Sierra View Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Porterville, California.
- Location
- 465 W Putnam Ave, Porterville, California 93257
- CMS Provider Number
- 555766
- Inspections on file
- 18
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Sierra View Medical Center during CMS and state inspections, most recent first.
A resident with a persistent vegetative state, chronic respiratory failure, and ventilator dependence had head lice first observed by a family member, who reported it to staff, but no timely action was taken to follow the facility’s head lice infection control policy. A CNA acknowledged being informed and shown a picture of the lice but could not recall reporting it to a nurse, and the LVN caring for the resident that day stated he was unaware of any lice. The Infection Control Nurse was not notified, the resident was not placed on contact isolation, and the physician was not notified for treatment until a later date when an RN assessed the resident after another family complaint and then initiated isolation, contrary to the facility’s written lice management protocol.
Surveyors found that empty and full oxygen cylinders were intermingled in the designated storage area, with three empty tanks stored alongside four full tanks. The Administrator confirmed the improper storage and was unsure of the cause. This deficiency was observed in one smoke compartment and affected 11 residents.
Surveyors identified that the facility's memorandum of understanding with partner facilities and providers, required for emergency preparedness, was expired at the time of review. The Administrator confirmed the agreement was not current and renewal was pending, resulting in noncompliance with emergency preparedness regulations.
Several residents receiving G-tube feedings were observed with their head of bed (HOB) elevated below the required 35 degrees, despite physician orders, care plans, and facility policy specifying this standard. Nursing staff acknowledged the HOB should have been higher during feedings, but did not maintain the required elevation, resulting in noncompliance with established protocols.
The facility did not consistently follow its policy requiring two licensed nurses to verify and sign narcotic count check sheets at each shift change, resulting in multiple instances of missing or incomplete documentation over several months. Interviews with the RN Supervisor and DON confirmed that this process was not properly followed, as required for controlled medication accountability.
Surveyors found that pre-made and opened food items, including sliced strawberries, strawberry puree, mixed fruit, brown rice, and breadcrumbs, were not labeled with use-by or opened dates and some were not covered as required. Staff confirmed these items should have been labeled and covered according to facility policy.
The facility did not perform required quarterly legionella testing of its water system, as confirmed by the absence of testing on several occasions and staff interviews. Additionally, an LVN failed to wear an isolation gown while providing suctioning care to a resident on contact and enhanced barrier precautions, contrary to facility policy.
The facility failed to ensure the Crash Cart was inspected daily, as required by policy. An RN confirmed that the Crash Cart Integrity Check List was not completed on multiple dates, potentially resulting in necessary supplies and medications being unavailable during an emergency.
The facility failed to ensure that two residents in a persistent vegetative state had appropriate surrogate decision-makers, relying instead on the Interdisciplinary Team (IDT) for advocacy. Despite attempts to contact a public conservatorship agency, no conservatorship was obtained, and the residents' rights to have a surrogate decision-maker were not honored.
The facility failed to ensure that two Respiratory Care Practitioners were competent in managing respiratory care equipment, leading to potential contamination and risk of respiratory infections for three residents. Observations revealed improper handling of tubing, and interviews confirmed that infection control policies were not followed.
The facility failed to follow infection control practices, including not changing suction canisters and Yaunker catheters per policy, not discarding contaminated T-pieces, improper storage of aerosol tubing, and inadequate hand hygiene by staff, leading to potential respiratory infection risks among residents.
The facility failed to re-evaluate the need for a left-hand mitten restraint for a resident after 90 days as per the physician's order. The restraint was found in the resident's room, and there was no current physician's order for its use, as the charge nurse did not re-evaluate the need for it.
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving g-tube feedings. An LVN confirmed the head of bed was at 25 degrees, contrary to the physician's order and facility policy, increasing the risk of aspiration.
A facility failed to ensure a physician-ordered medication, Pantoprazole, was available for a resident requiring it to reduce stomach acid. Despite being ordered from the pharmacy, the medication was not received in time for administration, contrary to the facility's policy on timely drug administration.
The facility failed to include required language in arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with officials. Despite the Admin/DON stating that the facility does not offer arbitration agreements, signed agreements were found for two residents, lacking the necessary language. The facility could not provide a policy for arbitration agreements when requested.
Failure to Implement Head Lice Infection Control Policy and Timely Isolation
Penalty
Summary
The facility failed to implement its infection control guideline for head lice for one resident. On 11/6/25, the resident’s family member observed lice on the resident’s pillow at approximately 8:13 p.m. and reported this to staff, though the family member could not later identify which staff were notified. The resident, who had been admitted on 10/30/25 with a persistent vegetative state, chronic respiratory failure, and ventilator dependence, was under the care of CNA 1 and LVN 1 on that date. CNA 1 stated the complainant told her about the lice and showed her a picture on 11/6/25, but she could not remember if she reported this to a nurse or who the nurse was. LVN 1, who also worked with the resident on 11/6/25, stated he was not made aware of any lice by family or staff. The Infection Control Nurse (ICN) confirmed that she was not notified of the lice infestation on 11/6/25 and that the resident was not placed on isolation until 11/16/25, ten days after lice were initially observed. The ICN stated that facility interventions for lice include immediately placing the resident on contact isolation and notifying the physician, and there was no physician notification documented on 11/6/25. On 11/16/25, RN 1, who was working with the resident, received a complaint from the family about lice, assessed the resident, and noted lice, at which point the resident was placed on isolation. RN 1 reported he had not received any prior report indicating the resident had lice, although the complainant told him she had reported the issue to other staff previously. Review of the facility’s undated policy "INFECTION CONTROL GUIDELINE FOR PEOPLE WITH HEAD LICE" showed that patients with lice are to be placed in contact isolation, with gown and glove use, bagging of linens, and physician notification for treatment, measures that were not implemented when lice were first reported on 11/6/25.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to properly maintain the storage of medical gas cylinders, specifically oxygen tanks, as required by NFPA 101 and NFPA 99 standards. During a tour of the facility, surveyors observed that empty and full oxygen cylinders were intermingled within the designated storage area. Specifically, three empty oxygen tanks were found stored in the section intended for full tanks, alongside four full tanks. This observation was made in one of three smoke compartments and affected 11 of 33 residents. Upon interview, the Administrator confirmed the finding and indicated uncertainty regarding why the tanks were misplaced. The report notes that the storage closet did not comply with the requirement to segregate empty cylinders from full ones, as outlined in the relevant fire and safety codes. No additional information about the medical history or condition of the affected residents was provided in the report.
Plan Of Correction
Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During the building tour it was discovered that 3 empty oxygen tanks were being stored in the full section. The facility had Engineering remove the tanks. Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/ Safety & Security Manager had an additional 6 tank holder ordered so that there is available storage capacity for empty tanks, this will reduce the risk of comingling tanks. (see attachment C) PI Monitoring: The Facility will utilize its Environment of Care (EOC) rounds to ensure that proper tank storage is being adhered to.
Expired Emergency Operations Agreement
Penalty
Summary
The facility failed to maintain an up-to-date Emergency Operations Plan (EOP) as required by federal regulations. During a record review and interview with the Administrator, surveyors found that the memorandum of understanding with partner facilities and providers, which is necessary to ensure the continuity of services to residents in the event of limitations or cessation of operations, was expired. The agreement provided by the facility had an expiration date in February 2025, and at the time of the survey, it was no longer valid. The Administrator confirmed during the interview that the agreement was expired and stated that renewal was in process. This lapse in maintaining a current arrangement with other facilities could affect the facility's ability to properly respond during an emergency, as required by the emergency preparedness regulations. No specific residents or medical histories were mentioned in relation to this deficiency.
Plan Of Correction
Sierra View Medical Center Distinct Part Skilled Nursing Unit submits this plan of correction as part of the requirement under the State and Federal regulations. The plan of correction is submitted and shall not be construed as admission to the alleged deficiency cited or any liability. The plan of correction shall constitute a credible allegation of compliance. Potential Patients affected The organization was unable to find in a retrospective review that any patients had been adversely affected and were not placed in an immediate jeopardy situation. Immediate Organizational Action During document review, it was noted that the Hospital's Memorandum of Understanding (MOU) with its regional partners had expired on February 26, 2025. The MOU is normally updated by the EMS Coordinator-Disaster Services Fresno County MHOAC and sent out for all parties to agree upon. The Environment of Care/Safety & Security Manager from Sierra View notified the coalition of the need for an updated MOU. The EMS Coordinator from Fresno County then submitted an addendum to the coalition for an extension of the MOU until December 31, 2025. All parties agreed and the amendment to the MOU was officially updated. (Please see attachments A & B highlighted areas) Organizational System Improvements: Persons responsible: Environment of Care/Safety & Security Manager The Environment of Care/Safety & Security Manager will attend regular meetings with the coalition to ensure the MOU does not lapse. PI Monitoring: The MOU will be presented no less than annually to the organization’s Safety Committee for tracking purposes.
Failure to Maintain Required Head of Bed Elevation During G-Tube Feedings
Penalty
Summary
The facility failed to ensure that the head of bed (HOB) was properly elevated for five residents receiving gastrostomy tube (G-tube) feedings. During multiple observations, residents were found lying in bed with the HOB elevated to levels ranging from 18 to 27 degrees, which was below the required 35 degrees as specified in their physician orders and care plans. Nursing staff, including registered nurses, a licensed vocational nurse, and the director of nursing, acknowledged during interviews that the HOB should have been elevated to at least 30 or 35 degrees during tube feedings, in accordance with both physician orders and facility policy. Record reviews for each resident confirmed active orders and care plans specifying the required HOB elevation during tube feedings. The facility's policy also directed staff to elevate the HOB to 35-45 degrees during and for at least one hour after feedings. Despite these clear instructions, staff did not maintain the required HOB elevation during observations, resulting in noncompliance with physician orders, care plans, and facility policy for the care of residents with feeding tubes.
Failure to Consistently Complete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its policy and procedure for medication storage, specifically regarding the completion of Narcotic Count Check Sheets (NCCS), was consistently followed. Record review revealed that, across several months, there were multiple instances where either one or no licensed nurses signed the NCCS at required times, despite the policy mandating that two licensed nurses verify and sign the count at each shift change. Specific dates were identified where signatures were missing or incomplete, indicating that the required physical inventory of controlled medications was not properly documented. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that two nurses are responsible for counting narcotics and signing the NCCS at the beginning and end of each shift. The facility's policy also requires this process to be documented for all controlled substances in accordance with federal and state regulations. The observed lapses in documentation and missing signatures on the NCCS represent a failure to adhere to these established procedures.
Failure to Label and Store Food Items According to Standards
Penalty
Summary
Surveyors observed multiple instances in which food items in the facility's kitchen were not properly labeled or stored according to professional standards and facility policy. Specifically, twelve individual containers of sliced strawberries were found in the refrigerator without labels or dates, and the Nutritional Lead confirmed that these should have been labeled with the prepared and use-by dates. Additionally, two containers of strawberry puree and one container of mixed fruit were found uncovered and undated in the tray line refrigerator, and the Nutritional Lead acknowledged that these items should have been covered and dated. Further observations revealed that a 25-pound bag of brown rice and a 25-pound bag of Panko dry breadcrumbs, both stored in plastic bins, were open but not labeled with the date they were opened. Staff confirmed that these items should have been dated upon opening. Review of the facility's policy indicated that all foods in process must be covered, labeled, and dated with the expiration or opened date, but these procedures were not followed for the items observed.
Failure to Conduct Legionella Testing and Adhere to Contact Precaution Protocols
Penalty
Summary
The facility failed to follow standard infection prevention and control practices in two key areas. First, the facility did not conduct required quarterly testing of its water system for legionella bacteria, as indicated by the absence of testing on several documented dates. The Safety and Security Manager confirmed that the facility's water was not tested for legionella on multiple occasions, despite a previous request to begin such testing and a water management program recommending quarterly sampling. The Director of Nursing was unaware that the testing had not occurred, and the facility's water management plan outlined the need for routine monitoring and sampling. Second, a Licensed Vocational Nurse did not adhere to contact precaution protocols while providing respiratory care to a resident on contact and enhanced barrier precautions. During a suctioning procedure for a resident who was coughing, the nurse failed to wear an isolation gown as required by the facility's policy for contact precautions. The nurse acknowledged the omission and stated an attempt was made to avoid close contact, despite the policy specifying the use of gloves and gowns when entering the room of a resident on contact precautions, especially when substantial contact with the resident or their environment is anticipated.
Failure to Inspect Crash Cart Daily
Penalty
Summary
The facility failed to ensure that the Crash Cart, used for 30 sampled residents, was inspected daily. During an interview and record review with a Registered Nurse (RN), it was found that the Crash Cart Integrity Check List (CCICL) was not completed on multiple dates. The RN confirmed that the crash cart is supposed to be checked every night shift and acknowledged that if the checklist is blank, it means the cart was not checked. The RN also stated that the cart needed to be checked to ensure that the supplies and medications were functioning and available in case of an emergency. A review of the facility's policy and procedure for Crash Carts indicated that daily inspections should include checking the defibrillator, the contents on top of the crash cart, the oxygen cylinder, and verifying tamper-evident seals. The policy also required the staff nurse to sign the CCICL to document the completion of these checks. The failure to complete these daily inspections had the potential to result in necessary supplies and medications being unavailable during an emergency.
Failure to Ensure Surrogate Decision-Makers for Residents
Penalty
Summary
The facility failed to ensure that two residents, who were in a persistent vegetative state and lacked family or conservators, had appropriate surrogate decision-makers. Instead, the facility's Interdisciplinary Team (IDT) was used as the sole source of advocacy for these residents. The facility's policy required the appointment of a surrogate decision-maker when a resident lacked decision-making capacity and had no written advance directive or court-appointed conservator. However, the facility did not follow this policy, resulting in the residents' rights to have a surrogate decision-maker not being honored. Interviews and record reviews revealed that the Next of Kin sections for both residents were blank, and the Person to Notify was listed as the facility's medical director. The Ombudsman, who previously attended care planning sessions, no longer participated due to a recommendation from the state ombudsman. Social Services attempted to reach out to a public conservatorship agency for guidance but did not obtain conservatorship, leaving the IDT to continue representing the residents. This failure was documented in the facility's policy and procedure and an All Facilities Letter from the state health care agency, which indicated the need for public patient representatives in such cases.
Failure to Ensure Competency in Respiratory Care Practices
Penalty
Summary
The facility failed to ensure that two Respiratory Care Practitioners (RCP 1 and RCP 2) were competent in setting up and managing respiratory care equipment according to facility policy. This was observed in the cases of three residents (Resident 8, Resident 6, and Resident 10). During observations, corrugated tubing with oxygen was found laying on the floor, on empty beds, and touching the headboard, which is against the facility's infection control policy. Interviews with the RCPs and the Infection Preventionist (IP) confirmed that the tubing should have been placed in a clear plastic bag when disconnected from the resident to prevent contamination. Additionally, the tubing and water traps were not changed as required when contamination was identified, and PRN tubing changes were not documented, only weekly changes were recorded. Further review revealed that the annual competency assessments for RCP 1 and RCP 2 did not include evaluation of their ability to maintain infection control practices during the setup and changing of the tubing. The Manager of Respiratory Care Services (MRCS) acknowledged that these practices should have been part of the competency assessment and need to be incorporated. The failure to follow proper infection control procedures and the lack of comprehensive competency assessments had the potential to result in contaminated respiratory equipment being used, posing a risk of respiratory infections to residents with compromised respiratory systems.
Infection Control Deficiencies in Respiratory Care and Hand Hygiene
Penalty
Summary
The facility failed to follow standard infection control practices in several instances, leading to potential risks of respiratory infections among residents. In one case, a suction canister liner containing respiratory secretions was not changed when it was over three-quarters full for a resident with a tracheostomy. The resident was observed coughing with sputum filling his tracheostomy tubing, and the Registered Nurse acknowledged that the canister should have been changed at 750 ml. The Administrator/Director of Nursing confirmed that the canister should have been changed at that level. In another instance, a Yaunker suction catheter was not replaced per policy for a resident. The catheter was found open and dated as opened five days prior, but it should have been replaced three days after opening. Additionally, a T-piece used in oxygen delivery was found unlabeled, undated, and contaminated with dried mucus in another resident's room. The Respiratory Care Practitioner confirmed that the T-piece should have been discarded and replaced due to the lack of labeling and dating. Further observations revealed that aerosol tubing was not stored and secured properly, leading to potential contamination. Tubing was found laying on the floor, on empty beds, and touching the headboard in multiple residents' rooms. The Infection Preventionist and Respiratory Care Practitioner both stated that the tubing should have been placed in a clear plastic bag when disconnected to prevent contamination. Additionally, hand hygiene was not performed by a Licensed Vocational Nurse before and after glove use while providing care to two residents, which included administering medications and suctioning airways through tracheostomies. The facility's policy on hand hygiene was not followed, as confirmed by the Administrator/Director of Nursing.
Failure to Re-evaluate Restraint Use
Penalty
Summary
The facility failed to re-evaluate the need for a left-hand mitten restraint for Resident 14 after 90 days as per the physician's order. During an observation, a hand mitten restraint was found on the over bed table in Resident 14's room. A review of the physician's order dated 12/12/23 indicated that the restraint was to be re-evaluated after 90 days, which should have been done by 3/12/24. However, the Regulatory Registered Nurse confirmed that the order was out of compliance. Further review with the Administrator/Director of Nursing revealed that there was no current physician's order for the restraint, as the charge nurse did not re-evaluate the need for it. The facility's policy indicated that restraints should be initiated or continued only with a physician's order.
Failure to Elevate Head of Bed During G-Tube Feeding
Penalty
Summary
The facility failed to ensure the head of bed was raised at least 35 degrees while a resident was receiving gastrostomy tube (g-tube) feedings. During an observation, the resident's head of bed was noted to be at a 25-degree position while the g-tube feeding was being administered. This was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the head of bed should be at least 35 degrees to reduce the risk of aspiration. The resident's physician's order and the facility's policy both indicated that the head of bed should be elevated to 30-35 degrees during feeding. The failure to comply with these instructions had the potential for aspiration and respiratory infection.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, Pantoprazole (Protonix), was available for administration to Resident 17, who required the medication to reduce excessive stomach acid. The Active Orders for Resident 17 indicated a daily dose of Pantoprazole 40 mg via gastric tube. During an observation and interview, an LVN stated that the medication was not available in the facility. Further review revealed that the medication had been ordered from the pharmacy two days prior but had not yet been received. The facility's policy on medication administration emphasizes the importance of timely and accurate drug administration, which was not adhered to in this instance.
Failure to Include Required Language in Arbitration Agreements
Penalty
Summary
The facility failed to ensure the required language was included in signed arbitration agreements for two residents, potentially affecting their awareness of their rights to communicate with federal, state, or local officials. During an interview, the Administrator/Director of Nursing (Admin/DON) stated that the facility does not offer arbitration agreements. However, a review of Resident 10's medical record revealed a signed arbitration agreement dated 6/29/19, which lacked the necessary language regarding the right to communicate with officials. This discrepancy was confirmed during a concurrent interview and record review with the Admin/DON, who acknowledged the existence of the signed arbitration agreement despite the facility's stated policy of not offering them. Similarly, during a concurrent interview and record review with Social Services (SS), it was found that Resident 12 also had a signed arbitration agreement that did not include the required language about the right to communicate with officials. The facility was unable to provide a copy of the policy and procedure for arbitration agreements when requested. This failure to include the necessary language in the arbitration agreements could lead to residents and their representatives being unaware of their rights to communicate with various officials.
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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