Sierra Valley Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 301 West Putnam, Porterville, California 93257
- CMS Provider Number
- 055568
- Inspections on file
- 32
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sierra Valley Rehab Center during CMS and state inspections, most recent first.
A resident with a chronic indwelling catheter and history of UTIs did not receive a physician-ordered urinalysis because an LVN failed to enter the order, resulting in a delay of care. Facility policy requires nurses to promptly and accurately enter new physician orders into the MAR/eMAR.
The facility failed to provide binding Arbitration Agreements in a form and manner that three Spanish-speaking residents could understand, leading them to sign without comprehending the implications. The agreements were presented in English, contrary to the facility's policy requiring translation for populations with limited English proficiency exceeding 5%.
The facility failed to follow infection control protocols, including not placing a symptomatic resident on Droplet Isolation Precautions, not dating or timing oxygen and nebulizer tubing, improperly managing a suction machine, and neglecting hand hygiene before meals.
The facility failed to provide adequate dining room accessibility and space for its 132 residents. Observations revealed that the dining room door was locked, limiting access, and the space could only accommodate a small number of residents at a time. Residents were observed waiting in the hallway for their turn to dine, as the dining room could not accommodate more than eight residents simultaneously. The Administrator acknowledged the issue, and no policy addressing dining room space was provided.
A facility failed to accurately complete the MDS for a resident by incorrectly coding Aspirin as an anticoagulant. The MDS consultant confirmed the error, and the MDS nurse acknowledged the mistake. This inaccuracy could potentially affect the resident's care, as the MDS is crucial for establishing person-centered care needs.
A facility failed to implement communication interventions for a Spanish-speaking resident, who was at risk for impaired communication. The resident's care plan lacked interventions despite goals for communication being set. The resident expressed difficulty in communicating with English-speaking staff and preferred communication in her language. A Registered Nurse Consultant confirmed the requirement for interventions in care plans, which was not met.
A resident was administered Potassium Chloride ER tablets inappropriately when an LVN crushed the tablets and mixed them with applesauce, contrary to guidelines that specify extended-release tablets should not be crushed. The DON confirmed the error, and a pharmacist reiterated that Potassium ER should not be crushed, aligning with the facility's policy against crushing such medications.
A facility failed to implement a physician's wound treatment orders for a resident's right heel blister. The physician ordered cleansing with normal saline and Betadine application twice daily, but the order was not recorded or carried out. The facility's policy requires immediate recording and implementation of such orders, which was not followed in this case.
A resident with documented hearing loss was not provided with hearing aids as recommended by an audiogram. Facility staff were unaware of the recommendation, and the facility's policy to ensure access to necessary adaptive equipment was not followed.
A facility failed to follow its policy for labeling IV tubing, as observed during an interview with an LVN. The IV tubing for a resident was not labeled with the date, time, and initials of the person who hung it, contrary to the facility's policy. This policy aims to prevent infections associated with contaminated IV therapy equipment, and it requires that any unlabeled tubing be changed and labeled.
The facility failed to complete the required annual competency for a CNA. The CNA was hired and completed their initial orientation and competency checklist shortly after hiring. However, the Director of Staff Development could not provide documentation of the CNA's 2024 annual competency, indicating it was not completed as required.
A cook in the facility failed to follow the standardized recipe for Zesty Spinach by adding unmeasured amounts of ingredients, contrary to the facility's food preparation policy. The cook admitted to not using the recipe and relying on taste, which was confirmed as incorrect by the Certified Dietary Manager.
A resident with hemiplegia did not receive necessary adaptive feeding devices as specified on their meal ticket, despite facility policies requiring such provisions. The oversight was confirmed by both the Registered Dietician and Certified Dietary Manager, highlighting a deficiency in care.
A facility failed to follow its smoking policy for a resident, as tobacco was found at the bedside without a completed smoking care plan or assessment. Staff confirmed that tobacco should be locked up, and the DON acknowledged the absence of necessary evaluations. The facility's policy requires smoking evaluations and care plans, which were not adhered to in this case.
The facility did not meet the required minimum square footage for resident rooms, affecting 20 out of 48 bedrooms. Rooms intended for multiple residents were below the 80 square feet per resident requirement, with measurements showing insufficient space. The Administrator acknowledged the deficiency but noted that residents had adequate privacy and storage. No previous room waiver was available.
A resident with severe cognitive impairment was verbally abused by his roommate, who had intact cognition, for over a year. The abuse included derogatory remarks and racial slurs, which were known to staff but not reported to the Administrator or DON as required by facility policy. The resident's condition improved after being moved to a different room.
A resident with severe cognitive impairment was subjected to persistent verbal abuse by a roommate with intact cognition. Despite staff awareness, the abuse was not reported to the Administrator as required by facility policy. The resident, who suffers from quadriplegia and dysphasia, showed signs of distress during the period of abuse but improved after being moved to a different room. Staff interviews confirmed the failure to report the abuse, which violated the facility's procedures.
The facility did not follow its policy for timely reporting a resident-to-resident abuse incident to the CDPH. An altercation occurred where a moderately cognitively impaired resident kicked a severely cognitively impaired resident. The incident was not reported within the required two-hour timeframe, leading to a 48-hour delay. The Administrator was unaware of the incident until two days later, and the Social Services Director confirmed the reporting lapse.
A facility failed to follow a resident's care plan by not using a mesh stop sign intended to prevent wandering residents from entering the room. This oversight was confirmed by a CNA and the SSD, despite the care plan's directive following an incident of inappropriate touching. The facility's policy emphasizes maintaining residents' well-being, which was not upheld in this case.
A facility failed to implement a physician's order to increase a resident's Xanax dosage to 1 mg three times a day. Instead, the resident continued to receive 1 mg twice daily due to a communication lapse by the Social Service Director, who did not relay the updated order to nursing staff. This oversight was contrary to the facility's medication administration policy.
A facility failed to complete competency evaluations for an LVN before allowing independent medication administration. The LVN's skills checklist was incomplete, yet they worked across all stations providing care. The facility's policy requires competency validation during onboarding, which was not adhered to, as confirmed by the DSD and Administrator.
A facility failed to document medication administration timely for a resident, leading to potential inaccuracies in medical records. A resident reported not receiving medications on time, and a review showed Levothyroxine Sodium was documented 10 days late by an ADON, contrary to policy requiring immediate documentation.
A resident with mobility issues and a care plan requiring a Hoyer lift for transfers experienced multiple falls and injuries due to staff not adhering to the care plan. Despite being assessed as dependent on assistance, staff used inappropriate transfer methods, leading to significant injuries, including broken bones and the need for surgery.
A facility failed to implement nutritional interventions for a resident as recommended in a Nutritional Risk Assessment. The assessment suggested adding a nutritional supplement, protein supplement, zinc, and vitamin C. During a review, the DON could not provide evidence of these recommendations being carried out, acknowledging they should have been addressed within 72 hours. The facility's policy required the FNS Director or Dietitian to complete dietary recommendations within three days.
A facility failed to implement a care plan for a resident at high risk for falls. The care plan required a bed alarm, but during an observation, the resident did not have one. Interviews with the ADON and MDSC confirmed the resident's fall risk and attempts to get out of bed. The resident's fall risk assessment showed a high score, and the ADON acknowledged the care plan was not followed.
A facility failed to ensure a resident's call light was within reach, as it was found hanging on the wall behind the bedside drawer. The resident, who had severe cognitive impairment and bilateral above-the-knee amputation, was unable to locate the call light. A CNA confirmed the call light was not accessible, contrary to the facility's policy requiring call lights to be within reach.
Failure to Enter and Implement Physician Order for Urinalysis
Penalty
Summary
A deficiency occurred when a physician ordered a urinalysis (UA) for a resident with a chronic indwelling catheter and a history of urinary tract infections (UTIs) due to the presence of spasms. The order was discussed with nursing staff on the date of service, but the Licensed Vocational Nurse (LVN) assigned to the resident did not enter the physician's order into the system. As a result, the urinalysis was not ordered or collected as required. Review of facility policy confirmed that nurses are responsible for promptly and accurately entering new physician orders into the Medication Administration Record (MAR/eMAR). This failure led to a delay in care for the resident.
Failure to Provide Arbitration Agreements in Residents' Preferred Language
Penalty
Summary
The facility failed to ensure that the binding Arbitration Agreement (AA) was presented in a form and manner that residents could understand, specifically for three residents who primarily spoke Spanish. The AAs were provided in English, which the residents could not read or understand. This led to the residents signing the agreements without comprehending their implications. Interviews with the residents revealed that they did not know what an arbitration agreement was and did not remember signing it. The facility's policy required that vital information be translated if the limited English proficiency population exceeded 5%, which was the case here. The Admission Coordinator acknowledged that the AAs were written in English, which hindered Spanish-speaking residents from reviewing the agreements to decide if they wanted to rescind them within the 30-day period allowed. The facility's policy on Binding Arbitration Agreements emphasized the importance of explaining the terms and conditions in a manner that residents understand, considering their language and literacy. Despite this, the facility did not provide the AAs in Spanish, failing to adhere to their own policy and procedures, and potentially compromising the residents' ability to make informed decisions.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control standards in several instances. One resident, who exhibited flu-like symptoms and was treated with influenza medication, was not placed under Droplet Isolation Precautions. Despite being symptomatic and receiving medications like Tamiflu and Xofluza, there was no documentation or evidence that isolation precautions were implemented to protect staff and visitors, as confirmed by the Director of Nursing and the Infection Preventionist. Additionally, two residents requiring oxygen therapy had issues with their equipment. The oxygen and nebulizer tubing for these residents were not dated or timed, and in one case, the oxygen tubing was found on the floor uncovered. The facility's policy required these items to be changed weekly and labeled, but this was not followed, as noted by the Licensed Vocational Nurse during observations. Another resident using a portable suction machine had the suction canister and tip improperly managed. The canister was not labeled or dated, and the suction tip was left uncovered on the bedside table. The facility's policy required the canister to be changed twice a week and the tip to be covered, but these procedures were not adhered to. Furthermore, a resident was not provided hand hygiene before being served lunch, contrary to the facility's hand hygiene policy.
Inadequate Dining Room Accessibility and Space
Penalty
Summary
The facility failed to ensure that the dining room was accessible and had adequate space to accommodate the 132 residents residing at the facility. During observations and interviews, it was noted that the dining room door was closed and had a coded lock, restricting resident access. The dining room contained seven round tables with a seating chart for 15 residents, but typically only accommodated around eight residents at a time. Residents were observed waiting in the hallway for their turn to enter the dining room, as the space could not accommodate more than eight residents at once. The Assistant Director of Nursing (ADON) confirmed that the facility lacked the space to accommodate more residents in the dining room simultaneously. Further observations revealed that the dining room door remained closed and locked, preventing residents from freely accessing the space. The Certified Dietary Manager (CDM) was unsure why the door was locked and confirmed that the dining room could not accommodate the additional residents waiting in the hallway. The Administrator acknowledged that the dining room should not have a closed, locked door and should be a common space allowing residents to come and go. A policy and procedure addressing dining room space was requested but not provided, indicating a lack of formal guidelines to ensure adequate dining accommodations for all residents.
Inaccurate MDS Coding for Resident's Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for one of the residents, identified as Resident 47. During an interview and record review, it was discovered that the MDS-Section N-Medications for Resident 47, dated January 6, 2025, incorrectly coded Aspirin as an anticoagulant. The Medication Administration Record (MAR) for February 2025 did not provide documentation that Resident 47 was on anticoagulant medications. The MDS consultant confirmed that Aspirin, which was prescribed to Resident 47, should not have been coded as an anticoagulant on the MDS. The MDS nurse acknowledged the mistake in coding Aspirin as an anticoagulant. The CMS Resident Assessment Instructions Manual specifies that anticoagulant medications such as warfarin, heparin, or low-molecular weight heparin should be coded if taken by the resident during the 7-day look-back period. However, antiplatelet medications like Aspirin should not be coded as anticoagulants. The failure to accurately code the medication could potentially lead to Resident 47 not receiving care based on his specific needs, as the MDS is a tool used to collect data to establish person-centered care needs.
Failure to Implement Communication Interventions for Spanish-Speaking Resident
Penalty
Summary
The facility failed to develop and implement communication interventions for Resident 329, who is at risk for impaired communication due to her primary language being Spanish. The care plan report for Resident 329 indicated goals for communication, such as being able to make needs known and having no declines in communication, but did not list any interventions to achieve these goals. This omission was identified during a review of the care plan report. During an interview, Resident 329, who only speaks Spanish, expressed that English-speaking staff sometimes did not understand her, and she did not understand them. Although staff used an interpreter to communicate with her, Resident 329 preferred to have someone who could speak her language directly. The Registered Nurse Consultant confirmed that care plans are required to have interventions listed, which was not the case for Resident 329. The facility's policy and procedure for comprehensive person-centered care plans also emphasized the need for interventions to address the underlying sources of problem areas, which was not adhered to in this instance.
Improper Administration of Potassium Chloride ER Tablets
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident. During an observation, an LVN was seen preparing to administer Potassium Chloride ER tablets to a resident by crushing them and mixing them with applesauce. This action was contrary to the medication's administration guidelines, which specify that extended-release tablets should not be crushed, as it can alter the medication's intended release and effectiveness. The LVN did not verify the medication's form against the resident's Medication Administration Record (MAR) and Order Listing Report (OLR), which did not specify the extended-release form. The Director of Nursing (DON) confirmed that the LVN should have clarified the discrepancy between the medication package and the MAR/OLR and should not have crushed the extended-release tablets. A pharmacist also confirmed that Potassium ER tablets should not be crushed. The facility's policy and procedure documents further supported that medications like extended-release tablets should not be crushed, and alternative forms should be sought if necessary. This failure had the potential to impact the resident's treatment for hypokalemia by not delivering the medication as intended.
Failure to Implement Physician's Wound Treatment Orders
Penalty
Summary
The facility failed to implement its policy and procedure for handling physician orders, specifically for a resident identified as Resident 126. The deficiency occurred when the wound treatment orders for Resident 126's right heel blister were not implemented. During an interview and record review, it was found that the physician had ordered a specific wound treatment on 2/19/25, which included cleansing the blister with normal saline, patting it dry, and applying Betadine twice a day. However, this order was not recorded in the resident's medical record, and the treatment was not carried out. The facility's policy requires that telephone and verbal orders be recorded and implemented immediately, with the nurse taking the order signing it with a full signature. The policy also mandates that all physician orders be complete and clearly defined to ensure accurate implementation. In this case, the registered nurse consultant confirmed that the physician's order for the wound treatment was not documented or implemented, leading to a failure in providing necessary wound care for Resident 126.
Failure to Provide Hearing Aids for Resident
Penalty
Summary
The facility failed to provide hearing aids for Resident 22, which was identified as a deficiency. The resident had an initial ENT consultation on June 11, 2024, where difficulty hearing and stuffy ears were noted, and an audiogram was recommended. The audiogram, conducted on July 10, 2024, confirmed that Resident 22 had a significant hearing loss that qualified them for hearing aids, particularly noting greater difficulty in the right ear. Despite these findings, Resident 22 reported not having hearing aids and not being seen by a hearing doctor recently. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's need for hearing aids. The Social Service Director Case Manager and Social Services staff both stated they were unaware of the audiogram's recommendation for hearing aids. The facility's policy on hearing and vision services mandates that residents receive necessary adaptive equipment, and the social worker is responsible for assisting residents in accessing these services. However, this policy was not followed, resulting in the deficiency.
Failure to Label IV Tubing as per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the administration of intravenous (IV) fluids, specifically in the case of one resident. During an observation and interview with a Licensed Vocational Nurse (LVN), it was noted that the IV tubing for a resident was not labeled as required. The LVN acknowledged that the tubing should have been labeled with the date, time, and initials of the person who hung the IV tubing. A review of the facility's policy, dated February 2023, confirmed that the tubing should be labeled to prevent infections associated with contaminated IV therapy equipment. The policy also stated that any unlabeled tubing must be changed and labeled accordingly.
Failure to Complete Annual Competency for CNA
Penalty
Summary
The facility failed to ensure that annual competencies were completed for one of the five sampled Certified Nursing Assistants (CNA). During an interview and record review with the Director of Staff Development (DSD), it was found that CNA 1, who was hired on December 26, 2023, had completed their new employee orientation and competency checklist by December 27, 2023. However, the DSD was unable to provide documentation of a 2024 annual competency for CNA 1, indicating that it had not been completed as required. The facility was also unable to provide the requested policy related to this requirement.
Failure to Follow Recipe in Food Preparation
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Food Preparation' when a cook did not measure recipe ingredients as required. During an observation and interview, it was noted that the cook, while preparing spinach to be pureed, added unmeasured amounts of garlic powder, iodized salt, chili powder, and melted butter, instead of following the specified recipe for Zesty Spinach. The cook admitted to not using the recipe and relying on taste instead. The Certified Dietary Manager confirmed that the cook should have followed the recipe and measured the spices as indicated. The facility's policy requires food to be prepared using approved recipes that are standardized to meet the resident census, with specific instructions on portion yield, preparation methods, ingredient quantities, and time and temperature guidelines.
Failure to Provide Assistive Feeding Devices
Penalty
Summary
The facility failed to provide necessary assistive feeding devices for a resident, identified as Resident 72, who required them due to hemiplegia following a stroke. During an observation, it was noted that Resident 72's lunch tray lacked the adaptive equipment specified on the meal ticket, such as a two-handle sip cup and special spoons. The resident confirmed not having received these items for some time. The Registered Dietician and Certified Dietary Manager acknowledged that the adaptive devices listed on the meal ticket were not provided, despite being responsible for ensuring the correct equipment was included with meals. Further review of Resident 72's records revealed that occupational therapy had recommended specific adaptive equipment to aid in self-feeding, including a universal cuff, built-up utensils, and a plate guard. These recommendations were documented in the resident's treatment notes and order listing report. The facility's policy on assistive devices emphasized the provision of specialized eating utensils to support resident independence, yet this policy was not followed in Resident 72's case, leading to a deficiency in care.
Failure to Implement Smoking Policy for Resident
Penalty
Summary
The facility failed to implement its Policy and Procedure (P&P) titled 'Smoking' for one of the residents, identified as Resident 4. During an observation, it was noted that Resident 4 had a can of tobacco at the bedside, which was against the facility's policy that requires tobacco to be locked up. Licensed Vocational Nurse (LVN) 4 confirmed that the tobacco should not have been left at the bedside. Additionally, the facility did not complete a smoking care plan or smoking assessment for Resident 4, which are necessary to ensure safe smoking practices. Interviews with staff and family members further highlighted the oversight. The Activities Assistant mentioned that Resident 4 should not have full access to his chewing tobacco as it could lead to excessive use. The Director of Nursing (DON) confirmed that there was no tobacco use care plan or safe smoking evaluation for Resident 4, which should have been in place. A family member also noted that Resident 4's tobacco pouches were usually at the bedside, indicating a lack of adherence to the facility's smoking policy. The facility's P&P requires a smoking evaluation upon admission and regular reevaluations, with any smoking-related privileges or restrictions noted in the care plan, none of which were completed for Resident 4.
Facility Fails to Meet Minimum Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation in 20 out of 48 facility bedrooms. During an observation and interview with the Environmental Services Director (ESD), it was noted that multiple occupancy rooms did not meet the required 80 square feet per resident. Measurements of these rooms revealed that they were significantly below the required space, with rooms housing three residents each but only providing between 208 and 219 square feet in total. The Administrator confirmed that there had been no changes to the room sizes or the facility floor plan since the previous survey. Despite the deficiency in room size, the Administrator stated that residents had a reasonable amount of privacy, adequate storage, and sufficient space for ambulation or wheelchair use. However, the facility was unable to provide a copy of a previous room waiver, indicating a lack of documentation to justify the current room sizes.
Failure to Protect Resident from Verbal Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from verbal abuse inflicted by his roommate. The resident, who had severe cognitive impairment and was unable to speak, was subjected to verbal aggression and derogatory remarks by his roommate, who had intact cognition. The abuse included being called a pedophile, racial slurs, and other derogatory terms. This situation persisted for approximately one year and seven months while the two residents shared a room. Interviews with staff members, including CNAs, LVNs, and the Director of Staff Development, revealed that the abusive behavior was known among the staff. Despite this, the verbal abuse was not reported to the Administrator or the Director of Nursing as required by the facility's policy. Staff members noted that the resident's condition improved after being moved to a different room, indicating the negative impact of the abuse on his well-being. The facility's policies on abuse reporting and behavioral assessment were not followed, as the staff failed to report the abuse immediately. The facility's policy required that any suspicion of abuse be reported to the Administrator and other officials according to state law. The failure to report and address the verbal abuse in a timely manner resulted in the resident experiencing agitation, restlessness, and difficulty sleeping, with the potential for psychosocial harm.
Failure to Report Verbal Abuse in LTC Facility
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting of verbal abuse, resulting in a deficiency. Resident 1, who has severe cognitive impairment and is unable to speak, was subjected to persistent verbal abuse by his roommate, Resident 2, who has intact cognition. Despite multiple staff members being aware of the verbal abuse, it was not reported to the Administrator as required by the facility's policy. Resident 1, who suffers from quadriplegia and dysphasia following a cerebral infarction, shared a room with Resident 2 for approximately one year and seven months. During this time, Resident 2 frequently directed verbal abuse towards Resident 1, including calling him derogatory names and using racial slurs. Staff members, including CNAs and LVNs, observed these interactions and noted that Resident 1 appeared more comfortable and rested after being moved to a different room. Interviews with various staff members, including CNAs, LVNs, the Social Service Director, and the Director of Staff Development, revealed that the verbal abuse was known but not reported to the Administrator or the Director of Nursing. The facility's policy requires that any suspicion of abuse be reported immediately to the Administrator, but this protocol was not followed. The failure to report the abuse allowed the situation to persist, impacting Resident 1's well-being.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely reporting of a resident-to-resident abuse allegation to the California Department of Public Health (CDPH). An incident occurred involving two residents, where one resident, who was moderately cognitively impaired, kicked another resident with severe cognitive impairment during an argument. This incident was not reported to the CDPH within the required timeframe as outlined in the facility's policy, which mandates immediate reporting within two hours for allegations involving abuse or resulting in serious bodily injury. The deficiency was identified during interviews and record reviews. The Administrator was unaware of the incident until two days after it occurred, indicating a lapse in communication and reporting procedures. The Social Services Director confirmed that the staff should have notified the abuse coordinator immediately, and the incident should have been reported to the CDPH as per the facility's policy. This oversight resulted in a delay of approximately 48 hours before the incident was reported to the appropriate authorities.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to ensure that the care plan for a resident was followed, specifically regarding the use of a mesh stop sign intended to deter wandering residents from entering the resident's room. The care plan, which was undated, included an intervention to place a bright-colored stop sign at the entrance of the resident's room due to an incident on 12/3/24 where the resident was allegedly inappropriately touched by another resident. During an observation and interview on 12/30/24, it was noted that the mesh stop sign was not in use, which was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that the sign should have been in place. The Social Service Director (SSD) also confirmed that the stop sign should always be used to prevent wandering residents from entering the room. The facility's policy on comprehensive, person-centered care plans emphasizes the importance of services that maintain the resident's highest practicable well-being, which was not adhered to in this instance.
Failure to Implement Physician Orders for Medication Dosage
Penalty
Summary
The facility failed to ensure that physician orders were implemented correctly for a resident, resulting in the resident not receiving the prescribed medication dosage. The physician's order, dated December 11, 2024, indicated that the resident's Xanax dosage should be increased to 1 mg three times a day. However, the Order Summary Report from December 30, 2024, showed that the resident was still receiving Xanax 1 mg twice a day, as per an earlier order from October 24, 2024. The Medication Administration Record for December 2024 confirmed that the resident was administered Xanax 1 mg twice daily. During an interview, the Social Service Director admitted to receiving the updated physician order but failing to communicate it to the nursing staff, which led to the resident not receiving the correct dosage as per the updated order. The facility's policy on administering medications requires that medications be administered according to prescriber orders, which was not followed in this case.
Incomplete Competency Evaluation for LVN
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) had completed the necessary competency evaluations before independently providing care to residents. The LVN Competency Skills Checklist for LVN 1 was found to be incomplete, lacking validation in several critical areas such as effective communication, nursing process utilization, emergency procedures, medication administration, and pain management. Despite these incomplete competencies, LVN 1 was assigned to work across all three stations in the facility, administering medications to residents without direct supervision. Interviews with the Director of Staff Development and the facility Administrator confirmed that LVN 1's competencies were not completed as required by the facility's policy. The policy, dated December 31, 2015, mandates that all competencies must be validated during the onboarding period, which is the first 90 days of employment, before a nurse can perform skills independently. The Administrator acknowledged that LVN 1 should not have been passing medications independently without completed competencies, indicating a lapse in adherence to the facility's procedures for ensuring staff competency.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to ensure proper documentation of medication administration for one resident, leading to potential inaccuracies in the resident's medical record. During an interview, a resident reported not receiving her scheduled 6 a.m. medications on time. A review of the Administration History (AH) for another resident revealed that Levothyroxine Sodium, a thyroid medication, scheduled for administration on December 9th, was not documented until December 19th by the Assistant Director of Nursing (ADON). The ADON admitted to administering the medication on the scheduled date but failed to document it immediately, as required by the facility's policy and procedure for administering medications. The policy mandates that the individual administering the medication must initial the resident's Medication Administration Record (MAR) immediately after giving each medication and before administering the next ones. This lapse in documentation could lead to inaccuracies in the resident's medical records, as the medication was documented 10 days after it was administered.
Failure to Implement Care Plan Leads to Resident Injuries
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident requiring assistance with activities of daily living (ADL), specifically in the use of a Hoyer lift for transfers. Despite the care plan indicating the necessity of a Hoyer lift, the resident was transferred using alternative methods, such as a sliding board and standing pivot, which were not appropriate for their condition. This led to multiple falls, resulting in significant injuries, including two broken bones in each lower leg, necessitating surgical intervention. The resident, who was readmitted with diagnoses including difficulty in walking, muscle wasting, and generalized muscle weakness, was assessed as being dependent on assistance for transfers. The care plan specified the use of a Hoyer lift, yet staff members, including a CNA, reported using a gait belt and other methods for transfers. The resident experienced falls during these transfers, with one incident involving the resident being asked to stand and use a walker, leading to a fall when the resident expressed feeling tired and weak. Interviews with staff revealed a lack of adherence to the care plan, with conflicting instructions from therapy and nursing staff regarding transfer methods. The resident, who was cognitively intact, reported that the Hoyer lift was never used, and staff continued to use inappropriate transfer techniques, resulting in further falls and injuries. The facility's failure to follow the established care plan and ensure the use of the Hoyer lift as required contributed directly to the resident's injuries.
Failure to Implement Nutritional Interventions
Penalty
Summary
The facility failed to implement nutritional interventions for a resident, as identified in a Nutritional Risk Assessment (NRA) dated September 6, 2024. The NRA recommended the addition of a nutritional supplement (Boost) 4oz daily, a protein supplement (Prostat) 30ml, zinc, and vitamin C. During an interview and record review on October 1, 2024, the Director of Nursing (DON) was unable to provide evidence that these nutritional recommendations were implemented. The DON acknowledged that the recommendations should have been addressed within 72 hours. The facility's policy and procedure for Nutritional Screening/Assessments/Resident Care Plan, dated 2023, stated that the Food and Nutrition Services (FNS) Director and/or Facility Registered Dietitian should complete dietary recommendations within three days.
Failure to Implement Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement the care plan for one of the residents, identified as Resident 1, who was at high risk for falls. The care plan, dated May 16, 2017, specified the use of a bed alarm to alert staff when the resident attempted to get out of bed. However, during an observation on July 19, 2024, it was noted that Resident 1 did not have a bed alarm on his bed. Interviews with the Assistant Director of Nursing (ADON) and the Minimum Data Set Coordinator (MDSC) confirmed that Resident 1 was at risk for falls and occasionally attempted to get out of bed. The Fall Risk Observation/Assessment conducted on July 5, 2024, indicated that Resident 1 had a high fall risk score of 24. The ADON acknowledged that the care plan was not followed, as Resident 1 was expected to have a bed alarm in place. The facility's policy and procedure on comprehensive person-centered care plans, dated December 2016, required the development and implementation of care plans with measurable objectives and timetables to meet residents' needs. The failure to provide a bed alarm as per the care plan had the potential to place Resident 1 at risk for falls resulting in injuries.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, identified as Resident 5. During an observation and interview, it was noted that Resident 5 was lying in bed and unable to locate his call light, which was hanging on the wall behind his bedside drawer. Resident 5 expressed his inability to find the call light, and a Certified Nursing Assistant (CNA) confirmed that the call light was not within reach, acknowledging that it should have been accessible to the resident. Resident 5's Minimum Data Set (MDS) assessment indicated a severe cognitive impairment with a BIMS score of 7 and limitations in both lower extremities that interfered with daily functions. The resident's care plan highlighted a self-care performance deficit related to general weakness, impaired balance, and bilateral above-the-knee amputation, necessitating assistance for personal care activities. The facility's policy on call light usage, dated 2018, required that call lights be placed within reach of each resident, which was not adhered to in this instance.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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