Trabuco Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Forest, California.
- Location
- 25652 Old Trabuco Road, Lake Forest, California 92630
- CMS Provider Number
- 555308
- Inspections on file
- 45
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 58
Citation history
Health deficiencies cited at Trabuco Hills Post Acute during CMS and state inspections, most recent first.
Pureed Vegetable Recipe Not Followed: The facility failed to follow the menu and recipe for pureed zucchini and yellow squash served to 16 residents on pureed diets. During observation, an employee prepared the vegetables in two batches, did not reserve the cooking liquid, added honey consistency thickened chicken broth, combined the batches, and then added thickener when the mixture was too runny. The DSS verified the employee was making his own version of the recipe and that excess liquid was added to the puree zucchini.
Food safety and sanitation deficiencies were identified in the kitchen and dish room. The dish machine sanitizer tested below the required ppm range, an aide moved from dirty dishes to clean dishes without washing hands or changing gloves, and food prep equipment was stored with water and food particles instead of being air-dried and clean. Surveyors also observed a dirty wall behind the refrigerator and two meal carts repaired with tape and other materials that did not create smooth, cleanable surfaces.
Incomplete hospice coordination and recordkeeping affected three residents. The facility did not include hospice visit frequency in the care plans or order summaries, lacked hospice aide notes and a complete hospice visitation calendar for one resident, did not have future hospice visit schedules available for another resident, and failed to accurately reconcile a morphine order. Hospice staff participation was also not documented in an IDT meeting, and staff acknowledged the missing or inconsistent hospice information in the records.
The facility had multiple infection control failures involving water safety, clean linen storage, housekeeping carts, urinal storage, isolation precautions, hand hygiene, and medication cart cleanliness. A resident with multiple loose stools was not placed on contact isolation when suspected C. diff was identified, a family member entered the room without PPE, and staff did not consistently perform hand hygiene after resident care. Housekeeping stored personal drinks in a supply cart, soiled towels were found in the clean linen area, and the medication cart contained residue, a dirty glucometer, and personal keys.
Ice Machines A and B were not cleaned and sanitized according to manufacturer instructions. The DOR of Maintenance stated he used two cleaning solutions instead of a cleaning solution and a sanitizer, and he did not use the Manitowoc products required for Ice Machine A. For Ice Machine B, he followed bottle directions instead of the manufacturer’s process and used an incorrect mix ratio compared with the label instructions.
Pest Control Program Not Effective in Dining Room: The facility failed to maintain an effective pest management program when six small flies resembling fruit flies were observed in the resident dining room, along with dark pinprick-sized residue on the walls that appeared consistent with fruit fly excrement. The DON-equivalent leadership and maintenance staff were unaware of the pests, and pest control reports did not show fly treatment during prior monthly visits.
Failure to Ensure Proper Self-Administration Assessment and Orders for Bedside Eye Drops: Two residents had eye drop medications at the bedside without the required documentation. One resident had artificial tears and Refresh Plus lubricant present with no physician order, self-administration assessment, or care plan, while another resident kept prescribed eye drops at the bedside despite an assessment that did not address safe bedside use and no physician order in the chart. An LVN and the DON verified the missing documentation and bedside storage concerns.
A resident’s record lacked a copy of an executed Advance Directive even though the chart included an acknowledgement form showing the resident had signed one and other documentation showed the resident had capacity. The resident stated he provided a copy to facility staff on admission, but SSD and the DON could not locate it in the medical record, and the chart lacked documentation of follow-up with the resident or family representative.
Failure to maintain privacy during GT feeding care. An RN started a resident's GT feeding and water flush in a shared room, pulled the curtain only between the resident and the hallway, and did not pull the curtain between the resident and the roommate who was sitting about two feet away. The RN lifted the resident's gown to check tube placement and connect the feeding and flush tubing, and the DON stated the curtain should have been pulled between the two residents to ensure privacy.
Psychotropic Medication Monitoring Deficiencies: The facility failed to document ordered nonpharmacological interventions for a resident with behavior episodes related to quetiapine and lorazepam, failed to continue behavior monitoring for a resident receiving quetiapine for psychosis, and failed to complete accurate orthostatic BP monitoring for two residents on quetiapine. RN and DON interviews confirmed the missing and inaccurate monitoring in the residents’ records.
A resident was transferred to an acute care hospital and later returned by ambulance, but despite a physician's bed-hold order, he was placed in a different room instead of his original room. The resident and family said they expected him to return to the held room, and the DON verified the prior room was available but was not used.
A resident was transferred to the hospital without the required bed-hold notice or documentation showing the bed-hold offer, daily rate, or acceptance. The record showed a physician order for a 7-day bed hold, but the consent form was incomplete, and the resident and family stated they were not told whether insurance would cover the bed-hold rate. The resident later returned to a different room, which surprised the family.
PASARR Recommendations Not Incorporated Into Care Plan: The facility failed to follow up on a resident’s PASARR level II determination and did not incorporate the recommended special services into the care plan. The resident had no capacity to understand and make decisions, and although the PASARR report showed nursing facility services were needed and special services were recommended, the record did not show documented follow-up or a care plan problem addressing the PASARR findings. The MDS Coordinator verified the missing documentation, and the DON was informed.
The facility failed to develop care plans for two residents’ identified needs. One resident had tube feeding with a required elevated HOB, but also preferred to keep it lower, and the care plan did not address that preference or the resident’s hearing aids. Another resident had an 11.5% weight loss in one month, but no care plan was developed for the weight loss and the RD’s recommendation for large entree portions TID was not shown as implemented.
Inaccurate post-fall neuro checks and missing orthostatic blood pressures. After an unwitnessed fall, a resident had an order for 72-hour neuro checks and a care plan intervention to obtain BP in lying, sitting, and standing positions within the first 24 hours. The record showed repeated neuro assessments with the same vital signs carried forward instead of newly obtained readings, and there was no documented evidence that orthostatic BP measurements were completed. The RN and DON both verified the findings.
A resident with bilateral hearing aids was observed having difficulty hearing and communicating, and stated the aids had not been charged. Records showed the resident’s hearing aids and charger were brought to the facility and assessments documented use of hearing aids in both ears, but there was no physician order for hearing aid use and staff did not charge or assist with the devices. The care plan identified the resident as hard of hearing but did not address hearing aid use, and the DON stated nurses were responsible for inserting, storing, and charging the aids.
A resident at risk for pressure ulcers had a LAL mattress in use, but the mattress was repeatedly observed set at 150 lbs. even though the resident’s current weight was 102 lbs. The mattress manual said the pressure setting should be adjusted using the resident’s weight as a guide, and an LVN verified the mismatch during record review and interview. The DON stated licensed nurses were responsible for ensuring the mattress setting matched the resident’s weight.
Failure to follow a physician order for voiding trials. A resident with an indwelling urinary catheter for obstructive uropathy was observed with the catheter draining yellow urine, but the record did not show that the ordered voiding trials were completed. The DON verified there was no documentation of the trials in the MAR and no documentation that the physician was informed they were not done.
A facility failed to follow GT care procedures for two residents. An LPN did not check gastric residual before flushing a GT and pushed crushed meds through the tube instead of administering them by gravity. For another resident on continuous tube feeding, the HOB was repeatedly observed below the ordered 30-45 degrees, and the record did not show that the resident’s preference to keep it lower or the risks of doing so were discussed with the physician.
IV Therapy Not Labeled per Facility Policy: A resident receiving IV 0.45% Sodium Chloride for hydration had the IV solution bag, IV tubing, and peripheral IV site observed without the required date, time, or staff initials. The facility policy required IV tubing to be labeled with the date, time, and initials, and an RN confirmed the items should have been labeled when the IV was started.
Respiratory care was not provided as ordered for three residents. One resident’s oxygen cannula and nebulizer equipment were left out instead of being stored in a sanitary manner. Another resident’s CPAP was not cleaned or maintained per the manufacturer’s instructions, and staff were unsure when it was last cleaned. A third resident received a nebulizer treatment without an LPN/RN staying in the room to monitor the administration.
A resident who required PRN opioid pain management did not receive ordered Tramadol after readmission, even though the medication was in the facility and available. The resident reported that acetaminophen was being used instead and only helped a little, while the MAR showed no documented Tramadol administration after return from the hospital despite active physician orders for GT administration.
A resident with ESRD and dependence on dialysis had incomplete and inaccurate dialysis communication documentation, including incorrect access assessments and missing post-dialysis details. The facility did not document notifying the dialysis center about an unwitnessed fall, did not document informing the physician of the dialysis center’s recommendation to hold HTN meds on dialysis mornings, and continued giving those meds on dialysis days. After a new right arm access was placed, the resident was not documented as being assessed or monitored for change in condition after returning from the procedure.
The facility failed to properly handle pharmaceutical services in several areas. Unopened lidocaine patches were found intact in an incineration bin instead of being destructed before disposal, a controlled substance count log for one med cart had missing nurse initials/signatures, a resident’s alprazolam for anxiety was not administered even though it was available in the facility, and an LPN gave docusate sodium to a resident with loose stools without first checking CNA bowel documentation.
Medication administration errors caused the facility’s error rate to exceed 5%. One LVN gave a GT medication to a resident but left significant residue in the cup after failing to mix the crushed medication with water, resulting in an incomplete dose. Another LVN gave a resident sennosides-docusate sodium instead of the ordered sennosides during GT medication administration. The DON confirmed medications should be given as ordered and fully administered.
Medication storage and labeling were not maintained for two medication carts and three residents. Oral and external meds were stored together on one cart, a suppository was stored with oral meds on another cart, an opened breathing treatment was missing an opened date, a discontinued controlled med remained in the cart, and an unlabeled bottle of eye drops was left unsecured on a resident’s overbed table. One resident had dementia and could make needs known, and the MAR did not list the eye drops.
Dietary Aide 2 was found not competent in the automatic dishwashing process. The aide loaded dirty dishes and then handled clean dishes without changing gloves or washing hands, and incorrectly tested the sanitizer by dipping the strip into rinse water. The dish machine log was also incomplete, with no recorded wash temp, rinse temp, or sanitizer PPM before breakfast dishes were washed, despite policy and manufacturer requirements for monitoring and documenting dish machine sanitation.
Failure to Provide Ordered and Preferred Meal Items: A resident with DM, HTN, HLD, and a seizure disorder did not consistently receive a fruit cup with meals and was observed repeatedly asking staff for it. Another resident on a pureed diet, who lacked capacity for medical decisions and disliked broccoli, was served lunch without the alternative entree for the broccoli item, and the DSS verified the missing item.
A facility failed to allow perishable food brought in by family or visitors to be stored or heated for resident use. The policy required prepared outside food to be approved by Nursing, eaten within two hours, and discarded if not consumed. The ADON stated perishable outside food could not be stored and could not be heated, and 161 residents consumed an oral diet.
The facility failed to keep accurate and complete records for three residents. One resident’s skilled notes said he was on room air even though the MAR showed continuous oxygen and had blank documentation entries. Another resident’s pain logs did not show the highest pain level for shifts when PRN Tramadol was given. A third resident’s Social Service Assessment incorrectly stated hearing aid use was not applicable, despite other assessments and the resident’s statements showing he used hearing aids.
QAPI and QA Committee Review Failures: The facility failed to implement its QAPI plan and prior POC for multiple deficiencies, including F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881. Records reviewed with the Administrator did not show required audits and observations for F578 and F803 were completed, and the QA/QAPI binders did not show the audit findings were presented to the QA Committee for review and continued monitoring.
Failure to Monitor Antibiotic Use and Infection Screening: The facility did not complete or document infection screening evaluations for two residents who received antibiotics for UTI and URI, and a third resident's infection screening evaluation did not show whether symptoms met McGeer's criteria for a true infection. The IP stated infection screening should be completed for all residents receiving antibiotics, including on admission or readmission, and that the physician should be notified if criteria for a true infection were not met.
The facility failed to document that a resident was offered the influenza and pneumococcal vaccines, and failed to ensure another resident’s pneumococcal consent form specified the exact vaccine type. One resident had capacity to understand, but the record did not show the flu or pneumococcal vaccines were offered. Another resident had capacity to make decisions, signed a pneumococcal consent, and received Pneumovax 21, but the consent form left the vaccine type blank; the IP and DON acknowledged the findings.
A resident with capacity to understand had prior COVID-19 vaccination documented in CAIR, but the medical record did not show the resident was assessed for or offered the seasonal COVID-19 vaccine. The facility’s IP could not find documentation of an offer or assessment during record review, and the DON acknowledged the finding.
Call light systems were not working properly or were not within reach for three residents. One resident reported waiting over 15 minutes for staff after pressing the call button, and the call light did not illuminate or sound outside the room or at the nurses’ station; the DON verified the station’s audio was not working. Another resident’s call light cord and a silver bell were both out of reach while she sat in a wheelchair and needed help getting up, and an LVN verified the call light was not working. A third resident in bed could not reach his call light, which was dangling low on the side of the bed, and he reported bilateral hand numbness and weakness.
A resident with diabetes and a seizure disorder had multiple loose stools, but a CNA did not know when to report the bowel movements or how to document them correctly in the EHR. The CNA said the stool was not watery or formed, did not notify the nurse, and the DON/DSD confirmed the CNA in-services covered ADL care and charting but did not show how to document bowel movement descriptors in the facility’s EHR.
An accurate MDS assessment was not completed for two residents. One resident’s MDS did not reflect oxygen therapy documented in the MAR, and another resident’s admission MDS did not code the use of bilateral hearing aids despite observations showing the aids in place and the resident reporting hearing difficulty. The MDS coordinators verified the coding errors.
Incomplete Facility Assessment: The Facility Assessment did not include input from residents, resident representatives, or family members, and it lacked the facility's retention plan for events not requiring activation of the emergency plan. It also did not identify emergency resource contracts or the resources needed to care for residents during nights and weekends if regular staff were unavailable. The Administrator reviewed the assessment and verified the findings.
Surveyors found that two residents received PRN medications, including an antianxiety drug, an antidepressant, and a narcotic pain medication, without adherence to facility policies requiring non-pharmacological interventions and informed consent. For one resident, Ativan was given for anxiety while behavior monitoring flowsheets showed non-pharmacological interventions and outcomes as "NA," and Cymbalta was started for pain without any documented informed consent from the resident or representative. For another resident lacking decision-making capacity, Tramadol was administered for moderate pain without any physician order for non-pharmacological measures and without documentation that such interventions were attempted before giving the PRN dose. An RN confirmed that non-pharmacological interventions should have been used and documented for these PRN medications.
A resident who lacked capacity to make medical decisions had a care log binder containing their name, room number, and care notes left on a hallway railing near the main entrance. Over an extended period, multiple CNAs and visitors walked past the unsecured binder without addressing it. An LVN acknowledged the binder and reported that the family liked it kept in the hallway, and the DON later confirmed the binder should have been kept in the resident’s room and not in a public area, resulting in a failure to protect confidential health information.
A resident was admitted with matted hair over the occipital area, and nursing documentation noted that the scalp could not be visualized. Although facility policy required a licensed nursing assessment on admission, staff did not reassess the obscured area for an extended period, deferring to a family member who wished to work through the matted hair. The occipital scalp was not reassessed until the family member was able to detangle the hair and then observed dry blood, confirming that the area had not been timely or thoroughly assessed as required.
A resident with multiple pressure ulcers, including unstageable elbow ulcers and a stage 4 mid-lower back ulcer, had a physician’s order for a low air loss mattress with placement and settings to be checked every shift. Facility policy required evidence-based pressure injury prevention interventions and appropriate support surfaces, and the mattress manufacturer’s instructions specified that pressure settings be adjusted according to the resident’s weight and height. During observation, the resident’s low air loss mattress was found set at 450 psi despite the resident weighing 162 pounds, and an LVN confirmed the setting was incorrect and had been that way for some time. The Administrator and DON were informed and acknowledged that the mattress setting did not comply with the ordered and policy-based pressure injury prevention measures.
A resident had a PRN order for Dulcolax suppository to be given only if MOM was ineffective for constipation. Review of the MAR and staff interview showed that an RN administered Dulcolax without first giving MOM or obtaining an alternative one-time order, contrary to the physician’s instructions and the facility’s medication administration policy.
A resident with a recent fall, poor balance, and care plan interventions for neuro-checks had missing entries on the neurological flowsheet, and physician-ordered daily treatment for an eyebrow laceration and monitoring of a deep purplish discoloration were not documented on the TAR for a specific day. During interviews and concurrent record reviews, the DON confirmed the neuro assessments should have been completed, and an LVN acknowledged the absence of TAR entries and uncertainty about her presence that day, while facility leadership later acknowledged these documentation gaps.
A resident who exhibited aggressive behavior and required IM Ativan was not monitored every shift for 72 hours following the incident, as required by facility policy. Additionally, the resident's care plan was not updated to include interventions or monitoring related to the recent behavioral episode, despite documentation of the change in condition and staff acknowledgment of the oversight.
A resident with anxiety did not receive their prescribed clonazepam for several days due to the medication being unavailable, and there was no documentation that the physician, pharmacy, or responsible party were notified. Additionally, required narcotic count sheets for the medication were missing from the medical record, and the DON was unaware of the issue.
A resident with orders for stat CBC, BMP, and urinalysis had abnormal lab results, including elevated WBC and BUN, as well as abnormal urinalysis findings. These results were not promptly reported to the physician, and there was no documentation of notification, despite facility policy requiring timely communication of out-of-range lab values. Nursing staff and the DON confirmed the lack of prompt notification and documentation.
A resident experienced poor PO intake, increased weakness, sleepiness, and confusion, but the facility did not notify the resident's representative of these significant changes in condition as required by policy. Staff interviews and record review confirmed the lack of notification.
A resident's stat orders for CBC, BMP, and urinalysis with C&S were not completed promptly as required, with delays in sample collection and no documentation that the lab was contacted immediately. Nursing staff confirmed the lack of timely action and follow-up, and the DON acknowledged the deficiency.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions. Review of records showed incomplete documentation and planning, with missing interventions and unclear goals for the resident's care.
Pureed Vegetable Recipe Not Followed
Penalty
Summary
The facility failed to ensure the menu was followed for 16 residents who received pureed food when pureed zucchini and yellow squash were prepared for the lunch meal. Review of the diet count by modification/portion dated 2/26/26 showed 16 of 161 residents received pureed food preparation from the kitchen, with no restrictions to zucchini and yellow squash. The daily spreadsheet for 2/26/26 showed the lunch menu included pureed zucchini and yellow squash for the Minced and Moist, Pureed, and CCHO Pureed diets. During observation and concurrent interview on 2/26/26 at 1020 hours, [NAME] 1 prepared the pureed vegetables in two batches using the English version of the recipe. [NAME] 2 strained the vegetables but did not reserve the cooking liquid. [NAME] 1 measured portions with a #10 scoop, pureed the vegetables, and added one quart of honey consistency thickened chicken broth to the first batch and one cup to the second batch, then combined the batches. [NAME] 1 stated the mixture was too runny and stirred in two teaspoons of thickener, then placed the steam pan in the oven and said he would wait to see if it thickened over time. The DSS later verified that [NAME] 1 was preparing his own version of the puree vegetable recipe and that the recipe for pureed zucchini and yellow squash was not followed when an excess of liquid was added to the puree zucchini.
Food Safety and Sanitation Deficiencies in Kitchen and Dish Room
Penalty
Summary
The facility failed to ensure food safety and sanitation guidelines were followed in the kitchen and dish room. During observation of the dishwashing process, the sanitizer concentration in the rinse cycle tested below the required 50-100 ppm range for the low-temperature dish machine. The DSS verified that the tubing connecting the sanitizer to the dishwashing machine was twisted, and breakfast dishes were being washed at that time. During the same dish room observation, Dietary Aide 2 was seen loading dirty dishes into the dish machine and then unloading clean dishes without washing his hands or changing his gloves between the dirty and clean sides. Facility policy required either two people in the dish room or, if one person performed both tasks, handwashing between dirty and clean areas. The facility’s handwashing guidance also required dietary employees to clean their hands after touching unsanitary items such as dirty dishes. Additional observations found a heavy-duty blender stored with water inside and a robot coupe stored with water and food particles inside, rather than being air-dried and clean before storage. The wall above the reach-in refrigerator in the main production area was covered with a brown fuzzy residue. Two meal carts were also observed with repairs that were not smooth or cleanable: one had duct tape securing the door latch, and the other had upper and lower corners repaired with a blue, plaster-like material. The DSS and Director of Maintenance acknowledged these findings during the survey.
Incomplete Hospice Coordination and Recordkeeping
Penalty
Summary
The facility failed to provide necessary care and services for three residents receiving hospice services by not maintaining complete hospice-related information in the facility record and care plan. For one resident admitted under Hospice Provider B, the facility’s order summary and care plan did not include the frequency of visits by each hospice staff member, even though the hospice plan of care listed skilled nursing twice weekly, social work as needed, and hospice aide once weekly. The DON reviewed the record and confirmed the care plan should have included the hospice visit frequency and that the hospice plan of care should have been incorporated into the facility care plan. For another resident receiving hospice services through Hospice Provider C, the care plan for terminal prognosis related to Alzheimer’s disease did not show the frequency of visits by each hospice staff member, and the order summary also failed to show the visit frequency. The hospice record contained RN visit notes for February 2026, but no hospice aide progress notes for that month were present in the facility record. The hospice visitation calendar for February 2026 also did not show the scheduled weekly visits by the skilled nurse or hospice aide. During interviews, staff stated the hospice aide visited multiple times in February, but the calendar was incomplete and the notes were not uploaded or available in the resident’s records. For a third resident receiving hospice services through Hospice A, the facility record did not show future hospice visits, and the facility plan of care did not include the frequency of hospice staff visits. The resident’s hospice IDG meeting listed scheduled visits for chaplain, nursing, and social work, but the facility’s IDT care conference record did not show hospice staff participation. The physician’s order for morphine was also not accurately reconciled in the facility system, with the hospice medication list showing morphine concentrate 20 mg/ml, 5 mg every hour as needed for shortness of breath or pain, while the facility order listed morphine sulfate 20 mg per 5 ml with instructions that would provide a different dose. Staff acknowledged the discrepancy and that the hospice staff schedule was not available in the record.
Infection Control Failures Across Water Safety, Linen Storage, Isolation, and Medication Handling
Penalty
Summary
The facility failed to implement infection prevention and control practices across multiple areas, including water management, clean linen handling, housekeeping storage, hand hygiene, isolation precautions, and medication cart cleanliness. The report states the facility did not establish and implement a water management program with measures to prevent Legionella and other opportunistic pathogens, and did not show a way to monitor those measures. During observation, the water heater supplying the resident care area was set at 119 degrees Fahrenheit, and the IP could not show a risk assessment, a water system diagram, or specific control measures for each control area. In the laundry area, two soiled, stained towels were observed on top of a drawer in the clean linen area, and dust was observed accumulated around the top of the resident personal clothing washing machine. In another observation, housekeeping staff stored a personal water bottle and a cup of vitamins inside a housekeeping cart that also contained cleaning supplies and items used to stock resident rooms. The housekeeping supervisor stated personal drinks and belongings should not be in the cart. The facility also failed to ensure urinals for two residents were not stored hanging on trash bins in their rooms, and the DSD stated they should not have been stored there because of infection control concerns. The report also describes failures related to resident care and transmission-based precautions. A resident with four loose stools in less than 24 hours was not placed on contact isolation for suspected C. diff at the time the loose stools were documented, and the IP and LVN acknowledged the resident should have been on isolation. A family member was observed in the resident’s room without PPE despite contact isolation signage, and the family member stated no one had told her she needed PPE or handwashing precautions. A NP was observed leaving the room, using ABHR, then handling papers and going to the nurses’ station before washing hands. In another event, an LVN disconnected a resident’s enteral feeding tubing and then touched the medication cart and keys without removing gloves or performing hand hygiene. The medication cart itself had residue in the compartment storing the pill cutter and label stickers, a pill cutter with visible powder residue, a glucometer with brown-orange stains, and personal keys stored in the cart. Finally, a CNA did not report a resident’s loose stools to the nurse, and the resident’s bowel movements were not documented consistently, despite the resident later reporting multiple episodes of diarrhea and the chart showing loose/diarrhea stools.
Ice Machines Not Cleaned and Sanitized per Manufacturer Instructions
Penalty
Summary
The facility failed to maintain the cleanliness and sanitation of two ice machines, Ice Machine A and Ice Machine B. Review of facility documents showed that 161 residents in the facility consumed an oral diet. The manufacturer's guidelines for Ice Machine A required disassembly, descaling, and sanitizing every six months using Manitowoc-approved descaler and sanitizer, but the facility did not follow those instructions. During observation and interview with the Director of Maintenance, he stated he would clean and sanitize Ice Machines A and B and presented two bottles of solution: Essential Values Ice Machine Cleaner & Descaler and HydroBalance H.B. 30 Ice Machine Cleaner. He verified that he was using two cleaning solutions instead of a cleaning solution and a sanitizing solution, and stated he did not have the Manitowoc cleaner in stock and was using the HydroBalance and Essential Value brand cleaners for Ice Machine A. For Ice Machine B, the manufacturer's manual required monthly cleaning and sanitizing with proper mixing instructions, but the Director of Maintenance stated he would follow the bottle directions and said he used 6 to 7 ounces of solution per gallon of water. The bottle label for Essential Values Ice Machine Cleaner & Descaler instructed to mix 4 ounces with one gallon of water, and the Director of Maintenance verified he was not using the correct ratio for Ice Machine B.
Pest Control Program Not Effective in Dining Room
Penalty
Summary
The facility failed to ensure an effective pest management program was in place when small flies were observed in the residents’ dining room. During observation, six small flies resembling fruit flies were seen in the dining area, and the wall in the dining room had dark pinprick-sized specks of residue that resembled fruit fly excrement. The facility’s policy titled Control of Pests stated the community must have a pest control program in place and that pest control operators should conduct additional treatments if pests are observed in the community. The Director of Maintenance stated the facility used an outside pest control company for monthly service but was not aware of the flies or the dark residue on the dining room walls. Review of pest control reports dated 11/19 and 12/16/25, and 1/6 and 2/3/26, did not show treatment for flies. The DSS stated he was responsible for the dining room and kitchen areas and would report any pests, but he was not aware of the small flies or the residue in the resident dining room. A later observation showed staff cleaning the dining room walls, and the pest control vendor later stated he treated the dining room for flies and that the residue could be fruit fly excrement, though he would not confirm it.
Failure to Ensure Proper Self-Administration Assessment and Orders for Bedside Eye Drops
Penalty
Summary
The facility failed to ensure that two residents had proper assessment, physician orders, and care planning for self-administration of medications. The facility’s policy stated that a resident may only self-administer medications after the interdisciplinary team determines which medications may be safely self-administered, with the assessment documented in the medical record. It also stated that medications kept at bedside must have a physician’s order in the same manner as other medications. Resident 187 was observed in bed with two eye drop medications, artificial tears and Refresh Plus lubricant, on top of the bedside drawer. During a concurrent interview, an LVN verified the eye drops were present and stated they did not belong to the resident and she was unsure to whom they belonged. Review of the resident’s record showed the resident had capacity to make decisions, but there was no physician’s order for the eye drops, no order to self-administer the medications, and no documented self-administration assessment. The resident’s family member stated the resident used eye drops at home and self-administered them, but was not sure whether the facility had assessed her for self-administration. RN 2 and the DON verified the absence of the order, assessment, and care plan. Resident 162 was observed with an eye drop medication at the bedside and stated the eye doctor prescribed it for cataracts and that she had been administering it herself at the facility. The resident also stated staff were aware the eye drops were kept at the bedside. The resident’s record showed she had capacity to understand and make decisions and included a self-administration assessment indicating she was capable of self-administration, but the assessment did not show whether she could safely administer the eye drops stored at the bedside. The record also lacked a physician’s order for the eye drop medication. An LVN verified the medication should not have been stored unlocked at the bedside and confirmed there was no physician’s order; the DON acknowledged the findings.
Missing Advance Directive in Resident Record
Penalty
Summary
The facility failed to obtain and maintain a copy of an Advance Directive for one of six sampled residents, Resident 107, during the investigation of Advance Directives. The resident’s medical record showed a POLST dated 1/20/26 indicating the resident had capacity and that the advance directive was not available, and an Internal Medicine H&P/Progress Note dated 1/21/26 also showed the resident had the capacity to make decisions. An Advance Directive Acknowledgement form dated 1/21/26 showed the resident had executed an advance directive and signed the form. Despite the acknowledgement that an advance directive had been executed, the resident’s medical record did not contain a copy of the advance directive. The Social Service assessment did not document whether the resident had an advance directive, and the record also lacked documented evidence that facility staff followed up with the resident or the resident’s family representative. During interview, the resident stated he had an advance directive and had provided a copy to facility staff when admitted, and SSD 1 and the DON verified that the copy could not be located in the medical record.
Failure to Maintain Privacy During GT Feeding Care
Penalty
Summary
The facility failed to ensure resident privacy for one of four final sampled residents, Resident 68, during gastrostomy tube (GT) feeding administration. Facility policies titled "Promoting/Maintaining Resident Dignity" and "Flushing A Feeding Tube" stated that staff will maintain resident privacy and provide privacy by pulling the privacy curtain. Resident 68 had physician orders for Jevity 1.5 via GT at 65 ml/hr for 20 hours and for GT water flushes at 65 ml/hr for 20 hours. On 2/25/26 at 1221 hours, an RN was observed starting Resident 68's GT feeding and water flush in the resident's room. The privacy curtain was pulled between the resident and the hallway doorway, but no privacy curtain was pulled between Resident 68 and the roommate, who was sitting in a wheelchair approximately two feet away. The RN lifted the resident's gown, exposing the abdomen and incontinence brief, placed a stethoscope on the abdomen to check tube placement, aspirated gastric contents with a 60 ml syringe, and then connected the Jevity 1.5 and water flush tubing. The RN confirmed the privacy curtain had not been pulled between the resident and the roommate before the resident was exposed. During an interview on 2/27/26, the DON stated the privacy curtain should have been pulled between Resident 68 and the roommate for GT care to ensure privacy.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure three residents were free from unnecessary psychotropic medication use and related monitoring deficiencies. The report states that the facility did not ensure nonpharmacological interventions were provided for one resident when behavior episodes occurred related to quetiapine and lorazepam use. It also failed to ensure behavior monitoring was completed for another resident receiving quetiapine, and failed to ensure orthostatic blood pressure monitoring was completed and accurately documented for two residents receiving quetiapine. One resident had physician orders for lorazepam for anxiety manifested by persistent screaming and quetiapine for schizoaffective disorder manifested by sudden angry outburst. The resident’s February 2026 MAR showed multiple episodes of sudden angry outbursts and persistent screaming, but the MAR did not show whether nonpharmacological interventions were provided during those episodes. During interview and record review, RN 2 verified the behavior episodes and confirmed there was no documented evidence that the ordered nonpharmacological interventions were provided. Another resident had an order for quetiapine for psychosis manifested by disorganized thinking and an order to monitor behavior related to that condition. The record showed there was no documented evidence that the resident’s behaviors were monitored after 1/4/26. The same resident also had an order for orthostatic blood pressure monitoring every Sunday in sitting, standing, and lying positions, but the record did not show that blood pressure was monitored in those positions. The resident had fall incidents on 2/2/26, 2/20/26, and 3/2/26, and RN 2 confirmed the behavior monitoring and orthostatic blood pressure monitoring were not being completed. A third resident had orders for quetiapine and for weekly orthostatic blood pressure monitoring in lying, sitting, and standing positions. The February 2026 MAR showed blood pressure readings documented on Sundays, but the readings were not accurately obtained in all required positions on some dates. The DON reviewed the record and verified that the orthostatic hypotension monitoring for this resident was done inaccurately.
Resident Not Returned to Held Room After Hospitalization
Penalty
Summary
The facility failed to ensure that Resident 68 was returned to the same room after hospitalization, despite a physician's order for a 7-day bed-hold. Resident 68 was transferred to an acute care hospital and then returned to the facility by ambulance two days later. Medical record review showed the resident had been admitted to Room A and was readmitted to Room B, even though facility midnight census reports showed Room A was empty during the hospitalization period. During interviews, Resident 68 stated he expected and wanted to return to his original Room A but was placed in a new room instead. Family Member 2 stated she was surprised by the room change because the resident had a bed-hold and they assumed he would return to Room A. The DON verified that the resident had a physician's bed-hold order and was not readmitted to his previous room even though it was available.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide the required bed-hold notice and related transfer/discharge information for Resident 68 when the resident was transferred to an acute care hospital. The facility’s policy stated that before a resident is transferred to the hospital, written information about the duration of the bed-hold policy and any reserve bed payment must be provided to the resident or responsible party. However, the resident’s Bed Hold Notification Informed Consent form was only completed in the admission section and was blank for the transfer, bed-hold provision, and 24-hour notification sections, with no documentation showing the estimated daily rate or whether a bed hold was offered at the time of transfer. Resident 68 was transferred to the hospital and later readmitted to the facility, but the medical record did not show that a bed hold was offered and/or accepted at the time of transfer. Although there was a physician’s order for a seven-day bed hold, facility interviews showed conflicting understanding of the process, including whether consent had been obtained and whether the resident’s insurance covered the bed-hold rate. The BOM stated the resident did not have MediCal for the bed hold and was discharged, and the resident and Family Member 2 stated they were not told whether insurance would cover the bed hold or what the daily rate would be. Family Member 2 also stated they were surprised when the resident returned to a different room because they had assumed the resident would return to the original room.
PASARR Recommendations Not Incorporated Into Care Plan
Penalty
Summary
The facility failed to ensure PASARR level II recommendations were followed up and incorporated into the care of one sampled resident. Facility policy stated that recommendations from a PASARR level II determination and evaluation report would be incorporated into the resident’s assessment, care planning, and transitions of care, and that the comprehensive care plan would describe any specialized services or specialized rehabilitation services provided as a result of PASARR recommendations. Resident 3 was admitted to the facility and had an H&P documenting no capacity to understand and make decisions. A Department of Health Care Services letter stated a PASARR level II evaluation was conducted and that staff would receive the determination report, discuss the result with the resident, and incorporate the recommendations into the care plan. The PASARR Individualized Determination Report showed the resident required nursing facility services due to a medical and/or mental health condition and that special services were recommended. However, the medical record did not show the recommendations were followed up, and the care plan did not include a problem addressing the PASARR recommendations. The MDS Coordinator reviewed the record and verified there was no documented evidence that the PASARR level II recommendations were followed up, and the DON was informed and acknowledged the findings.
Care plans missing key resident needs
Penalty
Summary
The facility failed to develop care plans for two sampled residents. For one resident, the record showed tube feeding orders requiring the head of the bed to be elevated 30 to 45 degrees while feeding was infusing, but the resident was observed with the head of the bed below that range on multiple occasions. During an observation and interview, an LVN stated the resident preferred to keep the head of the bed lower, and the DON later confirmed the care plan did not address that preference. The same resident’s records also showed bilateral hearing aids and a charger were brought to the facility, the resident wore hearing aids on admission, and an activity assessment documented use of hearing aids in both ears. The care plan for impaired hearing, initiated on 1/23/26, did not mention the resident’s hearing devices. During interviews and observations, the resident stated the hearing aids had not been charged, could not hear well, and kept the hearing aids at the bedside to charge them. An LVN reviewed the records and verified the care plan failed to address use of the hearing aids. For another resident, weight records showed a drop from 156.0 lbs. to 138.0 lbs., and the IDT care conference note documented an 11.5% weight loss in one month. The RD recommended large entree portions three times daily, but the care plans did not show a plan developed for the weight loss, and there was no indication the RD recommendation had been implemented. The RD later verified that no care plan had been developed for the resident’s weight loss.
Inaccurate post-fall neuro checks and missing orthostatic blood pressures
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided according to orders and the resident’s care plan for one resident who had an unwitnessed fall. After the fall, the provider ordered neurological checks for 72 hours, and the care plan directed staff to conduct neurological checks for 72 hours and obtain blood pressure in the lying, sitting, and standing positions one time in the first 24 hours. The resident’s medical record showed the resident had the capacity to make medical decisions. Review of the neurological flowsheet showed repeated documentation of vital signs during the post-fall neurological evaluations, but the recorded values were the same as prior assessments rather than newly obtained for each check. The record showed blood pressure, pulse, respirations, and pain values being carried forward across multiple entries, with documentation times indicating the same measurements were used for later neurological checks. The record also failed to show that blood pressure was obtained in the sitting, lying, and standing positions within the first 24 hours after the fall, as directed by the care plan. During interview, the RN stated that for unwitnessed falls, residents should receive neurological evaluations per facility protocol, that new vital signs should be obtained for every neurological evaluation, and that each assessment should be compared with prior findings for changes. The RN reviewed the record and verified the findings. The DON also stated that licensed nurses should conduct the 72-hour neurological evaluations after an unwitnessed fall and that new vital signs should be obtained for every evaluation, and later acknowledged the findings.
Failure to Assist Resident With Hearing Aids
Penalty
Summary
The facility failed to ensure Resident 7 received proper assistance with hearing devices to maintain hearing abilities. Medical record review showed the resident was readmitted with left and right hearing aids and a charger brought to the facility, and assessments documented that the resident had hearing aids in both ears and used hearing aids in both ears. However, the resident had no physician's order for hearing aid use, and the facility did not charge or assist with the devices. During observation on 2/25/26, Resident 7 was in bed and stated, "I can't hear well." When asked about hearing aids, the resident said they forgot to charge them last night. After attempts to speak louder and closer, the resident still could not understand and became frustrated. On 2/27/26, the resident stated he charged his hearing aids himself the night before and kept them at his bedside with the charger. During interview and record review, LVN 1 stated residents with hearing aids should have a physician's order and initially said Resident 7 did not have hearing aids, then verified the records showed he did. LVN 1 also verified the care plan identified the resident as hard of hearing but did not address hearing aid use. The DON later stated nurses were responsible for inserting hearing aids each morning, storing them when not in use, and charging or changing batteries.
LAL Mattress Setting Not Matched to Resident Weight
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers for one of four sampled residents reviewed for pressure ulcers. Resident 9 had severely impaired cognitive skills for daily decision making, was at risk for developing pressure ulcers/injuries, and required substantial to maximal assistance for rolling from left and right in bed. The resident’s current weight was documented as 102 lbs., and the resident was observed lying in bed with a low air loss mattress in use. The low air loss mattress was observed on and set at 150 lbs. on multiple occasions, which did not match Resident 9’s current weight. The mattress manual stated the pressure adjust knob should be set using the resident’s weight as a guide. During interview and record review, LVN 8 verified the resident’s weight was 102 lbs. and confirmed the mattress setting did not match the resident’s weight. LVN 3 stated the mattress setting should be checked each shift and adjusted based on the resident’s current weight, and the DON stated licensed nurses were responsible for ensuring the mattress setting was appropriately set to the resident’s weight.
Failure to Follow Voiding Trial Order for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to follow the physician’s order for Resident 107, who had an indwelling urinary catheter for obstructive uropathy. The resident was observed with the catheter in place and draining yellow urine, and he stated he had the catheter because he was unable to urinate. The medical record showed an order dated 1/20/26 for the catheter to straight drainage and a subsequent order dated 1/21/26 for voiding trials in one week. Review of the record did not show documented evidence that the voiding trials were conducted after the 1/21/26 order. The resident’s H&P dated 1/21/26 showed he had the capacity to make decisions. During interviews, the DON stated the voiding trial results should be documented in the MAR and that licensed nurses were responsible for removing the catheter and monitoring bladder residuals with a bladder scanner. The DON also verified that the record lacked documentation of the voiding trials and that there was no documentation showing the physician was informed that the voiding trials were not conducted.
Feeding Tube Care and Administration Deficiencies
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a gastrostomy tube when an LVN administered medications through the GT without first checking for gastric residual and without giving the medications by gravity. During observation, the LVN prepared and crushed six medications, added water to the medication cups, checked GT placement, and flushed the tube with 30 ml of water, but did not check for residual before flushing. The LVN then aspirated the medication contents from the cups and pushed them through the GT rather than allowing them to flow by gravity. The LVN later stated that residual should have been checked and that medications should be given by gravity unless there was a physician order to push them, and the DON confirmed those expectations. The facility also failed to follow its tube-feeding procedures for another resident receiving continuous enteral feeding. The resident had an order for Jevity 1.5 at 65 ml/hr for 20 hours a day and an order to keep the head of the bed elevated 30-45 degrees while tube feeding was infusing. During observation, the resident’s tube feeding was running while the head of the bed was measured at 16 degrees, then later at 17 degrees and 15 degrees during additional observations. The resident stated he put the head of the bed down himself, and the LVN elevated it and reminded him to keep it elevated. The DON stated the resident’s head of bed should have been elevated 30-45 degrees and that staff should have notified the physician because the resident preferred to keep it lower. The DON also verified the medical record did not show that the facility discussed the risks of lowering the head of the bed during tube feeding. The report also notes the facility’s policies required checking residuals, flushing the tube after residual measurements, and maintaining the head of bed at least 30 degrees during feedings.
IV Therapy Not Labeled per Facility Policy
Penalty
Summary
Proper IV care was not provided for Resident 66, who was receiving IV 0.45% Sodium Chloride for hydration. During observation, the IV solution bag, IV tubing, and peripheral IV site on the resident’s right arm were noted to be in place, but none were labeled with the date, time, or staff initials. The resident’s medical record showed an order dated 2/24/26 for 0.45% Sodium Chloride IV solution at 75 mL per hour for one day, with a total volume of 1 liter. The facility’s policy titled Intravenous Therapy, dated 12/19/22, stated that IV tubing is to be labeled with the date, time, and initials, and that IV sites are changed every 72 hours unless otherwise ordered by the physician. During a concurrent interview, RN 2 verified that the sodium chloride solution bag, IV tubing, and IV site should have been labeled when the IV fluid was started for Resident 66. The DON was later informed and acknowledged the findings.
Respiratory equipment not stored or managed properly and nebulizer treatment left unattended
Penalty
Summary
Resident 187 was observed in the bedroom with the oxygen machine at the bedside and turned off, while the nasal cannula was on top of the bed and the nebulizer mask and tubing were placed on top of the bedside drawer. The resident had physician orders for oxygen therapy via nasal cannula at 2 LPM to maintain oxygen saturation to 92%, and for Ipratropium-Albuterol inhalation every four hours as needed for shortness of breath. During a concurrent interview, an LVN verified the nebulizer tubing and mask were not stored inside the clear plastic bag with label and stated they should have been placed there when not in use. Resident 49 had a CPAP machine at the bedside and stated he used it himself, putting on the mask at night and removing it in the morning. The resident stated he had been asking nurses to clean the CPAP because it needed cleaning after use, but no one was cleaning it, and he used facial wet wipes to clean the mask before bed. The resident was cognitively intact, and staff interviews showed the licensed nurses were responsible for the CPAP machine settings, turning it on and off, and cleaning the machine. Staff also acknowledged they were uncertain when it was last cleaned, there was no copy of the CPAP manual available, and the machine was not cleaned and maintained per the manufacturer's manual. Resident 54 was observed receiving a nebulizer treatment while seated in a wheelchair at the bedside, and no licensed nurse was in the room during the treatment. The resident had an order for Budesonide inhalation suspension via nebulizer twice daily for shortness of breath/cough. During interview, the LVN who administered the treatment verified he did not stay with the resident during administration and later checked on him and turned off the machine. The LVN acknowledged he needed to stay with the resident during the treatment to ensure the medication was received and to monitor the resident.
Failure to Provide Ordered PRN Pain Medication
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for one resident who required PRN pain medication. Resident 68 stated that after readmission to the facility, Tramadol had not yet been obtained from the pharmacy and that acetaminophen was being given instead, which helped only a little. The resident also stated that if Tramadol had been available when he returned, he would have wanted it administered for pain relief. Medical record review showed Resident 68 had physician orders for Tramadol 50 mg via GT every 4 hours PRN for moderate to severe pain, later changed to every 6 hours PRN for severe pain. The MAR showed the resident received Tramadol through 2/22/26, but there was no documented evidence that Tramadol was administered on 2/24/26 after readmission. The DON stated the controlled medication had been kept locked in a medication cart while the resident was in the hospital and later confirmed the Tramadol was in the facility on 2/24/26 and available to administer as needed.
Incomplete dialysis communication, missed notifications, and lack of post-procedure monitoring
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for a resident with end stage renal disease and dependence on renal dialysis. The resident was ordered to receive hemodialysis at Dialysis Center A on Tuesdays, Thursdays, and Saturdays, and the facility had a policy requiring ongoing assessment, monitoring for complications, and communication with the dialysis facility regarding dialysis care and services. The resident also had orders to monitor the hemodialysis access site in the right upper chest every shift for signs and symptoms of infection. The resident’s Hemodialysis Communication Forms contained incomplete or inaccurate documentation. Several forms documented the catheter location as the right upper chest and marked bruit and thrill as present, even though the resident’s access was a catheter and not an arm shunt. One form also did not document the post-dialysis weight. On other dates, the dialysis center documented no signs or symptoms of infection, but the catheter location was not documented. A nurse confirmed that bruit and thrill should be assessed for residents with a dialysis shunt in the arm and stated the communication forms should be complete and accurate. The facility also failed to document that Dialysis Center A was informed of the resident’s unwitnessed fall, which was treated as a change in condition and resulted in a neurological check order. In addition, the dialysis center recommended holding the resident’s hypertension medications on hemodialysis mornings, but the physician was not documented as being informed of those recommendations, and the medications were still administered on hemodialysis days. The resident later had hypotension during dialysis, with the dialysis center unable to remove more fluids. After the resident had a new hemodialysis access placed in the right arm, the record did not show that the resident was assessed or that change-in-condition monitoring was initiated after returning to the facility. The record also did not contain the surgeon’s after-care instructions for the operative site. Nursing staff confirmed that the resident should have been assessed after the procedure and that follow-up was needed when the after-care instructions could not be located.
Pharmaceutical Services Deficiencies in Drug Disposal, Controlled Substance Counts, and Medication Administration
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in several areas. In Medication Room [ROOM NUMBER], eight unopened lidocaine 4% patch packs were found intact in a white bin with a blue top labeled for incineration. RN 1 verified the patches were unopened and intact, and the DON also verified they were in the bin. The facility’s policy stated unused drugs are to be destroyed in a manner that renders them unfit for human consumption and disposed of in compliance with applicable requirements, but the patches had not been removed from the original packaging or otherwise destructed before disposal. Medication Cart A’s Controlled Substances Shift Count Log for February 2026 showed missing nurses’ initials on multiple controlled substance count entries, including the off-going nurse on 2/8/26, the oncoming nurse on 2/23/26, and the off-going nurse on 2/24/26. LVN 1 reviewed the log and verified the missing initials and signatures. The facility’s controlled substance policy stated two licensed nurses account for controlled substances and access keys at the end of the shift, and the DON verified that licensed nurses are required to count controlled drugs and initial the log at shift change. Resident 68 had an order for alprazolam 0.25 mg via GT at bedtime for anxiety, which was discontinued and then reordered after the resident returned from the hospital. The MAR showed alprazolam was scheduled for administration on 2/24/26 at 2100 hours, but the chart code indicated it was not given as scheduled. The resident stated he did not receive the medication because it was still being ordered from the pharmacy, while the DON later verified the alprazolam was in the facility and available to be administered. For Resident 200, the MAR showed docusate sodium 100 mg was to be held if the resident had loose stools, yet the resident reported loose stools and the Documentation Summary Report showed loose/diarrhea consistency stools three times during the day shift. LVN 7 administered the docusate sodium without checking the CNA documentation first and acknowledged he did not review the bowel documentation before giving the medication.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; the observed rate was 6.67%. During medication administration observations, two of five licensed nurses made errors. One LVN administered vitamin B12 100 mcg via GT to Resident 46, but a significant amount of whitish-pink medication residue remained in the medication cup after the dose was given. The LVN stated he forgot to bring a spoon to mix the medication after adding water, and later explained that crushed medications should be mixed with water to ensure the full dose is administered via the GT. A second LVN administered medications to Resident 69 via GT and gave sennosides-docusate sodium 8.6-50 mg instead of the physician-ordered sennosides 8.6 mg, two tablets via GT one time a day for bowel management. During interview and record review, the LVN verified the order called for sennosides and acknowledged administering the different medication. The DON stated medications should be administered according to physician orders and fully administered to residents, and that if residual medication is seen in the cup during GT administration, water should be added and the solution mixed to ensure the full dose is given.
Medication storage and labeling deficiencies
Penalty
Summary
The facility failed to provide proper medication storage and labeling for three residents and two medication carts. On Medication Cart A, oral medications were stored in the same cube as external medications: Lubricating Plus eye drops were stored with aspirin 81 mg, calcium carbonate, and Cepacol extra strength cough lozenges. Facility staff verified that internal and external medications should not be stored together because they are administered by different routes. On Medication Cart E, bisacodyl 10 mg suppositories were stored in the same compartment as loperamide 2 mg oral tablets and Cepacol extra strength oral lozenges. The cart also contained an opened box of ipratropium-albuterol inhalation solution for Resident 22 that was not labeled with the opened date. In addition, a bubble pack of lorazepam 0.5 mg for Resident 13 remained in the cart even though the medical record did not show an active order for the medication. Staff stated discontinued controlled medications should be removed from the cart by the end of the shift, and opened breathing treatment medications should be labeled with the opened date. During a room observation, a bottle of Refresh Tears was found on Resident 35’s overbed table, unattended, unsecured, and unlabeled. Resident 35’s record showed diagnoses of prediabetes, dementia, and lack of coordination, and the H&P stated the resident could make needs known. The MAR for February 2026 did not include Refresh eye drops as part of the resident’s medication list. Staff later verified the bottle was present in the room and stated the resident had not disclosed the medication.
Dietary Aide Not Competent in Dish Machine Sanitation
Penalty
Summary
The facility failed to ensure one of 16 kitchen staff members, Dietary Aide 2, had the appropriate skill set to safely perform automatic dishwashing. Facility policy required dishwasher water temperatures and sanitizing chemical concentrations to be measured and recorded, and manufacturer instructions required a minimum sanitizer concentration of 50 PPM. However, the dish machine log for the breakfast meal did not include entries for wash temperature, rinse temperature, or sanitizer PPM before the dishes were washed. Dietary Aide 2 was documented as competent in dish machine sanitation and proper PPM concentration, but the employee performance appraisal also noted a need for improvement in knowledge and quality of work, with concerns that the employee tends to forget procedures and shows no interest in trying or following instructions. During observation, Dietary Aide 2 loaded dirty dishes and then picked up clean dishes from the clean side of the dish machine without changing gloves or washing hands. When asked to test the sanitizing solution, Dietary Aide 2 dipped the test strip into the rinse water and stated he would tell his supervisor if the solution was not the correct PPM. The DSS confirmed the sanitizer tubing was twisted and the sanitizing solution was not reaching the dish machine, and stated the dishes would be rewashed.
Failure to Provide Ordered and Preferred Meal Items
Penalty
Summary
The facility failed to ensure that Resident 200 consistently received a fruit cup with meals. Resident 200, who had diagnoses including diabetes, high blood pressure, high cholesterol, and a seizure disorder, was observed awake in bed and stated he had not been provided fruit and that his family had brought fruit to the facility for him. During later observations, Resident 200 was seen asking staff for a fruit cup, stated he had to keep asking daily for one, and was again observed asking for a fruit cup at breakfast. The DSS and RD verified that Resident 200 was not served a fruit cup for lunch, and the DSS later verified he was not served a fruit cup for breakfast. The facility also failed to provide Resident 164 with the alternative entree when broccoli was not desired. Resident 164, who had no capacity to make medical decisions and was ordered a regular, pureed texture diet with thin liquids and a sippy cup for meals, was observed at lunch with pureed BBQ pork rib patty, pureed roasted sweet potatoes, bread or roll with butter or margarine, and pureed vanilla chocolate chip cake, but no pureed sautéed broccoli spears. The resident's lunch meal ticket showed she disliked broccoli, and the Staffing Coordinator and DSS both verified that when a resident dislikes an entree, the alternative entree should be served; the DSS confirmed Resident 164 was missing the alternative entree for the broccoli entree.
Outside Food Storage and Heating Restriction
Penalty
Summary
The facility failed to ensure perishable food brought in from outside sources for resident consumption was allowed to be stored and heated. Review of the facility policy titled Outside Food Brought in by Family or Visitors showed that prepared food brought by family or visitors had to be approved by Nursing to ensure it matched the diet order, had to be eaten within two hours of receipt, and any remaining food had to be discarded. During interview, the ADON stated the facility did not allow perishable food from outside sources to be stored, residents had to consume perishable food within two hours, and food brought from outside sources could not be heated. The report also noted that 161 residents in the facility consumed an oral diet.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three sampled residents. Review of the facility policy stated medical records must be accurate, relevant, and complete, with enough detail to provide a picture of the resident’s progress. Surveyors found that Resident 198’s skilled evaluation notes documented the resident as being on room air, while the MAR showed the resident was receiving continuous oxygen and had multiple blank entries for ordered care on a shift. During interview, nursing staff confirmed the notes were incorrect and acknowledged the MAR had gaps because documentation was not completed. For Resident 68, the MAR showed the resident received PRN Tramadol for pain on multiple occasions, but the shift pain monitoring entries often documented no pain for those same shifts. The record therefore did not show the highest level of pain for each shift as required. During interview, the DON confirmed that pain monitoring every shift should document the highest pain level for the shift and verified that the resident’s pain level was not documented correctly on the identified dates. For Resident 7, the admission assessments were inconsistent regarding hearing aid use. The clinical admission assessment and activity assessment showed the resident had and used hearing aids in both ears, but the Social Service Assessment marked hearing aid use as not applicable. When surveyed, the resident stated he could not hear well and described charging and using his hearing aids. The SSD reviewed the record and confirmed the Social Service Assessment was incorrect and should have reflected that the resident used hearing aids.
QAPI and QA Committee Review Failures
Penalty
Summary
The facility failed to implement its QAPI plan and the past Recertification Survey POC for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881. The report states that the facility did not ensure audits and observations for F578 and F803 were completed, despite the POC requiring Medical Records staff to audit completion of POLST forms and the availability of Advanced Directives in resident medical records within 72 hours of admission, and requiring the DSS, RD, or trained dietary staff to conduct kitchen rounds five days a week for three months and weekly tray line audits for three months. On 3/4/26 at 1310 hours, the Administrator reviewed the facility’s QA and QAPI program binders with surveyors. The facility’s records did not show that the required audits and observations for F578 and F803 were completed, and the QA and QAPI binders did not show that the audit and observation findings for F554, F578, F583, F693, F755, F761, F803, F812, F880, and F881 were presented to the QA Committee for review and continued monitoring. The Administrator verified these findings.
Failure to Monitor Antibiotic Use and Infection Screening
Penalty
Summary
The facility failed to monitor and address antibiotic use for three residents reviewed for antibiotic stewardship. The facility's Antibiotic Stewardship policy stated that nursing should assess residents suspected of infection and complete an SBAR before notifying the physician, use CDC NHSN surveillance definitions, updated McGeer's criteria, or another surveillance tool to define infection, and review antibiotic orders obtained on admission or readmission for appropriateness. However, the medical record for one resident showed an order for azithromycin for an upper respiratory infection, and the record did not show that an infection screening evaluation was completed to determine whether the symptoms met criteria for a true infection. A second resident had an order for Macrobid for a urinary tract infection, but the medical record did not show that an infection screening evaluation was completed. A third resident was prescribed levofloxacin after admission/readmission, and the infection screening evaluation documented an active diagnosis of infection, tachycardia, a temperature above 100 degrees Fahrenheit, and a pulse oximetry reading below 94% on room air, but it did not document whether the symptoms met McGeer's criteria for a true infection. The record also did not show that the physician was notified when the symptoms did not meet McGeer's criteria and the antibiotic was prescribed. The IP stated the infection screening evaluation should be completed for all residents receiving antibiotics and that the physician should be notified if criteria for a true infection were not met; the DON was informed and acknowledged the findings.
Failure to Document Vaccine Offerings and Specific Pneumococcal Consent
Penalty
Summary
The facility failed to offer and provide education for the influenza and pneumococcal immunizations for two of six sampled residents. Resident 66 was admitted to the facility and had an H&P showing the resident had the capacity to understand. Review of the resident’s CAIR report did not show whether the seasonal influenza vaccine or pneumococcal vaccine had been received, and the medical record did not contain documented evidence that the resident was offered either vaccine. Resident 195 was admitted to the facility and had an H&P showing the resident had the capacity to understand and make decisions. The resident signed a pneumococcal vaccine consent form and consented to receive the vaccine, and the form stated the resident had been educated on the risks, benefits, and potential side effects. However, the section identifying the kind of pneumococcal vaccine to be given was left blank. The immunization report later showed the resident received Pneumovax 21, and the IP confirmed the consent form did not indicate the type of pneumococcal vaccine the resident received.
Failure to Assess or Offer Seasonal COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure residents were assessed for seasonal COVID-19 vaccination status or offered the COVID-19 vaccine for one of six sampled residents, Resident 66. The facility's policy stated it was to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 by educating and offering residents and staff the COVID-19 vaccine. Resident 66 was admitted to the facility and had an H&P examination dated 9/5/25 showing the resident had the capacity to understand. A CAIR report showed Resident 66 had received two doses of the COVID-19 vaccine in 2021 and that the earliest recommended date for the seasonal COVID-19 vaccine was 8/22/25. However, the medical record did not contain documented evidence that Resident 66 was assessed for or offered the seasonal COVID-19 vaccination. During interview and concurrent record review, the IP verified she could not find documentation showing the resident was offered or assessed for the seasonal COVID-19 vaccine, and the DON was informed and acknowledged the findings.
Call Light Systems Not Working or Within Reach
Penalty
Summary
The facility failed to ensure that resident call systems were working properly and that call buttons were within residents’ reach for three sampled residents. The report states that these failures created a risk for delay in staff response when residents summoned assistance. The deficiency involved Resident 196, Resident 199, and Resident 201, each of whom had difficulty accessing or using the call system when they needed help. Resident 196 stated she had waited over 15 minutes over the weekend for staff to respond after pressing her call button for pain medication. When she was asked to demonstrate the call light, she pressed the button, but the light outside her room did not illuminate and was not audible. The same issue was confirmed at the nurses’ station panel, and the Director of Maintenance verified that Station A’s call light system did not have audio and that the facility was waiting for a company to work on the audible portion. Resident 196’s medical record showed diagnoses including post status multiple bone fractures, osteoporosis, chronic back pain, diabetes, and generalized weakness. Resident 201 was observed sitting in a wheelchair and asked for the call light button to be provided. Her call light cord was on the upper right side rail and not within reach, and a silver bell on the overbed table was also out of reach. She stated she had been waiting for staff to help her get off the wheelchair and could not bend at the waist because of back pain. LVN 2 later verified that the call light was not working and that the bell was not within reach. Resident 201’s diagnoses included recurrent falls, diabetes, chronic low back pain, and generalized weakness. Resident 199 was observed in bed asking for help raising the head of the bed, but he could not reach his call light and did not know where it was. His call light was dangling down the left side of the bed with the button positioned near the bottom, making it not easily accessible. OTA 1 verified the placement, and CNA 9 stated that Resident 199 would use his call light. Resident 199’s diagnoses included polyneuropathy due to diabetes, degenerative spine disease with progressive weakness, and bilateral hand numbness.
Inadequate CNA Training on Bowel Movement Documentation
Penalty
Summary
The facility failed to ensure CNA 6 knew when to report and how to correctly document a resident’s bowel movements in the electronic health record. Resident 200, who was admitted with diagnoses including diabetes and a seizure disorder, told staff he had four loose stools on 3/2/26 and described the stool as running through him like sift. CNA 6 stated she was told in report that the resident had two loose stools and that she was to monitor his bowel movements, but the bowel movement documentation in the record showed multiple entries on 3/3/26 describing the resident as incontinent with loose/diarrhea consistency. During interviews, CNA 6 stated she changed the resident’s diaper several times and described the stool as like baby food texture, not watery or loose but not formed. She said she did not report the bowel movements to the nurse because it was not really like diarrhea and she did not know how to document it. LVN 7 verified the documentation findings and stated the information had not been reported to him. The DSD stated ADL care and charting were covered in CNA in-services, but bowel movement descriptors were not shown during those in-services, and the facility’s lesson plan on ADL care and documentation emphasized accurate and detailed bowel movements without showing how to document them in the facility’s EHR system.
MDS assessments were coded inaccurately for oxygen use and hearing aids
Penalty
Summary
An accurate MDS assessment was not completed for Resident 198 because the assessment did not code that the resident received oxygen therapy during the seven-day look-back period. The resident’s MAR for February 2026 showed continuous oxygen administration from 2/8/26 through 2/14/26, but the MDS dated [DATE] failed to reflect oxygen use. During interview and record review on 3/3/26, the MDS Coordinator stated staff should check the MAR or nurses’ progress notes when completing the oxygen section, and verified that the resident had received oxygen and that the MDS was coded incorrectly. An accurate MDS assessment was also not completed for Resident 200 because the admission MDS did not code the resident’s use of hearing aids. The resident was observed awake in bed with bilateral hearing aids in place and stated he was hard of hearing in both ears. The resident’s admission MDS showed moderate difficulty hearing but indicated no hearing aids. The record also showed the resident’s hearing aids were brought to the facility on 2/20/26, and the MDS Coordinator verified she completed the hearing assessment, coded the resident as moderately difficult to hear with no hearing aids, and did not conduct further observations after the hearing aids were brought in.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure the Facility Assessment was complete. Review of the assessment dated [DATE] showed that it did not include input from residents, resident representatives, or family members. It also did not include the facility's retention plan for events that did not require activation of the emergency plan, and it did not specify which contracts the facility had obtained to use for emergency resources. In addition, the Facility Assessment did not show the resources needed to care for residents during nights and weekends if regular staff were not available. On 2/27/26 at 1300 hours, the Administrator was interviewed during a concurrent review of facility documents and reviewed the Facility Assessment, verifying the findings.
Failure to Use Non-Pharmacological Interventions and Obtain Informed Consent Before PRN Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not implementing or documenting required non-pharmacological interventions and not obtaining informed consent prior to administering certain medications. Facility policies on psychotropic medication use required that non-pharmacological interventions be attempted unless clinically contraindicated and that residents or their representatives be informed in advance of risks, benefits, and alternatives, with documentation of this informed consent. The facility’s pain management policy similarly required development, implementation, monitoring, and revision of interventions to manage pain, including a range of non-pharmacological measures. For one resident, the physician ordered Ativan 0.5 mg by mouth every six hours as needed for anxiety manifested by inability to relax, along with behavior monitoring that specified non-pharmacological interventions such as relaxation, adjusting room temperature/lighting, repositioning, toileting, music/television, and snacks, with outcomes to be documented every shift. The MAR for March showed Ativan was administered on multiple occasions, but the behavior monitoring documentation for the relevant dates and shifts listed the non-pharmacological interventions and outcomes as "NA," indicating they were not documented as attempted. The same resident had an order for Cymbalta 40 mg at bedtime for pain management, which was administered on two occasions in March. Review of the medical record showed no documented evidence that informed consent for Cymbalta was obtained prior to its administration, either via a written consent form or a narrative note. For another resident, the H&P documented that the resident had no capacity to make medical decisions. A physician’s order directed Tramadol 50 mg by mouth every six hours as needed for moderate pain. The orders did not include any directive for non-pharmacological interventions to be attempted prior to administering Tramadol. The MAR showed Tramadol was administered twice, and there was no documentation that non-pharmacological interventions were performed before giving the medication. During interviews, an RN confirmed that non-pharmacological interventions should be used for as-needed medications and acknowledged that there were no such interventions documented for this resident, and also verified the lack of behavior monitoring interventions for the first resident. The Administrator and DON were informed of and acknowledged these findings.
Failure to Safeguard Confidential Resident Care Log in Public Hallway
Penalty
Summary
The deficiency involves the facility’s failure to safeguard a resident’s confidential medical information in accordance with its policy on confidentiality of personal and medical records. The facility’s policy dated 12/2022 defined keeping information confidential as safeguarding written and other stored information from unauthorized disclosure without the consent of the individual or representative. Resident 4, who had been admitted on an unspecified date and whose H&P dated 7/19/25 documented no capacity to make medical decisions, had a Resident Care Log binder containing personal health information. On 1/9/26 at 1538, this binder was observed tucked on the railings outside the resident’s room in a hallway leading to the facility’s main entrance, rather than being secured. From 1538 to 1557 on the same day, multiple staff and visitors were observed repeatedly walking past the binder without acknowledging or securing it, including CNAs and groups of visitors exiting near the front entrance. During an interview and concurrent observation at 1609, an LVN acknowledged the binder in the hallway and stated the resident’s family liked to have it there. When the binder was opened, it contained the resident’s name, room number, and care notes. The LVN acknowledged that people walked up and down the hallway near the front exit. In a subsequent interview at 1634, the DON verified that the Resident Care Log binder was not supposed to be in the hallway, stated it should be in the resident’s room, and acknowledged that the binder contained the resident’s name, confirming that the medical record was not properly safeguarded from unauthorized access.
Failure to Timely Reassess Resident’s Occipital Area Obscured by Matted Hair
Penalty
Summary
The facility failed to complete a timely and thorough assessment of a newly admitted resident’s occipital (back of head) area when it was initially unable to be visualized due to matted hair. Facility policy titled “admission of a Resident” required a licensed nursing assessment and development of a plan of care upon admission. The resident was admitted and a nurse’s progress note, entered late and dated 3/12/24, documented that the resident’s hair was matted to the occipital area and the scalp could not be visualized. Despite this, there was no documented reassessment of the occipital area until 3/27/24, 16 days later, when a family member worked through the matted hair and observed dry blood on the scalp. In an interview, an LVN stated that at admission staff could only see the matted hair, that the family member wanted to work through the matted hair, and that the scalp was only seen once the hair was worked through, confirming the delay in reassessment and complete assessment of the resident’s occipital area. The Administrator and DON were later informed of and acknowledged these findings, and the surveyor concluded that the failure to reassess the occipital area in a timely manner had the potential to negatively impact the resident.
Improper Low Air Loss Mattress Setting for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident with existing pressure ulcers. Facility policy on Pressure Injury Prevention and Management, revised 9/2023, required evidence-based interventions for residents at risk or with pressure injuries, including use of appropriate pressure-redistributing devices and support surfaces. The Apex Domus 4 low air loss mattress manual specified that mattress pressure settings should be adjusted according to the resident’s weight and height to avoid bottoming out. The resident’s medical record showed orders for a low air loss mattress for wound management with placement and settings to be checked every shift, as well as detailed wound care orders for unstageable pressure ulcers on both elbows and a stage 4 pressure ulcer on the mid lower back. During an observation and concurrent record review, the resident was found on a low air loss mattress set at 450 psi, while the resident’s current weight was documented as 162 pounds. The LVN present confirmed that the mattress setting was incorrect for the resident’s weight and stated that the setting had been at that level “for a while.” The facility’s Administrator and DON were later informed of and acknowledged these findings. The failure to ensure the low air loss mattress was properly set in accordance with the resident’s weight constituted noncompliance with the facility’s own pressure injury prevention policy and the physician’s order to check mattress placement and settings every shift.
Failure to Follow PRN Laxative Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services in accordance with physician orders and its own medication administration policy for one resident. The facility’s policy dated 12/2022 required that medications be administered by licensed nurses or other legally authorized staff as ordered by the physician and in accordance with professional standards of practice. For this resident, the physician’s order dated 3/11/24 specified that Dulcolax 10 mg rectal suppository was to be administered every 24 hours as needed for constipation only if Milk of Magnesia (MOM) was ineffective. Review of the resident’s March 2024 MAR showed that Dulcolax was administered on 3/16/24, but there was no documentation that MOM had been given prior to the suppository as required by the order. In an interview, RN 1 confirmed that Dulcolax was administered on that date and that MOM had not been administered beforehand, acknowledging that the resident should have received MOM first or that a one-time order for Dulcolax should have been obtained. The Administrator and DON were later informed of and acknowledged these findings.
Incomplete Neurological and Wound Care Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with its documentation policy. The facility’s policy titled “Documentation in Medical Record” (revised 12/2022) required licensed staff and interdisciplinary team members to document all assessments, observations, and services provided, ensuring documentation was accurate, relevant, and complete. For one resident who had an actual fall with no injury and poor balance, the care plan dated 3/20/24 included an intervention to complete neuro-checks. Review of this resident’s Neurological Flowsheet showed missing entries under the every-eight-hours section for items numbered 17 and 18. During an interview and concurrent closed medical record review with the DON and ADON, the DON verified that the neurological assessments should have been completed and documented. Further review of the same resident’s Order Summary Report showed physician orders dated 3/12/24 for treatment of a right above-eyebrow laceration with betadine daily for 21 days, and for daily monitoring of a deep purplish discoloration on the left side of the body for 30 days. Examination of the Treatment Administration Record (TAR) for 3/24/24 revealed no entries documenting the eyebrow laceration treatment or the monitoring of the purplish discoloration on that date. In a subsequent interview and concurrent record review with an LVN, the LVN acknowledged the lack of entries on the TAR for that day and stated she would need to investigate further, as she was unsure if she had been out of the facility that day. The Administrator and DON were later informed of and acknowledged these findings.
Failure to Monitor and Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for one resident who experienced a change in condition characterized by aggressive behavior. The resident, who had the capacity to make medical decisions, was observed barricading himself in his room, yelling, and posing a danger to himself and others. The licensed nurse administered IM Ativan as ordered and indicated that the resident would be monitored closely for safety. However, there was no documented evidence that the resident's change in condition was monitored every shift for 72 hours as required by facility policy. Progress notes and the eINTERACT Change of Condition Report confirmed the aggressive episode, but subsequent monitoring was not documented in the medical record. Additionally, the resident's care plan, which previously addressed a mood problem, was not revised to include new interventions or monitoring related to the recent episode of physical aggression. Review of the care plan and interviews with nursing staff confirmed that the care plan was not updated to reflect the resident's change in condition. The facility's policy required care plan revisions upon a status change, but this was not followed in this instance. The Administrator and DON acknowledged these findings during the survey.
Failure to Provide and Document Pharmaceutical Services for Antianxiety Medication
Penalty
Summary
The facility failed to provide pharmaceutical services as required for one resident with a history of generalized anxiety disorder. Specifically, the resident had a physician's order for clonazepam, an antianxiety medication, to be administered at bedtime. Review of the medication administration record (MAR) showed that the medication was not available and not administered from 6/22 to 6/28, with the MAR marked as absent or left blank for those dates. There was no documented evidence that the physician, pharmacy, or the resident's responsible party were notified about the unavailability of the medication, despite a nurse stating that such notifications were made but not documented in the medical record. Additionally, the facility failed to maintain required narcotic count sheets for the resident's clonazepam for May and June, as these records were missing from the medical record. Interviews with staff revealed that a new supply of the medication was not reordered as needed, and the DON confirmed the absence of the narcotic count sheets and was unaware of the medication's unavailability. These failures were identified through observation, interviews, and review of facility policies and records.
Failure to Promptly Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to provide timely notification of abnormal laboratory results to a resident's physician, as required by facility policy. Specifically, a resident was admitted with the capacity to make medical decisions and had physician orders for stat CBC, BMP, and urinalysis with culture and sensitivity, as well as IV hydration. The laboratory results for these tests, including a significantly elevated WBC, abnormal urinalysis findings, and a high BUN, were received and reported by the laboratory, but there was no documented evidence that these abnormal results were promptly communicated to the resident's physician. Interviews with nursing staff, including an LVN and an RN, confirmed that the abnormal laboratory results were not promptly reported to the physician and that there was no documentation of such notification in the resident's medical record. The facility's policies required prompt notification of out-of-range laboratory results to the ordering provider, but this was not followed in the case of this resident. The DON acknowledged these findings during the investigation.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of significant changes in the resident's condition, as required by facility policy. Specifically, the resident experienced poor oral intake, refused meals and fluids, exhibited increased weakness, was sleepy, and showed increased confusion on 8/3/25. Despite these changes, there was no documented evidence in the closed medical record that the resident's family member or representative was informed of these developments. The facility's policy mandates prompt notification of the resident, physician, and representative in such situations, especially when the resident may not be able to communicate these changes personally. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's representative was not notified following the change in condition. The LVN acknowledged that both the physician and family member should have been informed after the change was identified. The deficiency was identified through interviews, closed medical record review, and review of the facility's policies and procedures.
Failure to Timely Complete Stat Laboratory Orders
Penalty
Summary
The facility failed to ensure that stat laboratory tests ordered for one resident were performed in a timely manner as required by physician orders and facility policy. Specifically, a stat order for CBC, BMP, and urinalysis with culture and sensitivity was placed by the physician, but documentation showed delays in the collection of these samples. The CBC and BMP were collected the following day at 1145 hours, and the urinalysis was collected at 0500 hours, rather than immediately as required for stat orders. There was no evidence in the medical record that the laboratory was contacted promptly to perform the stat tests. Interviews with nursing staff confirmed that the licensed nurse did not collect the urine sample or contact the laboratory right away, and there was no documentation of follow-up or shift-to-shift endorsement regarding the stat laboratory orders. The Director of Nursing acknowledged these findings. The resident involved had the capacity to make medical decisions and was admitted and discharged within the review period. Facility policies required timely provision of laboratory services and proper urine sample collection, but these were not followed in this instance.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not include all necessary interventions or clearly defined goals and timelines for meeting the resident's needs.
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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