Woodcrest Post Acute & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverside, California.
- Location
- 8133 Magnolia Avenue, Riverside, California 92504
- CMS Provider Number
- 055474
- Inspections on file
- 46
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Woodcrest Post Acute & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of lower extremity fracture and osteomyelitis, who had become non‑weight bearing and only able to perform minimal side stepping with moderate assistance, was discharged home when insurance benefits were exhausted. The care plan called for discharge home with family, and case management informed a family member of the discharge date and that 24/7 care would be needed, but did not clearly communicate the resident’s current ADL and ambulation limitations or document any caregiver training or assessment of the family’s ability to provide required care. Staff interviews confirmed that the resident was not ambulating, required assistance for transfers, and that the family was not prepared for the level of care needed, contrary to facility policy requiring evaluation of caregiver availability, capacity, and capability in the post‑discharge plan.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with multiple complex medical conditions was discharged without a complete post-discharge plan of care, missing critical information such as responsible party contacts, wound care instructions, and follow-up appointment details. Gaps in communication and documentation by the case manager and nursing staff led the resident's family to seek emergency care within 24 hours of discharge.
A deceased resident's body was left in a shared room for 12 hours, causing trauma to two other residents. Despite the death being pronounced in the morning, the body was not removed until the evening, leading to distress and negative psychosocial outcomes for the roommates. Staff interviews revealed a lack of communication and adherence to protocol, and the facility's policies on dignity and resident rights were not followed.
The facility failed to respond promptly to call lights for three residents, resulting in unmet needs. A resident with osteoarthritis reported no response to her call light for restroom assistance. Another resident with a fracture waited over 10 minutes for help, expressing frustration over previous delays. A third resident with cognitive impairment had his call light on for over 15 minutes, needing to be changed. Staff interviews confirmed the policy for prompt responses, but observations showed staff ignoring activated call lights.
The facility failed to ensure accurate PASARR screenings for two residents, leading to deficiencies. One resident was admitted with dementia, schizophrenia, and major depressive disorder, but the screening inaccurately reported no serious mental disorders. Another resident with psychosis and major depressive disorder also had an inaccurate screening. The facility relied on hospitals for accurate screenings and did not verify them upon admission, leading to potential care issues.
A facility failed to notify the state-designated authority after a resident was diagnosed with schizophrenia. The resident, admitted with psychosis and major depressive disorder, received the new diagnosis from a psychiatrist. Staff interviews revealed confusion about the PASARR process, with Social Services and an RN unsure if a new Level I screening was needed for the diagnosis, leading to the oversight.
The facility exceeded the acceptable medication error rate of 5%, with errors affecting two residents. One resident received the wrong iron supplement, while another received incorrect constipation medication. The DON and Administrator expected adherence to physician orders and a medication error rate below 5%.
The facility failed to administer medications on time for three residents, with medications being given beyond the allowed time frame. Residents reported having to seek out nurses for their medications, and records showed multiple instances of late administration without documented reasons. The facility's policy on medication timing was not consistently followed.
A facility failed to provide sufficient nursing staff, leading to inadequate care for residents. Staff reported being consistently short-staffed, with CNAs managing an unmanageable number of residents. A resident expressed dissatisfaction due to delays in personal care and lack of showers. The facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD), resulting in increased workloads and inadequate care.
The facility did not update or post daily staffing information, including actual hours worked by nursing staff, as required. The document 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was not updated with necessary details for multiple dates. The Interim Director of Staff Development was responsible for these calculations but lacked access to payroll data, leading to non-compliance with the facility's policy.
A resident with a history of stroke and aphasia was found unable to reach her call light, as it was placed on her roommate's TV mount. This was confirmed by a CNA, LVN, and the DON, all of whom stated that the call light should be within the resident's reach. The facility's policy also required call lights to be accessible, but it was not followed in this case.
A facility failed to notify a resident's responsible party (RP) when the resident was transferred to a hospital due to chest pain. Despite the facility's policy requiring notification of the RP during a change of condition (COC), there was no documentation of such notification. The resident had a history of supraventricular tachycardia and hypertension and could not make medical decisions independently. Interviews with staff confirmed the oversight, and the Director of Nursing acknowledged the failure to follow protocol.
A facility failed to communicate a physician's order for physical therapy to a hospice provider for a resident under hospice care, resulting in the resident not receiving the prescribed therapy. The resident, with conditions including supraventricular tachycardia and rheumatoid arthritis, was under hospice care, and the order was not communicated as required by facility policy.
A resident with a full code status was found unresponsive, without a pulse, and not breathing. Despite the resident's condition, LVN 2 and RN 2 did not initiate CPR, citing the resident's body as cold and stiff. Interviews with other staff and the DON confirmed that CPR should have been performed according to the facility's policy and the resident's full code status.
A resident missed multiple doses of prescribed medications, including apixaban and amiodarone, with no documentation or reason provided. Interviews with the DSD and DON confirmed the lack of documentation and administration, contrary to the facility's policy.
A resident fell and broke his hip after the facility failed to repair a loose toilet seat that was reported to staff. The issue was not recorded in the maintenance log or addressed, leading to the resident's fall and subsequent surgery.
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for a resident and her family member. The resident, with a history of multiple medical conditions, expressed a desire to go home, but her family member was not adequately prepared for her discharge. There was no documented evidence of discharge preparations between the issuance of the discharge notice and the planned discharge date, leading to inadequate preparation and orientation.
The facility failed to notify the family member designated as the Power of Attorney (POA) for a resident about a change in the resident's condition. Despite the POA being effective immediately, the Treatment Nurse only informed the resident and the physician, neglecting to notify the POA. This oversight prevented the POA from fulfilling their duties effectively.
Failure to Inform Family of Functional Status and Provide Adequate Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary discharge planning in accordance with its own policy for a resident discharged home after treatment for a right lower leg fracture and left ankle/foot osteomyelitis. The resident had been mostly independent with ADLs and used a rollator for longer distances prior to hospitalization, but during the facility stay he was non‑weight bearing on the left lower extremity, had weakness in the right lower extremity, and was only able to perform a few feet of side stepping with a front‑wheeled walker and moderate assistance. The care plan identified a goal to discharge the resident back to the community with his wife and for the facility to discuss the discharge plan with the resident and family as appropriate. Case management documentation showed that the case manager informed a family member that the resident’s insurance benefits would be exhausted and that he would discharge home, and that the family would assist with care at home. Subsequent documentation noted that during an insurance meeting, the team, including the physician and rehab director, was aware the resident would exhaust benefits and discharge home with 24‑hour family care. However, there was no documentation that the family member was informed of the resident’s current functional limitations, including his limited ambulation status, or that caregiver training was offered or provided, or that the family’s capacity to perform the required care was assessed, as required by the facility’s discharge policy. Interviews further confirmed these gaps. The resident reported he was discharged due to exhaustion of insurance benefits and that he and his wife were now bedridden, with family providing care. A CNA stated she never saw the resident walk and that he required assistance to get into the car at discharge. The case manager acknowledged she did not discuss the resident’s limited ambulation status with the family and could not recall if caregiver training was offered. The family member stated she was told only that the resident would need 24/7 care, did not know he could not walk, was not offered caregiver training, and required assistance from another family member and paramedics to manage the resident at home. The facility’s policy required evaluation of caregiver availability, capacity, and capability to perform required care as part of the individualized post‑discharge plan, which was not documented or demonstrated in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Provide Complete Post-Discharge Plan of Care
Penalty
Summary
The facility failed to ensure that a resident received a comprehensive post-discharge plan of care containing all necessary information for the continuation of care after discharge. The resident, who had a complex medical history including a left above-the-knee amputation, COPD, and cirrhosis with ascites, was discharged without complete documentation regarding responsible party contact information, activity levels, equipment and supplies, home health agency details, wound care instructions, ombudsman information, follow-up appointments, and pharmacy information. The discharge summary also lacked documentation of discharge diagnosis and prognosis. Interviews with facility staff revealed that while the case manager and social service staff attempted to coordinate discharge planning, there were gaps in communication and follow-through. The case manager did not make follow-up appointments as ordered, nor did she discuss the possibility of applying for additional services through Medi-Cal. The home health agency and insurance care coordinator were notified of the resident's needs, but no appointments were scheduled prior to discharge. The resident's family was left without clear instructions, leading them to contact the facility for advice when the resident experienced swelling in his leg after discharge. As a result of the incomplete discharge planning and lack of necessary information, the resident's family sent him to the emergency room within 24 hours of discharge. Facility policy and job descriptions indicated that nursing services and case management were responsible for preparing and communicating the post-discharge plan, but these requirements were not met in this instance, resulting in a breakdown in the continuity of care.
Failure to Remove Deceased Resident Promptly
Penalty
Summary
The facility failed to treat residents with respect and dignity when a deceased resident's body was left in the room with two other residents for approximately 12 hours. This incident involved Residents A and B, who shared a room with Resident C, who passed away early in the morning. Despite the death being pronounced at 8:57 a.m., Resident C's body was not removed until 7:30 p.m. that evening. During this time, Residents A and B experienced negative psychosocial outcomes, including trauma and distress, as they were forced to remain in the room with the deceased. Interviews with Resident B revealed that the presence of the deceased body was traumatic and disrespectful, as staff entered the room without acknowledging the living residents. Resident B's family requested that meals be served elsewhere due to the smell, but this was not accommodated. Resident A also expressed anger and distress over the situation, stating that the staff did not offer a room change. Medical records and social service notes confirmed the residents' distress and the offer of psychological support and room changes after the incident. Staff interviews indicated a lack of communication and adherence to protocol. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) acknowledged the inappropriate delay in removing the body and the failure to offer room changes to the living residents. The Director of Nursing (DON) admitted that the situation was not handled efficiently and that staff expectations were not met. The facility's policies on dignity and resident self-determination were not followed, as staff failed to promote a dignified environment and respect the residents' rights.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights within a reasonable time for three residents, leading to unmet needs. Resident 5, who has osteoarthritis, muscle wasting, and a history of falling, reported to her family that she activated her call light for restroom assistance, but no one responded. Resident 6, with a fracture, hypertension, and difficulty walking, was observed with an activated call light for over 10 minutes without response. He expressed frustration over waiting more than an hour for assistance earlier in the day. Resident 7, with metabolic encephalopathy, osteoarthritis, and moderate cognitive impairment, had his call light on for over 15 minutes without response, needing to be changed. Staff interviews revealed that the facility's policy is to answer call lights promptly, and all staff are responsible for responding, regardless of resident assignment. However, observations showed staff walking past activated call lights without checking on residents. The Director of Nursing confirmed the expectation for timely responses and that call lights should be within residents' reach. The facility's policy, dated March 2021, emphasizes the importance of timely responses to residents' requests and needs.
Inaccurate PASARR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I preadmission screening and resident review (PASARR) for two residents, leading to deficiencies in the screening process. Resident #3 was admitted with a medical history of dementia, schizophrenia, and major depressive disorder, yet the PASARR Level I screening inaccurately indicated that the resident did not have any serious diagnosed mental disorders. Interviews with facility staff, including Social Services, a Registered Nurse, the Director of Nursing, and the Administrator, confirmed the inaccuracy of the screening. Similarly, Resident #59 was admitted with diagnoses of psychosis and major depressive disorder. The PASARR Level I screening for this resident also inaccurately reported no serious diagnosed mental disorders. Interviews revealed that the facility relied on the hospital to complete the screenings accurately and did not review them for accuracy upon admission. The Director of Nursing and the Administrator acknowledged the inaccuracies in the screenings and the potential for misleading the facility about the residents' needs. The deficiency arose from the facility's reliance on hospitals to conduct accurate PASARR screenings without verifying the information upon admission. This oversight led to inaccurate screenings for both residents, potentially affecting the care and services they required. The facility's policy required all new admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but the lack of verification contributed to the deficiency.
Failure to Notify State Authority of New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to notify the appropriate state-designated authority after a resident was diagnosed with a new mental illness, specifically schizophrenia. The resident, who was admitted on December 15, 2023, had a medical history that included psychosis and major depressive disorder, both diagnosed on the day of admission. On December 29, 2023, the resident received a new diagnosis of schizophrenia from a psychiatrist. Despite this new diagnosis, there was no evidence in the resident's medical record that a referral was made to the state-designated authority as required by the preadmission screening and resident review (PASARR) requirements. Interviews with facility staff revealed a lack of clarity and responsibility regarding the PASARR process. Social Services (SS) #7 indicated that Level I screenings were typically completed at the hospital before admission and that a new screening would only be necessary if there was a change in the resident's condition. SS #7 believed that the resident's mental status had not changed, and therefore, a new Level I screening was not required. Registered Nurse (RN) #8 also expressed uncertainty, stating that a new Level I screening would be completed for a new order of psychotropic medication, but not necessarily for a new diagnosis. This confusion and lack of action led to the failure to notify the appropriate authority about the resident's new diagnosis of schizophrenia.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by two medication errors out of 33 opportunities, resulting in a 6.06% error rate. This affected two residents during medication administration. Resident #10, who was admitted with a diagnosis of unspecified anemia, was prescribed ferrous fumarate 324 mg to be taken three times a day. However, during an observation, LVN #6 administered ferrous sulfate 325 mg instead of the prescribed medication. Resident #39, admitted with diagnoses including adult failure to thrive and unspecified dementia, was prescribed Senna-S for chronic constipation. The order specified two tablets of Senna-S to be given twice daily. During medication administration, LVN #6 gave one Geri-kot 8.6 mg tablet and one docusate sodium 100 mg capsule instead of the prescribed combination. Interviews with the DON and the Administrator revealed expectations for nurses to administer medications as per physician orders and maintain a medication error rate below 5%.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure medications were administered on time as prescribed by the physician and according to the facility's policy for three residents. During an unannounced visit, it was observed that medications due at 9:00 a.m. were still being administered by an LVN at 11:42 a.m., well beyond the two-hour window allowed by the facility's policy. Interviews with the LVNs revealed inconsistencies in understanding the time frame for medication administration, with some stating a two-hour window and others a one-hour window. Resident 1, who was alert and conversant, reported having to look for the nurse when it was time for his pain medication. A review of Resident 1's medication administration record showed multiple instances of late administration, including critical medications such as Imatinib and Aspirin. Similarly, Resident 2, who also had the capacity to understand and make decisions, received medications like Metformin and Hydralazine late, with no documentation explaining the delays. Resident 3, who had been discharged, also experienced late medication administration, including Aspirin and Atenolol, with no documented reasons for the delays. The facility's policy required documentation for early, late, or omitted medications, but this was not adhered to. The Director of Nursing acknowledged the difficulty in predicting outcomes from late medication administration, depending on the medication type and frequency.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as observed during an unannounced visit on July 23, 2024. Interviews with staff, including CNAs and LVNs, revealed ongoing staffing issues, with reports of being consistently short-staffed across all shifts. CNAs reported being assigned an unmanageable number of residents, with one CNA stating they had 26-27 residents to care for. This shortage was corroborated by the staffing coordinator, who noted that the facility did not meet the required Direct Care Service Hours per Patient Day (DHPPD) on several occasions, leading to increased workloads and inadequate care. Resident 4, who was interviewed during the visit, expressed dissatisfaction with the care received due to staffing shortages. The resident reported that staff were often too busy to respond promptly to call buttons and that there were significant delays in receiving personal care, such as being changed or showered. The resident had not received a shower since May 28, 2024, despite preferring showers over bed baths. A review of the resident's medical records confirmed the lack of showers and no documented evidence of refusal or preference for bed baths. The facility's staffing coordinator and Director of Nursing acknowledged the staffing deficiencies, noting that the required DHPPD was not consistently met, and CNAs were often overburdened with too many residents. The facility's policy, which mandates sufficient staffing to meet residents' needs, was not adhered to, resulting in inadequate care and potential resident dissatisfaction. The facility was actively recruiting more staff and asking current staff to work additional hours to address the staffing shortfall.
Failure to Update and Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that updated staffing information, including the total number and actual hours worked by licensed and unlicensed nursing staff, was posted in a prominent place readily available to residents and visitors. During an observation, it was noted that the document titled 'Census and Direct Care Service Hours Per Patient Day (DHPPD)' was posted in the facility lobby but was not updated with the necessary information. The forms lacked details such as the actual total direct care service hours, actual total CNA direct care service hours, the average patient census, the actual DHPPD, and the actual CNA DHPPD for multiple dates. Interviews with the Staffing Coordinator and the Interim Director of Staff Development (IDSD) revealed that the IDSD was responsible for calculating and posting the actual direct care service hours and DHPPD. However, the IDSD stated that these calculations were done weekly based on data from payroll, to which she did not have access. Consequently, the documents from July 1 to July 14 were not updated. The facility's policy required daily posting of staffing numbers within two hours of each shift's start, but this was not adhered to, as confirmed by the Administrator.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, had her call light within reach, which is a violation of her rights to a dignified existence and self-determination. During unannounced visits, it was observed that Resident 2, who was alert but had unclear speech due to aphasia, was unable to reach her call light as it was hanging on the TV mount of her roommate. This was confirmed by a Certified Nurse Assistant (CNA) who acknowledged that the call light was not within Resident 2's reach, which would prevent her from calling for help. Resident 2's medical record indicated she was admitted with a diagnosis of stroke, resulting in right-sided weakness and aphasia, and her care plan specified that the call light should be within her reach due to her self-care deficit. Interviews with the CNA, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON) all confirmed that the call light should always be accessible to Resident 2. The facility's policy on answering call lights, dated March 2021, also stated that call lights should be within easy reach of residents when they are in bed. The DON acknowledged that the policy was not followed in this instance.
Failure to Notify Responsible Party of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a change of condition (COC) and the resident was transferred to a general acute care hospital (GACH). This deficiency was identified during unannounced visits conducted on June 24 and 25, 2024. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the facility's protocol required notifying the doctor and RP when a resident experienced a COC or was sent to the hospital. However, a review of the resident's records showed no documentation that the RP was informed of the transfer to the hospital for chest pain on July 15, 2023. The resident in question had a history of supraventricular tachycardia and hypertension and was unable to make medical decisions independently. Despite this, there was no evidence in the resident's chart that the RP was notified of the hospital transfer. The facility's policy, dated December 2023, clearly stated that a nurse should notify the resident's representative in such cases and document the information in the medical record. The DON acknowledged that the facility did not adhere to its policy, resulting in the RP being unaware of the resident's health condition.
Failure to Communicate PT Order to Hospice
Penalty
Summary
The facility failed to ensure that a physician's order for physical therapy was communicated to the hospice provider for a resident under hospice care. This oversight resulted in the resident not receiving the prescribed physical therapy. The resident, who was admitted with diagnoses including supraventricular tachycardia and rheumatoid arthritis, was under hospice care since November 29, 2023. A physician's order for physical therapy was issued on December 5, 2023, following an orthopedic appointment, but there was no documented evidence that this order was communicated to the hospice provider. During interviews, the Director of Rehabilitation (DOR) confirmed that the order for physical therapy was not communicated to him, which was against the facility's protocol. The Director of Nursing (DON) stated that hospice managed all care for residents under hospice, implying that the hospice provider might have declined the therapy. However, the facility's policy required communication with the hospice provider to ensure resident needs were met. The failure to communicate the physician's order for physical therapy to the hospice provider was a deficiency identified during the survey.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive, despite being designated as a full code. The resident, who had a medical history including atrial fibrillation and hypertension, was admitted to the facility and had the capacity to understand and make decisions. The resident's Minimum Data Set indicated a full code status, meaning CPR should have been initiated if the resident was found without a heartbeat or not breathing. On the day of the incident, the resident was found unresponsive, without a pulse, and not breathing by LVN 2, who was the charge nurse at the time. Despite the resident's body being cold and stiff, LVN 2 acknowledged that CPR should have been initiated but did not proceed with it. RN 2, the supervisor, was informed of the situation and also decided against performing CPR, citing the resident's condition as cold and lifeless. Both LVN 2 and RN 2 failed to initiate CPR, contrary to the facility's policy and the resident's full code status. Interviews with other staff members, including RN 3 and the Director of Nursing (DON), confirmed that CPR should have been initiated for a full code resident found unresponsive. The facility lacked a written policy for CPR, relying instead on the POLST forms in residents' charts. The DON stated that the staff should have assessed the situation, checked the POLST, and initiated CPR if the resident was a full code. The failure to perform CPR resulted in the resident not receiving necessary life-saving measures.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to ensure pharmacy services were provided to meet the needs of the residents when four medications were not administered during the scheduled time with no documentation for one resident. Resident 1, who was alert and oriented, reported missing doses of apixaban and amiodarone. A review of Resident 1's medical record revealed that the 9 pm dose of amiodarone was not given on three occasions, the 5 pm dose of apixaban was not given once, the 5 pm dose of ascorbic acid was not given once, and the 9 pm dose of atorvastatin was not given on three occasions. There was no documentation for these missed doses, and no reason was provided for not administering the medications as ordered by the physician. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the lack of documentation and administration for the missed doses. Both the DSD and DON acknowledged that the medications should have been administered as ordered and that any missed doses should have been documented with a reason. The facility's policy on medication administration documentation, which requires documentation of all administered medications and reasons for any missed doses, was not followed in this instance.
Failure to Repair Loose Toilet Seat Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a resident (Resident 3) by not repairing a loose toilet seat that was reported as needing repair. This failure led to Resident 3 falling off the loose toilet seat and sustaining a broken hip, which required surgical repair. The incident occurred after Resident 3 had informed the Social Service Assistant (SSA) about the loose toilet seat the day before the fall, but the issue was not recorded in the maintenance log or addressed in a timely manner. Resident 3, who was alert and conversant, reported the loose toilet seat to the SSA on April 2, 2024. Despite this, the SSA did not record the issue in the maintenance log or verbally alert the maintenance staff. On April 3, 2024, Resident 3 fell while attempting to use the toilet, resulting in a broken hip. The resident was assessed by nursing staff and subsequently transferred to the hospital for surgical repair. The resident's medical history included hypertension, end-stage renal disease, and a stroke, and he was previously independent with toilet transfers and walking. Interviews with staff revealed that the maintenance logs were not utilized properly, and the SSA was not initially aware of their existence. The Director of Nursing (DON) confirmed that the maintenance department was notified of the loose toilet seat only after the fall occurred. The facility's policy on safety and supervision emphasized the importance of identifying and reporting accident hazards, but this protocol was not followed in this instance.
Inadequate Discharge Preparation and Orientation
Penalty
Summary
The facility failed to ensure adequate preparation and orientation for a safe and orderly discharge for Resident 2 and her family member. Resident 2, who had a history of encephalopathy, cerebrovascular accident with left-sided weakness, type 2 diabetes, and chronic kidney disease, expressed a desire to go home by the end of February 2024. However, her family member was not adequately prepared for her discharge, and there was no documented evidence that the family member was notified of the discharge notice issued on February 9, 2024, due to non-payment. The notice was effective on March 10, 2024, but Resident 2's family member was not informed until February 27, 2024, and requested more time to make arrangements at home. Despite this, the facility did not provide sufficient discharge preparations between February 9 and February 27, 2024. Interviews with the Certified Nurse Assistant (CNA) and the Social Services Director (SSD) revealed that Resident 2 required assistance with personal hygiene, had poor balance, and would benefit from assistance if discharged home. The SSD stated that Resident 2 was self-responsible and had been provided with personalized resources on March 8, 2024, including home health, transportation, and pharmacy referrals. However, the SSD also mentioned that some services required private pay, and Resident 2 needed to agree to the expenses. The SSD believed that the three-day period between March 8 and March 10, 2024, was sufficient for Resident 2 to arrange private caregivers and other options, but Resident 2's family member filed an appeal on March 9, 2024, delaying the discharge. Further review of Resident 2's records indicated that she required supervision and assistance with various activities of daily living, as documented in her Minimum Data Set (MDS) dated February 14, 2024. The facility's policy on preparing residents for discharge, dated December 2023, stated that residents should be prepared in advance for discharge and that a post-discharge plan should be developed. However, the facility did not adhere to this policy, as there was no documented evidence of discharge preparations with Resident 2 and her family member between February 9 and February 27, 2024, leading to inadequate preparation and orientation for a safe and orderly discharge.
Failure to Notify POA of Resident's Condition Change
Penalty
Summary
The facility failed to ensure that the family member (FM) designated as the Power of Attorney (POA) for Resident 2 was notified about a change in the resident's condition. Resident 2, who had diagnoses including type 2 diabetes mellitus with a right foot ulcer, end-stage renal disease on dialysis, and Alzheimer's disease, experienced a deterioration of a diabetic ulcer on February 6, 2024. Despite the POA being effective immediately as of September 16, 2022, the Treatment Nurse (TN) only notified Resident 2 and the physician about the condition change, failing to inform the FM who was the designated POA. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) both stated that the responsible party should be notified of any changes in condition, but this protocol was not followed in this instance. Interviews with the Director of Staff Development (DSD) and a review of Resident 2's records confirmed that the FM should have been notified of the change in condition. The facility's policy indicated that a resident representative, including a POA, should be notified to support the resident in decision-making. However, the TN was unaware of the POA status and did not notify the FM. The DON acknowledged that the POA should have been notified and could not explain why the TN failed to do so. This oversight resulted in the FM being unable to fulfill their POA duties effectively, as they were not informed of the resident's deteriorating condition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
