwashing, potentially leading to illness. The facility's policy and procedure titled 'Homelike Environment,' revised in February 2021, emphasized the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inadequate Supervision of Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision of residents who smoke, leading to a deficiency in safety practices. Two residents, both with moderate cognitive impairments and requiring assistance with daily activities, were found in possession of cigarette lighters, contrary to the facility's smoking policy. Resident 104, with a history of hemiplegia, hemiparesis, and diabetes, was observed with a lighter on his bedside table, which he claimed as his own. Similarly, Resident 79, diagnosed with Parkinson's Disease and diabetes, was seen with a lighter on his walker while smoking in the patio area. The facility's smoking policy and risk evaluations clearly stated that these residents should not have cigarette lighters in their possession and required supervision while smoking. Despite these guidelines, staff failed to enforce the policy, as evidenced by the residents' access to lighters. Interviews with staff, including a registered nurse and the Director of Activities, revealed a lack of awareness and enforcement of the policy, acknowledging the potential hazards posed by residents having lighters, especially in a facility where oxygen is used. The facility's policies on safety and supervision emphasize the importance of preventing accidents and ensuring a hazard-free environment. However, the failure to supervise residents adequately and prevent them from possessing lighters represents a significant oversight. This deficiency poses a risk of fire or accidents, particularly given the presence of oxygen in the facility, which could endanger both residents and staff.
Deficiency in Resident Room Square Footage Requirements
Penalty
Summary
The facility failed to ensure that 40 out of 54 residents' rooms met the square footage requirement of 80 square feet per resident in multi-resident rooms. The deficiency involved 5 two-bedroom and 35 three-bedroom configurations, which did not provide the minimum required space per resident. The facility's policy and procedure, revised in 2017, stated that all resident rooms should meet federal and state requirements, including providing at least 80 square feet per resident in multi-bed rooms. Despite this policy, the rooms in question did not meet these standards, as detailed in a room waiver request submitted by the facility's administrator. During the recertification survey, observations indicated that nursing staff's duties were not hindered by the space provided, and there were no observed deficits in care, privacy, or safety for the residents. Interviews with residents revealed that they felt their rooms were spacious enough to accommodate their needs, including the use of wheelchairs and walkers, and did not report any difficulties for staff in providing care. However, the facility's failure to comply with the square footage requirements represents a deficiency in meeting regulatory standards for resident living space.
Failure to Notify Resident's Representative of Diabetic Ulcer
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in condition for a resident with a diabetic ulcer. The facility's policy and procedure required prompt notification of changes in a resident's medical condition to the resident, their attending physician, and their representative. However, the RR was not informed about the resident's diabetic ulcer, which was documented upon the resident's readmission to the facility. The lack of notification prevented the RR from requesting necessary medical treatment and care for the resident, potentially leading to a serious condition. The resident, who was admitted with diagnoses including encephalopathy, quadriplegia, and type 2 diabetes mellitus, had a diabetic ulcer on the left lateral malleolus. Despite the presence of the ulcer being noted in the Admission Data Collection and subsequent physician's orders for treatment, there was no documentation indicating that the RR was informed of the ulcer. The facility's records, including Nursing Progress Notes and Weekly Wound Notes, failed to show that the RR was updated about the resident's wound condition. Interviews with the RR and the Social Services Director (SSD) revealed that the RR was unaware of the diabetic ulcer until the resident was transferred to a General Acute Care Hospital for further evaluation. The SSD acknowledged the absence of documentation regarding communication with the RR about the wound and stated that there should have been records of attempts to reach the RR. This deficiency violated the RR's right to be informed of the resident's medical condition changes.
Failure to Develop and Implement Care Plan for Prevalon Boots
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, specifically regarding the use and maintenance of Prevalon boots. The resident, who was admitted with conditions including encephalopathy, quadriplegia, and type 2 diabetes mellitus, had a care plan that mentioned the use of bilateral Prevalon boots but did not include instructions on how to clean or maintain them. This omission was noted during a review of the resident's care plan, physician's orders, and treatment administration records, none of which provided guidance on the maintenance of the boots. Interviews with facility staff, including a CNA, LVN, and the Treatment Nurse, revealed a lack of documentation and understanding regarding the cleaning and maintenance of the Prevalon boots. The CNA admitted there was no place to document when the boots were cleaned, and the LVN acknowledged that a care plan should have been in place to ensure proper maintenance. The Treatment Nurse confirmed that without documentation, there was no evidence of the boots being maintained, which could lead to infection. The facility's policy and procedure on comprehensive person-centered care plans required that care plans describe services to maintain the resident's well-being and be updated as conditions change. However, the Director of Nursing confirmed that the facility did not follow these procedures, as there was no specification on how to clean the Prevalon boots. This lack of adherence to policy posed an infection control issue, potentially affecting the resident's existing conditions.
Failure to Implement Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was dependent on dialysis and repeatedly refused prescribed medications, vitamins, and supplements. This resident, who had diagnoses including end-stage renal disease, anemia, and hypertension, was admitted to the facility with severely impaired cognition. Despite the resident's refusal of essential medications and supplements, the facility did not create a care plan to address these refusals or explore alternative measures to ensure the resident's compliance with their treatment regimen. The facility also failed to inform the resident's responsible party about the repeated refusals of medications and supplements. The responsible party was not made aware of the resident's non-compliance, nor was there any documented evidence that the facility staff communicated the resident's status to the dialysis center. This lack of communication and failure to hold an interdisciplinary team (IDT) meeting, despite requests from the dialysis center and the responsible party, contributed to the resident's deteriorating health condition. As a result of these deficiencies, the resident was admitted to a generalized acute care hospital due to severe muscle weakness and abnormal laboratory values, including a critically low hemoglobin level. Interviews with facility staff revealed that there was no documented evidence of attempts to address the resident's refusals or to inform the medical doctor and family. The facility's policies and procedures regarding care plans and resident rights were not followed, leading to significant health complications for the resident.
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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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