Tulare Healthcare & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulare, California.
- Location
- 680 East Merritt Avenue, Tulare, California 93274
- CMS Provider Number
- 055649
- Inspections on file
- 40
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Tulare Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident’s Release for Responsibility for Leave of Absence (RFRFLOA) form was left incomplete when the resident went out for an appointment. The form contained only the date and time out, with no nurse initials, no expected return time, and no documentation of the actual return time or nurse initials upon return. Multiple staff members, including a CNA, RN, LVNs, the Social Services Director, and the receptionist, stated that licensed nurses are responsible for completing the RFRFLOA with transport and when the resident leaves and returns, as required by the facility’s “Out on Pass” policy.
A dessert item on the written winter menu was changed from apple crisp to apple cake without required RD review and approval. A resident’s lunch tray was observed with cake instead of the planned dessert, and the substitution list documented the change due to the original item being out of stock but lacked RD initials. The CDM acknowledged making the substitution without notifying the RD, and the RD confirmed she had not been informed, contrary to facility P&P requiring dietitian review of all menu substitutions.
A resident with a fractured leg and chronic pain was left in bed while maintenance installed side rails using a power drill, causing the bed to shake and resulting in severe pain despite the resident's request to be moved. The procedure continued for about 15 minutes, and the DON later stated that maintenance should have stopped if pain was reported.
A resident with a left tibia fracture missed a scheduled orthopedic follow-up appointment because the facility did not arrange transportation as required. Documentation showed the need for the appointment and transportation, but the resident was not picked up, and the Social Service Designee confirmed that no alternative arrangements were made.
A resident with dementia and a history of elopement was found outside the facility without a required wander guard, despite care plan interventions and facility protocols mandating its use and monitoring. Staff observed the missing device but did not replace it, leading to the resident leaving unsupervised.
A resident reported that a CNA was rough during a wheelchair transfer, causing pain. Although the incident was documented and reported to the DON, the required SOC 341 abuse report was not sent to the Ombudsman as per facility policy, as confirmed by review of fax records and staff interviews.
A facility's generator failed during a planned power outage, leaving 13 residents who required oxygen concentrators without power for approximately 15 minutes. The generator malfunctioned due to a faulty oil pressure sensor, which was not detected during annual maintenance. This failure put residents at risk of respiratory distress.
The facility failed to follow infection control policies, including maintaining cleanliness in the laundry room, proper storage of cleaning tools, and adherence to PPE protocols. Nursing staff did not remove N95 masks after leaving precaution rooms, and some staff entered isolation rooms without full PPE. Hand hygiene was neglected, with CNAs wearing long false nails and not sanitizing hands between resident rooms. The facility also mixed clean and dirty items in utility areas and did not conduct required water testing for Legionella.
The facility failed to schedule regular resident council meetings, denying residents their right to organize and participate in such groups. The last meeting was recorded in July, and interviews revealed that one resident had only met once, while two others were unaware of the council's existence. The facility's policy required monthly meetings, but the administrator confirmed the last available notes were from July.
A resident's leg became red and swollen due to the facility's failure to follow physician orders to wrap the leg daily. Additionally, two residents did not receive required weekly nursing assessments, and three residents lacked assessments for self-administering medications, as observed by the DON and an LVN.
The facility did not complete activity assessments for five residents within the required timeframe, as per their policy. Additionally, an activity care plan was not developed for one resident, despite the policy requiring it after the initial assessment and MDS completion. These oversights meant the facility was unaware of the residents' activity preferences.
The facility did not complete Social Service Assessments (SSA) within the required seven days for three residents, potentially affecting their psychosocial needs. One resident's SSA was started late, while two others had their assessments completed six and nine days overdue, respectively. This was contrary to the facility's policy mandating timely completion of SSAs.
The facility failed to serve meals at safe and palatable temperatures for two residents, who reported consistently cold breakfasts. Observations showed uncovered meal carts and inadequate temperature checks, with food served below required temperatures. This non-compliance with facility policy potentially impacted residents' nutritional needs.
A Dietary Aide in the facility's kitchen failed to wash his hands after changing a sanitizer solution and before handling food, contrary to the facility's infection control policy. The aide acknowledged the oversight, which was observed during an interview. The policy requires hand washing during food preparation to remove contamination when changing tasks.
The facility failed to ensure that call lights were within reach for four residents, potentially preventing them from calling for assistance and delaying care. Observations showed call lights on the floor or behind beds, contrary to the facility's policy requiring them to be accessible. Staff confirmed the call lights should have been within reach.
A resident requested more information on advance directives, as noted in their AHCD. Despite the facility's policy requiring the Social Services Director or Designee to provide such information, the request was not fulfilled. The resident, who was cognitively intact, did not receive the requested information, resulting in a deficiency.
A former DON disclosed a resident's medical diagnosis to the resident's roommate, violating the facility's PHI policy. The incident was confirmed through interviews and a review of the resident's medical record, despite the DON having completed HIPAA education.
A resident with a Stage 3 pressure ulcer did not receive necessary preventative interventions as per the facility's policy. Despite recommendations for a Low Air Loss Mattress, the resident was observed on a regular mattress, and the Plan of Care lacked specific measures to prevent wound worsening. This led to a surgical procedure to remove non-living tissue, indicating a lapse in protocol adherence.
A PTA failed to use a facility-provided gait belt while assisting a resident with ambulation, instead holding onto the resident's pants waistband. The resident's care plan indicated a risk for falls due to balance issues, and the facility's policies required the use of gait belts for safety. The PTA used a personal, fraying gait belt, contrary to facility procedures.
A resident with chronic pain did not receive prescribed pain medications and non-pharmacological interventions as ordered, resulting in unmanaged pain and refusal to eat. The facility failed to administer Tylenol between scheduled Norco doses and did not consistently apply non-pharmacological interventions, despite the resident's high pain levels.
A resident did not receive their prescribed Brinzolamide for glaucoma due to the facility's failure to reorder the medication in a timely manner. The medication was unavailable for administration at scheduled times, as confirmed by an LVN and documented in the resident's records. The facility's policy required medications to be reordered three to four days in advance, which was not followed.
The facility failed to follow its medication storage policy, resulting in medications being found at residents' bedsides, improper storage of Aplisol, and mixing of topical and oral medications in carts. LVNs confirmed these practices were against policy, risking unauthorized access and cross-contamination.
A resident's need for a follow-up dental appointment was overlooked, resulting in her not wearing her loose lower denture. The resident's dental notes indicated that her dentures were 5-6 years old, and no follow-up appointment had been scheduled since her last dental visit. The MDSC confirmed the lack of follow-up dental notes and acknowledged the necessity for a denture realignment appointment.
The facility failed to honor meal preferences for two residents, leading to potential nutritional issues. One resident did not receive the requested juice, and another was served cheese despite a documented dislike. The Dietary Manager confirmed these discrepancies against the Meal Tray Tickets.
The facility failed to obtain a therapeutic diet order for a resident with no teeth and no dentures, who expressed difficulty eating due to their condition. The resident's care plan noted oral health problems and recommended consulting a dietitian if chewing issues were observed. However, the Registered Dietician did not recognize any chewing issues, maintaining a regular texture diet order. This oversight did not align with the facility's policy to ensure diets meet nutritional guidelines and physician orders.
The facility failed to maintain accurate medical records for two residents. One resident's MDS assessment inaccurately reported dental status, and their OSR included a discontinued medication order. Another resident's hospital transfer lacked a physician order, and their H&P and Discharge Summary were inaccessible. These issues contradict the facility's policy on accurate documentation.
The facility did not complete previous employment and personal reference checks for two RNs before hiring them. This was confirmed during a review of their employment records and an interview with the Administrator, who acknowledged the oversight. The facility's policy requires screening potential employees for any history of abuse, neglect, or mistreatment, which was not followed in these cases.
A resident who eloped from the facility was not monitored every 30 minutes as required. The resident was found outside and returned, but subsequent monitoring was inconsistent, with checks ranging from one to three times a day. The DON confirmed the monitoring did not meet the facility's policy for preventing further elopement.
A resident was discharged with another resident's medications due to a failure in the facility's medication verification process. The RN did not perform the required checks, leading to the potential risk of the resident taking incorrect medications. The error was identified when the medications were returned by the resident's family.
A resident with dementia and anxiety was disrespected by a CNA during a dinner service. The resident, known for swinging his arms, nearly hit the CNA, who responded by blocking his arm and telling him he "hits like a girl." The CNA admitted to raising her voice, which violated the facility's policy on treating residents with respect and dignity.
A resident experienced a significant change in condition requiring hospitalization, but the facility failed to notify the physician. The resident's responsible party confirmed the transfer to an acute hospital, and a review of the medical record showed no documentation of physician notification. The facility's administrator and DON acknowledged the lack of documentation, despite the facility's policy requiring such notification.
A resident was transferred to an acute hospital without an assessment or documentation of a significant change in condition by the nurse on duty. The facility's policy requires such documentation, but it was not followed, leading to a deficiency in meeting professional standards of quality.
A resident did not receive wound care as ordered, with missing documentation in the TAR for multiple dates. The resident had a Stage 2 pressure ulcer and abdominal wounds requiring specific treatments. Interviews with an LVN and the DON confirmed the absence of documentation, indicating treatments were not administered. Facility policy requires immediate documentation of treatments.
A resident under respite care fell while attempting to stand from her wheelchair, resulting in a black eye and a cut to the lip. The LVN notified the hospice agency but failed to inform the resident's responsible party, contrary to the facility's policy requiring notification of any change in condition, including falls.
Incomplete Leave-of-Absence Documentation for Resident Out on Pass
Penalty
Summary
The facility failed to follow its policy and procedure for documenting a Release for Responsibility for Leave of Absence (RFRFLOA) for one sampled resident. Review of the resident’s RFRFLOA form dated 4/10/26 showed that only the date and time out (10:00 a.m.) were recorded, while the nurse’s initials at time out, the expected date/time of return, the actual date/time of return, and the nurse’s initials at return were all left blank. The facility’s policy titled “Out on Pass” dated 2/2/26 required a licensed nurse to document the time the resident left the facility, the name of the accompanying responsible person, the destination, a contact phone number if possible, and the expected time of return, and to reassess the resident and account for medications upon return. Multiple staff interviews confirmed that it was the responsibility of the licensed nurse to complete the RFRFLOA when a resident left and returned to the facility. A CNA, an RN, two LVNs, the Social Services Director, and the Receptionist each stated that nurses were responsible for completing the RFRFLOA with the transport driver or when the resident left and returned. During a concurrent interview and record review, the Receptionist confirmed that the resident went to an appointment at 10:00 a.m. on 4/10/26 and that the RFRFLOA was not completed by the nurse at departure or upon return, despite the policy requirements.
Unapproved Menu Substitution Without RD Notification
Penalty
Summary
The facility failed to follow its menu and substitution policy when a planned dessert item was changed without required approval from the Registered Dietician (RD). On the winter menu for a specific lunch date, the written menu indicated that chicken jambalaya, seasoned zucchini with parsley garnish, garlic bread, apple crisp, and milk were to be served. During observation of a resident’s lunch tray in the hallway, the tray instead contained macaroni and cheese, zucchini, and a large piece of cake. Review of the facility’s substitution list for that date showed that apple crisp had been replaced with apple cake due to the apple crisp being out of stock, and the section for RD initials was left blank. In an interview, the Certified Dietary Manager (CDM) stated that apple cake was substituted for apple crisp because not all ingredients for the apple crisp were available and acknowledged that the RD should have been called to approve the substitution but was not. In a separate interview, the RD confirmed she had not been made aware of the substitution and stated she should have been notified prior to the change. Review of the facility’s “Menus” policy and procedure indicated that foods served should adhere to the written menu and that any substitutions must be reviewed by both the dietary manager and the dietitian for appropriateness per the diet order and recorded on the substitution list. The failure to obtain RD review and approval for the dessert substitution was identified as having the potential to place residents at risk of inadequate nutrition.
Failure to Accommodate Resident Needs During Bed Rail Installation
Penalty
Summary
A deficiency occurred when a resident with a left tibia fracture and chronic pain syndrome was left lying in bed while maintenance staff installed metal side rails using a power drill. Despite the resident's request to be removed from bed and placed in a wheelchair due to pain, maintenance continued drilling for approximately 15 minutes, causing the bed to shake and resulting in severe pain for the resident. The resident reported crying and experiencing significant discomfort during the incident. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a full support brace on the affected leg. The maintenance staff stated that the installation was ordered by the DON and confirmed that the procedure was performed while the resident remained in bed. The DON acknowledged that maintenance should have stopped if the resident complained of pain. Facility policy states that residents have freedom of choice regarding their care, but this was not accommodated during the event.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident with a left tibia fracture to attend a scheduled follow-up appointment with an orthopedic doctor. The resident's admission record and order summary indicated the need for a follow-up appointment and transportation arrangements. Progress notes documented the scheduled appointment, but the resident was not picked up by transportation and missed the appointment. During an interview and record review, the Social Service Designee confirmed that transportation was not arranged and acknowledged that the facility should have notified transportation and attempted to find an alternative provider. The facility's policy stated that the Social Service Department could coordinate transportation to outside services as necessary.
Failure to Implement Elopement Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with a known history of elopement attempts. The resident, who had dementia and a moderate cognitive impairment as indicated by a BIMS score of 9, was identified as being at risk for wandering and elopement. The care plan required that a wander guard be placed on the resident every shift and that its placement and function be monitored. However, on the day of the incident, staff observed the resident without a wander guard, and multiple staff interviews confirmed that the device was not replaced when missing, despite facility protocol requiring immediate replacement. The resident was last seen in the facility hallway and was later found unsupervised outside the facility, approximately 0.2 miles away. Staff interviews revealed that the LVN noticed the missing wander guard but did not replace it, believing it was not her responsibility. The DON confirmed that the resident was not wearing the required wander guard when found outside. Facility policies required comprehensive assessment and implementation of resident-centered care plans to mitigate safety risks, but these were not followed in this instance, resulting in the resident eloping from the facility.
Failure to Report Alleged Abuse to Proper Authorities
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely reporting of an allegation of abuse. Specifically, a resident reported to the DON that a male CNA was rough on purpose during a wheelchair transfer, which caused the resident pain. Progress notes documented the resident's statement, and the DON confirmed the report was made. However, during a review of records and interviews, it was determined that the required SOC 341 form, which is used to report suspected abuse, was not sent to the Ombudsman as mandated by facility policy. The fax transmittal record showed the form was not sent to the correct fax number for the Ombudsman, and the Administrator confirmed the omission. The facility's policy required that the SOC 341 be sent to the Ombudsman, Law Enforcement, and CDPH Licensing Certification within two hours of the allegation.
Generator Failure During Power Outage
Penalty
Summary
The facility failed to provide a working generator for 13 residents who required oxygen concentrators during a planned power outage. The generator, which was supposed to supply power during the outage, malfunctioned due to a faulty oil pressure sensor. This malfunction was not detected during the annual maintenance of the generator, leading to a power loss for approximately 15 minutes. During this time, the residents who depended on oxygen concentrators were at risk of being without oxygen, potentially leading to respiratory distress. The issue was identified during an interview with the Administrator, who confirmed the generator's failure during the planned outage. The Maintenance Environmental Services staff also confirmed the generator's malfunction and attributed it to the oil pressure sensor failure. The Director of Nurses acknowledged that all 13 residents required oxygen concentrators, highlighting the critical nature of the generator's failure. The facility's policy on emergency generator testing, dated 9/2017, indicated that generators should be maintained in an operational state, but this was not adhered to, resulting in the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures across multiple areas, leading to potential risks of spreading infectious diseases. In the laundry room, the Environmental Services Director (ESD) and housekeepers observed unclean conditions, including dusty debris, cobwebs, and personal items in the clean area, which violated the facility's policy for maintaining a clean and sanitary environment. Additionally, a used toilet brush was improperly stored on a clean housekeeping cart, contrary to the facility's housekeeping policy. Nursing staff also failed to follow personal protective equipment (PPE) protocols. Two staff members, an LVN and a CNA, did not remove their N95 masks before leaving a transmission-based precaution room, as required by the facility's PPE policy. Furthermore, a speech therapist and a housekeeper entered a droplet precaution isolation room without wearing the full required PPE, despite clear signage indicating the necessity for gowns, gloves, and face shields. Hand hygiene practices were not consistently followed, with CNAs providing resident care while wearing long false nails and failing to perform hand hygiene before entering and after exiting residents' rooms. The facility also did not maintain separate clean and dirty utility areas, as required by CDC guidelines, leading to the mixing of clean and dirty items. Additionally, the facility did not conduct water testing for Legionella, as mandated by CMS guidelines, which could lead to the growth and spread of the bacteria in the water system.
Failure to Schedule Regular Resident Council Meetings
Penalty
Summary
The facility failed to arrange regularly scheduled resident council meetings for three sampled residents, resulting in the denial of their right to organize and participate in resident/family groups. The last recorded resident council meeting was held on July 29, 2024, as indicated by the Resident Council Minutes. Interviews conducted on October 22, 2024, revealed that one resident stated they had only met once, while two other residents were not aware of the existence of a resident council. The facility's policy and procedure, dated November 1, 2013, stated that resident council meetings should be scheduled monthly or more frequently if requested. However, the administrator confirmed that the last meeting notes available were from July 29, 2024.
Failure to Follow Physician Orders and Conduct Assessments
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in the resident's left leg becoming red and swollen. The resident, who was alert and oriented, reported that her leg should have been wrapped daily as per physician orders, but staff had not done so for several days. A family member confirmed that the leg had not been wrapped since the resident's admission to the facility. A Licensed Vocational Nurse (LVN) acknowledged the physician's order to wrap the leg daily and confirmed that the leg was not wrapped during observations. The facility administrator admitted that there was no policy in place for following physician orders. Additionally, the facility did not complete weekly nursing assessments for two residents, which are crucial for monitoring changes and progress in resident status. The Director of Nursing (DON) and an LVN confirmed that these assessments were not conducted as required. Furthermore, the facility failed to follow its policy on medication self-administration for three residents, as assessments to determine their capability to self-administer medications were not completed. This oversight was observed through the presence of eye drops in residents' rooms without proper assessments documented in their medical records.
Failure to Complete Activity Assessments and Care Plans
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Activity Program' by not completing activity assessments for five sampled residents. Specifically, the Minimum Data Set Coordinator (MDSC) confirmed that activity assessments were missing for residents admitted or readmitted on various dates, including Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41. The facility's policy required that these assessments be completed within seven days of admission, but this was not done for any of the mentioned residents. The absence of these assessments meant the facility was not aware of the residents' activity preferences. Additionally, the facility did not complete an activity care plan for Resident 438, as required by their policy. The policy stipulated that after the initial activity assessment and the Minimum Data Set (MDS) are completed, an individualized care plan should be developed and implemented for each resident. However, the MDSC confirmed that no care plan was in place for Resident 438, indicating a failure to follow through with the necessary steps to ensure the resident's activity needs were met.
Failure to Timely Complete Social Service Assessments
Penalty
Summary
The facility failed to complete Social Service Assessments (SSA) within seven days of admission for three residents, potentially impacting their psychosocial needs. Resident 337 was admitted on an unspecified date, but their SSA was not started until 10/21/24. Resident 388 was admitted on 10/8/24, and their SSA was completed on 10/21/24, six days overdue. Resident 438 was admitted on 10/12/24, and their SSA was completed on 10/21/24, also late. The facility's policy requires SSAs to be completed within seven days of admission, which was not adhered to in these cases.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and palatable temperature for two residents. Resident 41 reported that their breakfast was cold and bland, while Resident 42 stated that breakfast was consistently cold, particularly the sausage and eggs. Both residents were cognitively intact, with BIMS scores of 13 and 15, respectively. Observations revealed that meal carts in the B-wing hallway were not covered, and it took approximately 10 minutes to distribute meal trays, contributing to the food cooling down. A CNA confirmed that residents had complained about cold food and that the open food cart contributed to the issue. The facility's policy required meat and eggs to be served at temperatures above 140 degrees, with instructions to reheat if temperatures were not met. In another instance, a dietary aide failed to take the temperature of bread pudding before serving it on a lunch tray. The dietary manager confirmed that all food should have its temperature checked before serving. A random lunch tray was tested, revealing that the pork was at 117.8 degrees, carrots at 121.1 degrees, and rice at 134.9 degrees, all below the required serving temperatures. The facility's policy indicated that meat entrees and other hot foods should be served at temperatures higher than 140 degrees, with a preferred range of 160 to 175 degrees. The failure to adhere to these temperature guidelines resulted in meals being served at unsafe and unappetizing temperatures, potentially affecting residents' nutritional intake.
Failure to Follow Hand Hygiene Protocol in Dietary Department
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dietary Department-Infection Control' when a Dietary Aide (DA) did not wash his contaminated hands before returning to food service. During an observation and interview, the DA was seen changing the red bucket sanitizer solution and placing the bucket back on the counter. Immediately after, the DA resumed handling food without performing hand hygiene. The DA acknowledged that he should have washed his hands before returning to handle food. The facility's policy indicated that proper hand washing should occur during food preparation as often as necessary to remove soil and contamination when changing tasks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for four residents were within their reach, which could potentially prevent them from calling for assistance and delay care provision. During observations and interviews, it was noted that Resident 337's call light was found on the floor on the right side of her bed, making it inaccessible. Certified Nursing Assistant (CNA) 6 confirmed that the call light should have been within the resident's reach. Similarly, Resident 70's call light was observed on top of the bed frame behind the head of the bed, out of reach, as confirmed by the Director of Nursing (DON), who stated that the call light should be clipped to the sheet. Further observations revealed that Resident 10's call light was hanging on the wall behind the bed, and CNA 7 acknowledged that it should have been within reach. Additionally, Resident 41's call light was found on the floor, out of reach, as confirmed by Licensed Vocational Nurse (LVN) 1. The facility's policy and procedure on the communication-call system, dated 10/09/24, clearly indicated that the call alert device should be placed within the resident's reach. This failure to adhere to the policy resulted in the deficiency noted in the report.
Failure to Provide Requested Information on Advance Directives
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives, resulting in a deficiency. A resident, identified as Resident 41, requested more information on advance directives, as indicated in their Advance Health Care Directive (AHCD) dated June 7, 2024. However, during an interview and record review with the Administrator on October 24, 2024, it was found that no information was provided by social services, and there were no progress notes documenting the provision of additional information. The facility's policy, dated July 31, 2024, states that if a resident requests more information on advance directives, the Social Services Director or Designee should provide a copy of the Advance Directive form for review. Despite this policy, the resident's request was not fulfilled, leading to the identified deficiency. Resident 41 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 on May 31, 2024, and 14 on September 12, 2024, indicating their capability to make informed decisions.
Breach of Resident's PHI by Former DON
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information (PHI) as per their policy and procedure titled 'Disclosure of PHI'. This breach occurred when the former Director of Nursing (FDON) disclosed one of Resident 61's medical diagnoses to Resident 61's roommate, Resident 15. The incident came to light when Resident 61's family member was questioned by Resident 15 about the medical condition, which Resident 15 had learned from the FDON. The FDON had previously completed the facility's Health Information Portability and Accountability Act (HIPAA) education, which emphasizes the importance of protecting PHI. The facility's policy, dated December 1, 2012, aims to limit the access, use, and disclosure of PHI to the minimum necessary to accomplish the intended purpose. Despite this, the FDON, who was employed at the facility from October 16, 2023, to July 12, 2024, disclosed sensitive health information without authorization. This disclosure was confirmed through interviews with Resident 15, the Administrator, and the Payroll Clerk, as well as a review of Resident 61's medical record, which included the diagnosis in question.
Failure to Implement Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to adhere to its policies and procedures for pressure injury prevention for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with a pressure injury to the sacrum, did not receive the necessary preventative interventions as outlined in the facility's policy. Despite the presence of a Stage 3 pressure wound for over 19 days, the resident was observed lying on a regular mattress instead of a Low Air Loss Mattress, which was recommended to off-load pressure and prevent further skin breakdown. Interviews with staff confirmed that the resident was not provided with the appropriate pressure-relieving mattress. The resident's Plan of Care did not include specific measures to prevent the worsening of the pressure wound, despite the resident being at moderate risk for skin breakdown according to the Braden scale. The facility's policy on pressure injury prevention included the use of pressure redistributing devices and positioning aids, but these were not implemented for the resident. This oversight resulted in the need for a surgical excisional procedure to remove non-living tissue from the resident's pressure wound, highlighting a significant lapse in the facility's adherence to its own protocols for pressure injury prevention.
Failure to Use Gait Belt During Resident Ambulation
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the use of gait belts during resident ambulation, as observed with Resident 438. A Physical Therapy Assistant (PTA) was seen assisting Resident 438 to walk by holding onto the resident's pants waistband instead of using a facility-provided gait belt. The gait belt on Resident 438 was noted to be fraying, indicating wear and tear. The PTA admitted to not using a gait belt, despite acknowledging its role in reducing falls and maintaining resident safety. The PTA used his own gait belt, which was not in optimal condition, rather than a facility-provided one. Resident 438's care plan highlighted a tendency to lose balance during transfers and ambulation due to decreased motor planning, safety awareness, increased loss of balance, leg weakness, and pain, placing the resident at risk for falls. The care plan included interventions such as gait training and safety measures. The facility's policies, dated 9/16 and 1/1/12, emphasized the use of gait belts to assist clinical staff in moving residents safely and to prevent falls, specifying the use of an underhand grasp for greater safety. The Director of Rehabilitation Services confirmed that holding residents by their pants during ambulation was not appropriate.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to adhere to physician orders for pain management for a resident, resulting in unmanaged pain and refusal to eat. The resident, who experienced chronic pain in the knees, feet, and back, reported a pain level of 8 out of 10. Despite having physician orders for Norco and Tylenol to manage pain, the resident did not receive Tylenol as needed between scheduled doses of Norco. An LVN was unable to administer pain medication during a lunch break due to not having access to the narcotic drawer, further contributing to the resident's unmanaged pain. Additionally, the facility did not implement non-pharmacological interventions as ordered for the resident. The resident's Medication Administration Record indicated that non-pharmacological interventions were not consistently applied on several occasions when the resident reported pain. The resident's plan of care emphasized the need for timely pain relief and evaluation of pain interventions, but these measures were not followed, leading to the resident experiencing significant pain and refusing meals.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to reorder medication in a timely manner for one of the residents, identified as Resident 28, which resulted in the resident not receiving his physician-ordered medication. Resident 28 was prescribed Brinzolamide Ophthalmic Suspension 1% to be instilled as one drop in both eyes three times a day for glaucoma. On the date of the survey, it was observed and confirmed through an interview with LVN 6 that the 12 p.m. dose of Brinzolamide was not available for administration. A review of Resident 28's Medication Administration Record indicated that the doses scheduled for 12 p.m. and 5 p.m. were missed. Additionally, the facility's progress notes documented that the eye medication was missed earlier that day. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply, which was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication Storage in the Facility' for three residents when medications were found at their bedsides. During observations, single-use vials of eye drops were found on the bedside tables of three residents. A Licensed Vocational Nurse (LVN) confirmed that medications should not be at the bedside as it allows unauthorized access. The facility's policy indicates that medications should be stored safely and securely, accessible only to authorized personnel. Additionally, the facility did not follow the manufacturer's instructions for storing Aplisol, a tuberculosis testing medication, which was found in a medication cart instead of being refrigerated as required. This could lead to a loss of potency and inaccurate test results. Furthermore, the facility's policy was not followed when topical and oral medications were stored together in medication carts, risking cross-contamination. LVNs acknowledged that medications should be stored separately, as per the facility's policy.
Failure to Schedule Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure that a resident received a follow-up dental appointment, which was necessary for the adjustment of her dentures. During an observation and interview, the resident indicated that her lower denture was loose, leading her to not wear it. A review of the resident's dental notes revealed that her dentures were 5-6 years old, and there was no record of a follow-up appointment with the dentist since her last visit several months prior. The Minimum Data Set Coordinator confirmed the absence of follow-up dental notes and acknowledged that a follow-up appointment should have been scheduled for denture realignment.
Failure to Honor Meal Preferences for Residents
Penalty
Summary
The facility failed to honor meal preferences for two residents, which could potentially impact their nutritional needs. In the first instance, a Certified Nursing Assistant (CNA) delivered a lunch tray to a resident that was missing the requested juice. The Meal Tray Ticket (MTT) for this resident indicated that 4 ounces of juice should have been included, but it was not present. The resident confirmed that he did not receive the juice he had requested. In the second instance, another resident was served a meal that included cheese, despite her documented dislike for it. The resident expressed dissatisfaction with being served cheese quesadillas, which she did not like. The Dietary Manager confirmed that the MTT for this resident indicated a dislike for cheese, and acknowledged that the resident should not have been served cheese. The facility's policy requires that meals be consistent with residents' preferences, and if a preferred item is unavailable, a substitute should be provided.
Failure to Obtain Therapeutic Diet Order for Edentulous Resident
Penalty
Summary
The facility failed to obtain a therapeutic diet order for Resident 388, who was observed to have no teeth and no dentures. During an observation and interview, Resident 388 expressed difficulty eating an uncut zucchini due to their edentulous condition. The resident's care plan, dated 10/14/24, indicated a nutritional problem with interventions including a No Added Salt diet and regular texture. However, the care plan dated 10/22/24 noted oral/dental health problems related to being edentulous, with an intervention to consult with a dietitian if chewing or swallowing problems were noted. Despite this, the Registered Dietician stated that Resident 388's diet order was regular texture and did not acknowledge any chewing issues, even though the resident had no teeth. The facility's policy on therapeutic diets, dated 6/1/14, aims to ensure diets meet nutritional guidelines and physician orders, which was not adhered to in this case.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, which could potentially impact their care. For one resident, the Minimum Data Set (MDS) assessment inaccurately indicated that the resident had no natural teeth, despite being edentulous. Additionally, the Order Summary Report (OSR) incorrectly included a physician order to monitor for adverse reactions to Zoloft, an antidepressant medication that had been discontinued earlier in the month. The Minimum Data Set Coordinator (MDSC) confirmed these inaccuracies during a review. For another resident, the Director of Nursing (DON) was unable to locate a physician order for a hospital transfer that occurred the previous year. Furthermore, the facility could not obtain the resident's History and Physical (H&P) or Discharge Summary from the hospital due to issues accessing the hospital's electronic health record system. The facility's policy and procedure on medical record completion and correction emphasize the need for complete and accurate documentation, which was not adhered to in these instances.
Failure to Conduct Employment and Reference Checks for RNs
Penalty
Summary
The facility failed to ensure that previous employment and personal reference checks were completed for two registered nurses (RN 1 and RN 2) before they were hired. This oversight was identified during a review of the Employee Information Sheets and Previous/Current Employment Verification forms for both RNs, which showed that these checks were not conducted prior to their hire dates. During an interview and record review with the Administrator, it was confirmed that the necessary checks were not performed, despite the facility's policy requiring screening of potential employees for any history of abuse, neglect, or mistreatment of residents. The policy mandates obtaining information from previous or current employers and checking with appropriate boards and registries.
Inadequate Monitoring After Resident Elopement
Penalty
Summary
The facility failed to adequately monitor a resident who had previously eloped from the facility, as required by their policy. The resident was found outside the facility on Prosperity Ave in Tulare, CA, in their wheelchair, and was redirected back by a staff member. Despite the recommendation for monitoring every 30 minutes, the resident was only checked once on the day of the incident and inconsistently monitored in the following days, with checks ranging from one to three times a day. The Director of Nursing acknowledged that the documentation showed insufficient monitoring, which did not align with the facility's policy for preventing further elopement.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was sent home with another resident's prescribed medications. During an interview, the resident expressed concern about the potential risk of taking the wrong medication. The incident occurred when a Licensed Vocational Nurse handed the resident a bag filled with medications without verifying that they were the correct prescriptions. The Registered Nurse admitted to not performing the necessary double or triple checks to confirm the medications were intended for the discharged resident. The Director of Nurses confirmed that the resident was mistakenly sent home with another resident's medications, which were later returned by the resident's family. The facility's policy and procedure for the discharge and transfer of residents, dated February 2018, requires a triple check of all prescribed medications before they are given to a resident upon discharge. This policy was not followed, leading to the potential for the resident to take incorrect medications.
Violation of Resident's Rights Due to Disrespectful Treatment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, resulting in a violation of the resident's rights. The incident involved a resident with unspecified dementia and anxiety, who was admitted to the facility with cognitive impairments that made communication challenging. During a dinner service, the resident exhibited a behavior of swinging his arms at staff, which was a known behavior pattern. A Certified Nursing Assistant (CNA) was assisting the resident when he began to hit the table and nearly struck her arm. In response, the CNA blocked the resident's arm and verbally admonished him by saying, "We don't hit," and further remarked that he "hits like a girl," which she later acknowledged was disrespectful. The CNA admitted to raising her voice during the incident, which was confirmed by the facility's administrator. The administrator stated that the CNA should not have raised her voice and should have sought assistance instead. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this situation. The incident was documented in a Facility Reported Event, and the CNA's actions were found to be in violation of the resident's rights to a dignified existence and respectful treatment.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident, which required hospitalization. During an interview, the resident's responsible party stated that the resident was transferred to an acute hospital. A review of the resident's medical record showed no documented evidence that the physician was notified of this significant change in condition and subsequent transfer. The facility's administrator confirmed the lack of documentation and was unaware of the specific change in condition that necessitated the transfer. The Director of Nurses stated that it was the facility's practice to notify the physician of significant changes in a resident's condition, as outlined in the facility's policy and procedure for alert charting documentation.
Failure to Document Change in Condition
Penalty
Summary
The facility failed to assess and document a significant change in condition for one of the sampled residents, leading to a deficiency in meeting professional standards of quality. The incident involved a resident who was transferred to an acute hospital without an assessment being completed by the nurse on duty. The resident's Responsible Party reported the transfer, and upon review, there was no documented evidence of an assessment or a completed Change of Condition form in the resident's medical records. Interviews with the facility's Administrator and Director of Nurses (DON) confirmed that the nurse on duty did not perform the required assessment or documentation. The facility's policy, titled 'Alert Charting Documentation,' mandates that licensed nurses must note and document any change in a resident's medical condition. However, this procedure was not followed, resulting in a lack of awareness about the specific change in condition that necessitated the resident's transfer to the hospital.
Failure to Document and Administer Wound Care
Penalty
Summary
The facility failed to provide wound care for a resident according to the physician's orders, as evidenced by missing documentation in the Treatment Administration Record (TAR). The resident had multiple wounds requiring specific treatments, including a Stage 2 pressure ulcer on the coccyx, surgical sutures and scarring on the abdomen, and a dehisced surgical wound on the abdomen. The prescribed treatments involved cleansing with wound cleanser, applying topical ointments, and covering with dressings as needed. However, the TAR lacked signatures on several dates, indicating that the treatments were not documented as completed. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the absence of documentation for the specified dates, which suggested that the treatments were not administered. The facility's policy and procedure for medication administration emphasized the importance of documenting the time and dose of treatments in the patient's medication record. The LVN acknowledged that the facility's practice was to document treatments immediately after completion, and the DON confirmed that the treatments were not provided on the specified dates.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party of a resident after a fall incident, which resulted in the resident sustaining a black eye and a cut to the left lower lip. The incident occurred when the resident, who was under respite care, attempted to stand from her wheelchair in the front lobby and fell. The Licensed Vocational Nurse (LVN) on duty notified the hospice agency but did not inform the resident's responsible party, despite the facility's policy requiring notification of any change in condition, including falls. The resident's medical records indicated that her son was the responsible party and had given consent for treatment. The facility's Fall Management Program policy, dated March 13, 2021, mandates that the licensed nurse notify both the resident's attending physician and responsible party of all incidents.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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