Ceres Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Ceres, California.
- Location
- 1711 Richland Avenue, Ceres, California 95307
- CMS Provider Number
- 055935
- Inspections on file
- 18
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Ceres Postacute Care during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, morbid obesity, osteoarthritis, muscle weakness, and abnormal gait had an active PT plan with goals for ambulation and a prescribed frequency of five sessions per week to improve mobility and independence. The resident, who was cognitively intact and dependent for transfers and ADLs, reported receiving PT only about twice weekly despite wanting more therapy. Review of therapy records showed the resident did not receive PT on three consecutive days, with inconsistencies between the Daily Activity Schedules, Daily Treatment Logs, and Service Log Matrix, and no valid documented reasons for the missed sessions. The PT, DOR, DON, and ADM acknowledged that PT services should meet the ordered frequency and be documented and billed timely, and that missed treatments could slow rehabilitative progress, yet the resident’s ordered PT frequency was not met.
The facility did not notify the State Agency within the required timeframe after a change in administrator. Staff interviews and document reviews confirmed the new administrator assumed the role, but there was no proof that the required notification was sent or received by the SA, and the previous administrator remained listed as active in the licensing system. There was also no facility policy for reporting such changes.
Surveyors found that smoke barrier doors in three compartments did not release from magnetic holders and close during fire alarm testing, despite activation of smoke detectors, pull stations, and waterflow tests. Staff and a vendor had differing understandings of the door operation, and the malfunction affected all residents in the affected areas.
Surveyors found that an emergency egress door required more than one action to unlock due to a turn button lock, affecting 25 residents in one smoke compartment. The Maintenance Director confirmed the door had been in this condition for an extended period.
Surveyors identified that the facility did not maintain or provide required annual inspection records for kitchen cooking equipment, including a gas range, ovens, and griddle. The Maintenance Assistant confirmed that inspections were not conducted, affecting 25 of 43 residents in one smoke compartment.
Surveyors found that the facility did not maintain its fire sprinkler system as required, with one sprinkler head covered in spider webs and dirt and another coated in paint. Staff interviews revealed that these issues had been overlooked for some time, affecting a portion of the resident population.
Surveyors found that a corridor door failed to latch because it was rubbing on the frame, affecting 25 residents in one smoke compartment. The Maintenance Director attributed the problem to the door hinges and stated that staff typically check the doors.
Surveyors found that non-compliant outlet adapters, extension cords, and daisy chained power strips were in use in several areas, including a nurse station, telecom room, and administrator office. Facility staff acknowledged the use of these devices due to a lack of available outlets or were unaware of their installation. These deficiencies affected multiple residents in one smoke compartment.
Survey results from the most recent recertification were not available in the facility's survey binder, making them inaccessible to residents, families, and legal representatives. Facility leadership confirmed the absence of these results, attributing it to a staff member removing the documents and not returning them, in violation of resident rights policies.
The facility's infection prevention and control program was found lacking in several areas, including missing or outdated policies, insufficient staff training, and improper use of PPE. Staff were unable to locate or identify key infection control policies, and some did not receive training on communicable diseases. A CNA failed to use PPE when caring for a resident with a chronic wound, and an LVN used the same gloves for multiple medication routes without changing them. Additionally, a resident's urinal was stored in a manner that risked cross contamination.
Staff failed to maintain refrigerator A at the recommended temperature range for cold food storage, with repeated observations showing the unit at 42°F, above the facility's policy and professional standards. Despite regular temperature checks and established procedures for reporting deviations, the refrigerator remained out of range, increasing the risk of foodborne illness for residents receiving meals from this unit.
A resident with a history of hemiplegia, diabetes, and failure to thrive had an area of excoriation on the left buttock that was not accurately assessed or documented by staff. Records and interviews showed that while the excoriation was monitored for infection, essential details such as measurements and progression were missing from assessments, making it impossible to determine if the condition was improving or worsening.
Two residents did not have individualized care plans addressing their specific needs. One resident with severe cognitive impairment and a history of hiding the corded call light was using a wireless handheld device, but this was not documented in the care plan, resulting in lack of access to a call light. Another resident with muscle wasting and malnutrition, who was on meal monitoring, consistently refused meal alternatives and supplements, yet there was no care plan outlining interventions for these refusals. Staff and DON confirmed that care plans were not updated to reflect these issues, leading to unmet care needs.
A resident with a history of cerebral infarction, muscle weakness, and impaired cognition experienced a fall, after which a post-fall assessment recommended monitoring proper shoe use and walker technique. Despite these recommendations, the care plan was not updated and continued to list non-skid socks as an intervention. Staff observations and interviews confirmed the care plan did not reflect the resident's current needs or the recommended interventions, resulting in unclear guidance for fall prevention.
Two LVNs failed to follow medication administration policies by using only one resident identifier instead of the required two or more, and one LVN documented a medication as given in the EMAR when it was not administered. These deficiencies involved residents with complex medical needs, including cognitive impairment and gastrostomy status.
A resident's room was found cluttered with boxes blocking the door and a carpet with curled edges, creating trip hazards and preventing the door from opening fully. Staff and multiple disciplines were aware of the unsafe conditions, but the care plan and interdisciplinary documentation did not address these environmental risks, despite facility policy requiring identification and intervention for such hazards.
A staff member who transitioned from CNA to RNA began working in the new role without a signed job description, as confirmed by interviews and employee file review. The DSD and DON both stated that signing a job description is required to ensure staff are aware of their new duties and responsibilities.
A resident with chronic pain was given oxycodone hydrochloride regularly without staff documenting monitoring for side effects, despite facility policy and professional guidelines requiring such monitoring. Both the LVN and DON confirmed that no documentation of side effect monitoring was present in the resident's records.
Two residents did not receive their prescribed medications within the required time frames, resulting in a medication error rate of 5.88%. An LPN administered an inhaler and eye drops late, with documentation indicating the medications were given on time. The DON confirmed that late administration is a medication error and that facility policy requires medications to be given within one hour of the scheduled time.
Surveyors found that several rooms did not meet the minimum required square footage per resident, with multiple rooms housing two or three residents in spaces smaller than regulations allow. Despite this, residents had adequate privacy, storage, and access to care and facilities.
A resident with multiple chronic conditions was readmitted from the hospital with prior wounds that were not properly assessed or treated by nursing staff, who documented only skin discoloration and failed to review previous records or follow hospital discharge wound care orders. The wounds were not monitored, measured, or reported to a physician, and no weekly assessments were performed. This lack of intervention led to the development of necrotic wounds, hospitalization for sepsis and necrotizing fasciitis, and ultimately surgical amputation of the resident's lower extremity.
A resident with multiple chronic conditions was readmitted with documented skin issues, but the admitting LPN failed to identify, assess, or measure wounds on the ankles, instead recording them as discoloration and not reviewing prior records or hospital wound care orders. No weekly wound monitoring or measurements were performed, and the wounds were not recognized until a wound physician's later assessment found them necrotic. The facility did not develop a comprehensive care plan for the wounds, resulting in a lack of appropriate treatment and monitoring, and the resident was later hospitalized for sepsis and required surgical amputation.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. A binder at the main entrance only contained survey documents from 2019 and earlier, missing documents from 2020 to 2024. The Administrator confirmed the absence of these documents, despite recent deficiencies from complaints and incidents. This failure violated residents' rights to access survey results.
The facility failed to maintain an adequate air gap under the food prep sink, risking water contamination. The CDM and MAINS confirmed the absence of a proper air gap, which is crucial to prevent backflow. The RD and facility policies highlighted the necessity of an air gap to avoid contamination, posing a risk to 36 residents.
The facility failed to cover an outside trash bin with a lid, as observed during a survey. The trash bin was found uncovered in the parking lot, with the lid open and hanging on the back. Maintenance staff confirmed the lid should always be closed to prevent pests. The facility's waste disposal policy requires waste to be in closeable, leak-proof containers, disposed of per regulations.
The facility failed to maintain a homelike environment for several residents due to stained floors and improper use of duct tape on call light cords. Observations showed persistent stains on floors in four residents' rooms, and duct tape was used inappropriately in two other residents' rooms, posing a potential safety hazard. Staff interviews confirmed these issues, highlighting deficiencies in providing a clean and safe environment.
The facility failed to develop and implement comprehensive care plans for the use of side rails for two residents, leading to potential safety risks. Despite policies requiring assessments and care plans for side rail use, staff interviews and record reviews revealed the absence of such plans. The Director of Nursing acknowledged the oversight, highlighting the importance of care plans in ensuring resident safety and proper communication of needs.
A resident's oxygen concentrator filters were found covered with lint and dust, indicating a failure in the facility's infection control program. The resident, admitted with multiple health conditions, expressed concern over the unclean filters. An LVN and the DON acknowledged the issue, noting the potential for respiratory infections. Facility policies and the concentrator's manual required regular cleaning, which was not adhered to.
A survey found that several rooms in the facility did not meet the minimum square footage requirement of 80 square feet per resident. Despite this, the facility ensured that residents had adequate privacy, storage, and space for care and ambulation. The facility maintained that the waiver of this requirement would not negatively impact resident health and safety.
Failure to Provide Ordered PT Frequency and Document Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered PT services to maintain and improve range of motion and mobility for one resident. During observation and interview, the resident was alert, oriented, and reported being unable to walk, with a history of weight gain and leg weakness. The resident stated he wanted to lose weight and regain leg strength to walk again and reported he was supposed to receive PT five times per week but had only been going twice per week. He stated he was making progress with PT but was not getting as much therapy as he should and would like to attend PT every day if possible. Record review showed the resident had chronic respiratory failure with hypoxia, abnormal gait and mobility, morbid obesity, metabolic encephalopathy, osteoarthritis in both knees, and muscle weakness. The MDS dated 4/14/26 documented a BIMS score of 14, indicating minimal to no cognitive impairment, and showed the resident was dependent for transfers and required assistance with dressing and personal hygiene. The PT recertification and updated therapy plan dated 4/22/26–5/21/26 documented short- and long-term goals for ambulation with parallel bars and a FWW, justified continued skilled PT to facilitate independence with functional mobility, and specified a treatment frequency of five times per week, with the resident demonstrating good rehab potential. Review of the Service Log Matrix for April showed the resident did not receive PT on 4/13/26, 4/14/26, and 4/15/26. The PTA initially stated the resident received PT on 4/13/26 but it was not billed, so it did not appear on the log, and confirmed the resident was scheduled but did not receive PT on 4/14/26 and was not scheduled and did not receive PT on 4/15/26, despite the plan calling for five sessions per week. Review of the Daily Activity Schedules and Daily Treatment Logs for those dates showed inconsistencies: the DAS showed the resident scheduled on 4/13/26 and 4/14/26 but the resident was not on the DTL for those days, and the resident was not on either the DAS or DTL for 4/15/26. The PT stated PT was provided on 4/13/26 but could not recall why it was not billed, acknowledged the resident was not scheduled and did not receive PT on 4/14/26 and 4/15/26, and could not recall why the resident was not on the DAS for those days. The PT stated that if a regular resident was not on the DAS, rehab staff should follow up, that PT services must be documented and billed timely, and that missing three days of PT was not acceptable and could potentially set back rehabilitative progress if missed treatments continued. The DOR stated that treatment notes should be billed within 24 hours as standard practice and that it was the responsibility of the DOR, rehab aide, and PT to ensure residents met their ordered PT frequency. The DOR noted the PT had access to the assignment board, that the board was mapped out weeks in advance, and that lack of documentation indicated services were not provided. The DOR also stated that missed treatments could slow rehabilitative progress. The DON and Administrator both stated that PT services should meet the ordered frequency, that missed treatments could cause a decline in rehabilitative progress, and that documentation and billing should be completed in a timely manner to reflect care provided. The facility’s policy on Specialized Rehabilitative Services stated that the facility will provide rehabilitative services as indicated by the MDS and that PT is among the specialized services to be provided by qualified personnel, with treatment discontinued or transitioned to a maintenance program only after goals are met. Despite this, the resident, who was a regular PT patient with an active plan for five sessions per week, missed three consecutive days of PT services without valid documented reasons and with inconsistent scheduling and documentation, leading to the cited deficiency.
Failure to Timely Notify State Agency of Change in Administrator
Penalty
Summary
The facility failed to notify the State Agency (SA) within ten days of a change in administrator (CHOA) that occurred on 11/13/2023. Multiple staff interviews confirmed that the new administrator (ADM 1) assumed the role on that date, following the resignation of the previous administrator (ADM 2). Staff, including the DON, Medical Records Director, and Social Services Director, were aware of the change internally, but there was uncertainty and lack of knowledge regarding the external reporting requirements to the SA. The new administrator and the Vice President of Operations (VPO) both stated that the responsibility for reporting the change to the SA was understood, but neither could provide proof that the required notification was sent or received by the SA. A review of facility documents showed that the offer letter for ADM 1 was dated 11/13/2023, and the resignation letter from ADM 2 was effective 9/15/2023. The Applicant Individual Information (HS215A) form was completed and signed by ADM 1 on 12/30/2023, but there was no evidence of receipt by the SA. Both ADM 1 and the VPO stated that documents were mailed to the SA, but neither could provide proof of mailing or confirmation of receipt. Additionally, there was no facility policy or procedure for reporting changes of administrator to the regulatory authority. A review of the State Agency's Electronic Licensing Management System (ELMS) indicated that as of 12/11/2025, ADM 2 was still listed as the active administrator, with no end date, and the most recent CHOA application was pending as of 12/3/2025. There was no record of a CHOA application between 4/22/2022 and 12/3/2025. The California Code of Regulations requires written notification to the Department within ten days of a change in administrator, including the name and license number of the new administrator. The facility was unable to provide evidence that this requirement was met.
Smoke Barrier Doors Failed to Close During Fire Alarm Testing
Penalty
Summary
During a facility tour and interviews, surveyors observed that the smoke barrier doors adjacent to Rooms 15 and 13, as well as the doors near Rooms 8 and the Dining Room, failed to release from their magnetic door holders and close during fire alarm testing. The testing included activation of a smoke detector, pull station, and waterflow test, but the doors did not respond as required. The doors are intended to close automatically in response to fire alarm system activation to prevent the spread of smoke and fire between compartments. The Maintenance Assistant stated that the doors typically close when only the pull station is tested, but during this inspection, the doors did not function as expected. A sprinkler vendor present at the time believed the doors only close when the sprinkler system is activated. This discrepancy in understanding and the failure of the doors to operate correctly during multiple types of fire alarm activations were directly observed by surveyors. This deficiency affected all 43 residents in the three smoke compartments of the facility. The failure of the smoke barrier doors to close and latch as required by NFPA 101 and related standards was confirmed through direct observation and staff interviews during the survey.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Fire Alarm System vendor was contacted immediately on 05/19/25. Repair to the automatic door releases were completed. A fire watch was instituted during the repair period. Facility was approved to be taken off from fire watch the following day by Life and Safety. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Maintenance will be doing random tests/checks to ensure proper function. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/25 How the facility plans to monitor its performance to make sure that solutions are sustained (repeated section): The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/25
Emergency Egress Door Required Multiple Actions to Unlock
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed that an emergency egress door near Room 1 was equipped with a door knob featuring a turn button lock. When tested, the door required two separate actions to unlock from the egress side. This configuration does not comply with NFPA 101 Life Safety Code requirements, which mandate that egress doors must be readily openable from the egress side without the use of a tool, key, or more than one action. The Maintenance Director confirmed during the interview that the door had been in this condition for some time. This deficiency affected 25 out of 46 residents located in one of the facility's three smoke compartments. The report does not mention any specific medical history or conditions of the residents involved at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The egress door near Room 1 was immediately repaired to eliminate the need for more than one action to open. A single-action, code-compliant push bar has been installed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: All door hardware was checked, and visual checks will be part of the preventive maintenance schedule to inspect egress hardware monthly. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The log will be part of the facility QA program, and any deficient practices identified will have a QAPI developed to monitor and/or correct the deficient practice. Date of Completion of Corrective Action: 05/19/25 K 222
Failure to Maintain and Document Annual Kitchen Equipment Inspections
Penalty
Summary
Surveyors found that the facility failed to maintain their kitchen cooking equipment in accordance with NFPA 96 standards. During a tour, observation revealed the presence of a six-burner gas range with two ovens and a griddle. When asked, the facility was unable to provide annual inspection records for the kitchen equipment, and no previous records were available for review. The Maintenance Assistant confirmed during an interview that the required inspections and servicing of the cooking equipment were not performed. This deficiency affected 25 of 43 residents in one of three smoke compartments, as the lack of inspection records indicated non-compliance with required fire safety standards for commercial cooking operations.
Plan Of Correction
K324 How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: An immediate inspection of all commercial kitchen equipment was completed by maintenance staff on 5/20/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: A log will be created to check the kitchen equipment monthly, thoroughly inspect and clean as needed. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: A log will be created to check the kitchen equipment monthly, thoroughly inspect and clean as needed. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/2025
Failure to Maintain Fire Sprinkler System Free of Foreign Material
Penalty
Summary
The facility failed to maintain its automatic fire sprinkler system in accordance with NFPA 25 standards, as evidenced by the presence of foreign material on sprinkler heads. During a facility tour, surveyors observed a sprinkler head on the overhang of the Southwest Emergency Exit by Room 21 that was covered with spider webs and dirt. The Maintenance Director acknowledged that this sprinkler head had been ignored and may have been in that condition for some time. Additionally, a sprinkler head located in the closet of the Administrator Room was found to have paint covering it. The Maintenance Assistant stated that he had never paid attention to the closet sprinkler heads and that the condition may have persisted for a while. These deficiencies affected 18 of 43 residents in one of three smoke compartments and were identified through direct observation and staff interviews.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Sprinkler head located on the overhang of the Southwest Emergency Exit by Room 21 was thoroughly cleaned on 5/20/25. Fire sprinkler vendor was notified and on 6/2/25 the sprinkler head located in closet of administrative DSD office is scheduled to be replaced by vendor. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Administrator will audit the reports from the sprinkler system vendor to check for accuracy and completion. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Administrator will audit the reports from the sprinkler system vendor to check for accuracy and completion. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 06/02/2025
Corridor Door Failed to Latch Due to Maintenance Issue
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed that the corridor door to Room 5 failed to latch when tested. The door was found to be rubbing against the door frame, which prevented it from properly securing. The Maintenance Director indicated that the issue was likely related to the door hinges and mentioned that staff usually checked on the doors. This deficiency affected 25 out of 46 residents in one of three smoke compartments. The report specifically notes that the corridor doors did not maintain the required latching function, as mandated by NFPA 101 and related regulations, which is necessary to resist the passage of smoke and fire. No additional details about the medical history or condition of the residents involved were provided in the report.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Maintenance staff on the same day after the first failed test addressed the issue with Rm. 5 door not latching by adjusting the hinges and striker plate, retested, and door successfully latched. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: Rounds will be done monthly by maintenance and the proper setting of the doors will be logged and the administrator will review the rounds and develop a log. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/19/2025
Non-Compliant Use of Electrical Equipment and Power Strips
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain electrical equipment in accordance with NFPA 101 and NFPA 70 standards. Specifically, a four multiplug outlet adapter was found in use at Nurse Station 2, with three of its four outlets occupied. The Maintenance Director acknowledged that the adapter was used due to an insufficient number of available outlets. In the Telecom Room near Room 21, two power strips were daisy chained together and connected to a small extension cord, all of which were in use. The Maintenance Assistant indicated that a vendor may have installed the surge protector and extension cord. Additionally, a brown extension cord was found supplying power to a computer in the Administrator Room, with the Maintenance Assistant unable to explain its presence. These observations affected 18 of 43 residents in one of three smoke compartments. The use of non-compliant outlet adapters, extension cords, and daisy chained power strips was directly observed by surveyors during their tour and interviews with facility staff. The report does not mention any specific medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The four multiplug outlet adapter in Nurse Station 2 was removed on 5/19/25. The two daisy chained power strips and small extension cord in the Telecom Room by Room 21 were removed on 5/19/25. The brown extension cord was in the Administrative DSD office was removed on 5/19/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this deficient practice. No residents were found to be affected by this deficient practice. What measures will be put into place or what systemic changes in the facility will make to ensure that the deficient practice does not recur: On 5/20/25 Administrator re-educated maintenance staff on NFPA electrical standards. Use of extension cords and outlet adapters is prohibited. Maintenance staff will do visual checks as part of their daily rounds for compliance. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator shall report the outcome of the checks/inspections to the Quality Assurance and Assessment Committee (QA&A) during its' monthly meeting. If determined that the facility has accomplished the objectives in the plan of correction as aforementioned and the results are successful, then the facility shall consider the matter resolved. The QA&A Committee shall continue to review until such time that the deficiency has been proven to be resolved for 3 consecutive months and/or as advised by the QA&A Committee. Date of Completion of Corrective Action: 05/20/25
Survey Results Not Posted for Resident Access
Penalty
Summary
The facility failed to make the results of its most recent survey readily accessible to residents, families, and their legal representatives. During an observation, the survey binder located near the main entrance did not contain the recertification results from the last survey. In interviews and record reviews, both the Senior President of Clinical Operations and the Administrator confirmed that the previous year's survey results were missing from the binder, with the Administrator stating that a staff member had removed the results and not returned them. The facility's policy and procedure on resident rights specifies that residents have the right to examine survey results, but this was not upheld as required.
Infection Control Program Deficiencies and Lapses in Staff Practice
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by several deficiencies in policy, staff practice, and environmental management. The written policies and procedures for the infection prevention and control program did not include a list of communicable diseases, nor did they specify when and to whom incidents of communicable diseases or infections should be reported. Additionally, the policies regarding COVID-19 infection prevention and control were outdated. Staff interviews revealed a lack of awareness and training regarding communicable diseases, with multiple staff members unable to locate or identify the relevant policies or the list of communicable diseases. The infection preventionist acknowledged the absence of required information in the policy binder and the need for updates. A certified nursing assistant failed to wear appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for a chronic leg ulcer. The CNA admitted to not wearing PPE, and both the infection preventionist and the director of nursing confirmed that PPE was required for such care to prevent cross contamination. Observations and interviews confirmed that staff were aware of the need for PPE but did not consistently follow protocols, increasing the risk of infection transmission. A licensed vocational nurse used the same pair of gloves to administer oral medication, injectable insulin, and eye drops to a resident, without changing gloves or performing hand hygiene between different routes of medication administration. The nurse acknowledged this practice and recognized it as incorrect. The infection preventionist and director of nursing both stated that gloves should be changed between different medication routes to prevent cross contamination. Additionally, a resident's urinal was observed hanging in a trash can with the handle touching the trash, a practice that both staff and the infection preventionist identified as a risk for cross contamination and infection. The resident preferred this arrangement for accessibility, but staff recognized it did not meet infection control standards.
Failure to Maintain Safe Cold Food Storage Temperatures
Penalty
Summary
Facility staff failed to ensure that cold food storage in refrigerator A was maintained under sanitary conditions in accordance with professional standards for food service safety. Observations on multiple occasions revealed that refrigerator A was operating at 42 degrees Fahrenheit, which is above the recommended safe temperature range for cold food storage. Kitchen staff acknowledged that the refrigerator temperature fluctuated depending on how often the door was opened and confirmed that the temperature should be maintained between 34 and 36 degrees Fahrenheit. The Certified Dietary Manager also stated that the acceptable range was between 34 and 39 degrees Fahrenheit, and that any deviation should be reported immediately, with food removed from the affected refrigerator. Review of facility policies indicated that refrigerator temperatures should be less than or equal to 41 degrees Fahrenheit, with a goal of maintaining 34 to 39 degrees. Staff interviews revealed that temperatures were checked up to three times daily, and that deviations were to be reported to maintenance. However, despite these procedures, the refrigerator remained above the recommended temperature on repeated checks, and there was no indication in the report that corrective action was taken at the time of the observations. This failure had the potential to contribute to the growth of foodborne pathogens and posed a risk of foodborne illness to residents receiving meals and nourishment from refrigerator A.
Failure to Accurately Assess and Document Skin Excoriation
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident with a history of hemiplegia, diabetes mellitus, and failure to thrive, specifically regarding an area of excoriation on the resident's left buttock. Documentation in the resident's records, including the Admission Record, Care Plan, Treatment Administration Record, and Progress Notes, indicated the presence of excoriation and the need for monitoring for signs of infection. However, the Nursing Admission Assessment did not include measurements or detailed information about the skin condition, and subsequent documentation lacked specifics on the progression or changes in the excoriation. Interviews with facility staff, including an LVN and the DON, confirmed that while the excoriation was a known and ongoing issue, assessments and documentation did not consistently include details such as measurements, appearance, or progression of the wound. The DON stated that expectations for skin documentation included appearance, stage, measurements, progression, odor, and drainage, but these elements were not present in the records reviewed. This lack of detailed and accurate assessment resulted in an inability to monitor the progression of the resident's skin condition and determine if it was improving or worsening.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to unmet care needs. For one resident with dementia, muscle weakness, and bipolar disorder, the care plan did not address her use of a wireless handheld call light device, despite her history of hiding the corded call light and her preference for the wireless option. Observations confirmed that the resident did not have access to a call light in her room, and staff interviews revealed that the use of the wireless device had been ongoing for over a month but was not reflected in the care plan. Staff acknowledged the importance of individualized care plans and the necessity of documenting specific interventions, such as the use of alternative call light systems, to ensure all staff are informed of each resident's needs. Another resident with muscle wasting and protein-calorie malnutrition, who was unable to complete a cognitive interview, was on meal monitoring due to weight loss. Documentation showed that this resident consistently consumed less than 75% of meals, and while staff offered meal alternatives and supplements, these were frequently refused. However, there was no care plan in place that addressed interventions for when the resident refused supplements or alternatives. Staff and the DON confirmed that interventions were not clearly defined or specific to this problem, and that care plans should have included strategies for addressing refusals to ensure the resident's nutritional needs were met. The facility's policy required comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, and resident preferences, with measurable objectives and interventions. In both cases, the lack of individualized and updated care plans led to inconsistent care and failure to address the residents' specific needs as observed and confirmed by staff and record review.
Failure to Revise Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the fall care plan for a resident following a fall incident. After the resident experienced a fall, a post-fall assessment recommended monitoring the proper wearing of shoes and the use of a front-wheeled walker (FWW) during ambulation. However, the resident's care plan continued to indicate the use of non-skid socks when ambulating with a FWW, rather than updating the intervention to reflect the recommendation for proper shoe use. Observations showed the resident ambulating with shoes and regular socks, and at times with only one shoe and a regular sock, which did not align with the care plan interventions. The resident had a history of cerebral infarction, macular degeneration, generalized muscle weakness, and abnormal gait, and was assessed as moderately cognitively impaired. The resident was receiving restorative services for ambulation and was able to walk with a walker without staff assistance. Interviews with staff, including the DON and LVN, confirmed that the care plan had not been updated to include the new interventions recommended after the fall, such as monitoring the proper use of shoes and ensuring the walker was kept close to the resident during ambulation. The facility's policy required that care plans be resident-centered and updated with new interventions if falls recurred. Despite this, the care plan remained outdated, listing non-skid socks as an intervention rather than the recommended use of shoes. Staff acknowledged the importance of revising the care plan to reflect the resident's current needs and function, but this was not done, resulting in a lack of clear guidance for staff to prevent further falls.
Failure to Follow Medication Administration Policies and Resident Identification Procedures
Penalty
Summary
The facility failed to meet professional standards of quality by not following its own policy and procedure for administering medications to two of nine sampled residents. Licensed Vocational Nurses (LVN) 1 and 3 used only one resident identifier, specifically the resident's name, prior to administering medications, instead of the required two or more identifiers such as checking the wrist band and photograph. This was observed during medication administration to residents who were non-verbal or cognitively impaired, and both LVNs acknowledged during interviews that they did not follow the full identification protocol as outlined in facility policy. Additionally, LVN 1 documented in the Electronic Medication Administration Record (EMAR) that an inhaler medication was administered to a resident when, in fact, it was not given. This was confirmed during observation and interview, where LVN 1 admitted to signing off on the medication without actually administering it, stating that it was forgotten during the medication pass. The facility's policy requires that medications be documented as given only after actual administration. The residents involved included individuals with significant medical conditions such as dementia, gastrostomy status, hypothyroidism, and a need for medications like insulin and inhalers. The failure to properly identify residents and accurately document medication administration was confirmed through observation, interviews with staff, and review of facility policies and resident records.
Failure to Maintain Resident Environment Free of Accident Hazards
Penalty
Summary
A deficiency was identified when a resident's room was found to be cluttered with multiple boxes blocking the door from opening fully and a carpet with curled edges on the floor. The resident, who had a history of Type 2 Diabetes Mellitus and generalized muscle weakness, was observed lying in bed and later ambulating both with and without a walker. The room was described as disorganized, with scattered personal belongings and a strong smell of urine. The presence of the boxes and the curled carpet created obstacles and potential trip hazards within the resident's environment. Interviews with facility staff, including the Social Services Director, Licensed Vocational Nurse, Housekeeping Staff, Certified Nursing Assistant, and the Director of Nursing, confirmed awareness of the cluttered and hazardous state of the resident's room. Staff acknowledged that the room posed safety and health risks, including being a potential fire and fall risk. Despite this, the resident's care plan and interdisciplinary team documentation did not address the environmental hazards or include interventions to mitigate these risks. The facility's policy on falls and fall risk management requires staff to identify and implement interventions related to specific risks, including environmental factors such as obstacles in the footpath. However, the lack of documentation and action regarding the cluttered room and trip hazards indicated a failure to ensure the resident's environment was free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Obtain Signed Job Description for Restorative Nurse Aide
Penalty
Summary
A staff member who transitioned from a Certified Nursing Assistant (CNA) to a Restorative Nurse Aide (RNA) did not have a signed job description for her new role prior to beginning her duties as an RNA. During an interview, the RNA stated she did not recall signing a job description after her transition. A review of her employee file by the Director of Staff Development (DSD) confirmed that there was no signed job description present. The DSD acknowledged that staff members are required to sign a job description when assuming a new role to ensure they are aware of their responsibilities. Further, the Director of Nursing (DON) confirmed that the RNA should have signed the job description before starting her new position, as this process ensures familiarity with the new job duties and responsibilities. The facility's RNA job description outlines specific skills and expectations, and the absence of a signed document indicated that the RNA may not have been fully informed of her new responsibilities.
Failure to Monitor for Oxycodone Side Effects
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of chronic pain syndrome was administered oxycodone hydrochloride every eight hours for pain management without adequate monitoring for side effects. Review of the resident's Medication Administration Record and Progress Notes revealed no documentation of monitoring for potential adverse effects such as constipation, decreased respirations, dizziness, or increased fall risk. Interviews with both the Licensed Vocational Nurse and the Director of Nursing confirmed that staff were not documenting any monitoring of the resident for side effects related to oxycodone use. The facility's policy on pain assessment and management required monitoring for adverse consequences of pain treatment, and professional references also indicated the need for monitoring patients on oxycodone for side effects. Despite these requirements, there was no evidence that staff tracked or documented the resident's response to the medication or any adverse effects, resulting in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Medication Error Rate Exceeds Acceptable Threshold Due to Late Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a calculated error rate of 5.88%. This deficiency was identified through observation, interview, and record review, where two medication errors were found among 34 opportunities for error. Specifically, two residents did not receive their prescribed medications at the correct times as ordered by their physicians. One resident, with a history of Chronic Obstructive Pulmonary Disease (COPD) and pneumonia, did not receive a prescribed inhaler medication (Salbutamol/Albuterol) at the scheduled time of administration. The medication was due at 8:00 a.m. but was not administered until 9:30 a.m., one and a half hours late. The nurse responsible for the medication pass signed the electronic medication administration record (EMAR) as if the medication had been given on time, but later admitted to forgetting to administer the inhaler at the prescribed time. The facility's policy requires medications to be administered within one hour of the scheduled time, and the nurse acknowledged this as a medication error. Another resident, diagnosed with Dry Eye Syndrome, did not receive prescribed lubricant eye drops at the scheduled time. The eye drops were ordered to be administered at 7:00 a.m., but were not given until 9:00 a.m., two hours late. The nurse did not verify the resident's identity or allergies prior to administration, and also acknowledged the late administration as a medication error. The facility's policy and professional references reviewed confirm that late administration constitutes a medication error, and the Director of Nursing confirmed the expectation for timely medication administration according to physician orders.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
During an environmental tour conducted with the Maintenance Supervisor and Maintenance Assistant, surveyors observed that multiple resident rooms did not meet the regulatory requirement of providing at least 80 square feet per resident in shared rooms. Specifically, rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17, and 18 were found to have less than the required square footage per resident. Despite these findings, it was noted that residents had reasonable privacy, adequate storage, accessible toilet facilities, and sufficient space for nursing care and ambulation. The deficiency was identified based on direct measurement and observation of the living spaces during the survey period.
Failure to Assess and Manage Wounds Resulting in Amputation
Penalty
Summary
Licensed nursing staff failed to provide wound care in accordance with professional standards and the resident's comprehensive care plan for a resident with multiple comorbidities, including end stage renal disease, diabetes, and chronic wounds. Upon readmission from the hospital, the resident's left inner ankle and right outer ankle were documented as areas of discoloration rather than wounds, despite previous records indicating the presence of a scab and a popped blister in those locations. The admitting nurse did not review prior wound documentation or hospital discharge orders, which included active wound care treatments, and did not transcribe or implement these orders. As a result, no wound care was provided, and the areas were not measured or monitored as wounds. From the time of readmission, there was no weekly wound monitoring, assessment, or measurement for the affected areas. Nursing staff did not notify the physician of changes or deterioration in the resident's condition, and there was no documentation of wound progression until a wound physician assessed the resident two weeks later, identifying both wounds as unstageable due to necrosis. The facility lacked a designated wound nurse, and charge nurses were responsible for wound care, but did not perform or document required assessments. The interdisciplinary team did not review the wounds, as they were not recognized as such by nursing staff. The lack of appropriate wound assessment, monitoring, and intervention led to the development of necrotic wounds on the resident's lower extremities. This resulted in the resident being admitted to an acute care hospital for sepsis related to necrotizing fasciitis, ultimately requiring surgical amputation of the left lower extremity. Facility policies and job descriptions required nursing staff to demonstrate competency in wound care, assessment, and documentation, but these standards were not met in this case.
Failure to Assess, Monitor, and Care Plan for Wounds Leads to Severe Resident Harm
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including end stage renal disease, diabetes, and chronic wounds, was readmitted to the facility and did not receive a complete and accurate initial wound assessment. The admitting nurse documented areas of discoloration on the resident's left inner and right outer ankles but did not identify or measure these as wounds, despite previous records indicating the presence of a scab and a popped blister in the same locations. The nurse did not review prior wound documentation or hospital discharge orders, which included active wound care treatments, and failed to transcribe or continue these orders upon readmission. From the time of readmission, there was no weekly wound monitoring, assessment, or measurement of the affected areas. The wounds were not identified as such until a wound physician assessed the resident two weeks later, at which point both ankle wounds were found to be unstageable due to necrosis. Facility staff did not conduct weekly wound measurements or notify the physician of changes to the wounds from the time they were identified by the wound physician until another assessment was performed over a month later. The facility lacked a designated wound nurse, and charge nurses were responsible for wound care, but no consistent monitoring or documentation occurred during this period. Additionally, the resident did not have a comprehensive, person-centered care plan addressing the wounds. The care plan only referenced discoloration and did not include specific interventions for wound care, monitoring, or physician notification. The lack of accurate assessment, documentation, and care planning resulted in the wounds progressing without appropriate intervention, ultimately leading to the resident's hospitalization for sepsis and surgical amputation of the left lower extremity.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies, in a place readily accessible to residents and their representatives. During an observation, a binder labeled Survey Inspection was found at the main entrance, containing only the 2019 health recertification survey deficiencies and plan of corrections, along with previous years' abbreviated surveys. There were no survey documents available from 2020 to 2024. In an interview, the Administrator confirmed that the binder lacked the necessary documents from 2020 to 2024, despite the facility having one complaint and three facility-reported incidents in the past 12 months that resulted in deficiencies. The facility's policy indicated that residents have the right to examine survey results, which was not upheld in this instance.
Deficiency in Air Gap Maintenance Under Food Prep Sink
Penalty
Summary
The facility failed to maintain an air gap under the food preparation sink, which is essential to prevent backflow and contamination of water used for cooking and drinking. During an observation and interview, the Certified Dietary Manager (CDM) confirmed the absence of an air gap and acknowledged the importance of having one to prevent water from backing up into the sink. The Maintenance Staff (MAINS) was unaware of the issue and later identified that the plumbing for the food prep sink drained into a hot water closet, where the air gap was insufficient, being less than two inches from the bottom of the drain. The Registered Dietitian (RD) also confirmed the requirement for an air gap to prevent contamination. The facility's policy and procedure, as well as the Food Code by the U.S. Food and Drug Administration, emphasize the necessity of an air gap as a reliable backflow prevention device. The lack of an adequate air gap under the food prep sink posed a risk of contaminated water backflowing into the sink, potentially leading to foodborne illness among the 36 residents.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly cover an outside trash bin with a lid, as observed during a survey. On the specified date, the trash bin was found uncovered in the facility's parking lot, with the lid open and hanging on the back of the bin. During a subsequent observation and interview, the maintenance staff confirmed that the lid was open and acknowledged that it should always be closed to prevent rodents and insects. The facility's policy and procedure on waste disposal, dated January 2018, requires that all waste destined for disposal be placed in closeable, leak-proof containers and disposed of in accordance with applicable federal, state, and local regulations. This failure to adhere to the policy had the potential to harbor and feed pests, which could lead to unsanitary conditions and the spread of disease.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for four residents due to stained floors in their rooms. Observations revealed that one-third of the floors in the rooms of Residents 10, 18, 19, and 26 had yellow and brown stains. Interviews with staff, including a CNA, LVN, Housekeeping Supervisor, Maintenance Staff, and the Director of Nursing, confirmed that the stains were persistent despite regular cleaning. The staff acknowledged that the stained floors did not promote a homelike environment and could cause residents to feel uncomfortable. Additionally, the facility failed to ensure a safe environment for Residents 6 and 23 due to the improper use of red duct tape to attach the call light cord to the call light socket. This was observed during a room inspection, and staff interviews confirmed that the use of duct tape was inappropriate and could pose a safety hazard. The Maintenance Staff initially claimed the tape was electrical and non-flammable but later admitted it was duct tape and should not have been used. The facility's policies and procedures emphasize maintaining a clean, sanitary, and orderly environment to reflect a homelike setting. However, the observations and staff interviews indicated that these standards were not met, resulting in deficiencies in providing a safe and comfortable environment for the residents involved.
Failure to Implement Care Plans for Side Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four of 13 sampled residents, specifically for the use of side rails for two residents. This deficiency was identified through observation, interviews, and record reviews. Resident 138, admitted with multiple diagnoses including COPD, heart failure, and anxiety, was observed using side rails for mobility without an individualized care plan in place. Similarly, Resident 4, who had a history of hypertension, bipolar disorder, and muscle weakness, also used side rails without a documented care plan. Interviews with staff, including LVNs and CNAs, revealed that there were no care plans, consents, or physician orders for the use of side rails for these residents. The staff acknowledged that care plans are essential for guiding resident care and ensuring safety, and the absence of such plans could lead to potential harm. The Director of Nursing confirmed that the facility did not follow its policy and procedures regarding care planning and side rail assessments, which are necessary to communicate residents' needs and prevent injuries. The facility's policies and procedures require comprehensive, person-centered care plans that include measurable objectives and timetables to meet residents' needs. Additionally, the proper use of side rails policy mandates assessments and care plans when side rails are used for mobility or transfer. The failure to adhere to these policies resulted in the deficiency, as the facility did not ensure that the necessary care plans were developed and implemented for the safe use of side rails by Residents 4 and 138.
Inadequate Cleaning of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain an effective infection control program when a resident's oxygen concentrator filters were found covered with lint and dust. This deficiency was identified during an observation and interview with the resident, who expressed dissatisfaction with the condition of the oxygen concentrator filters and requested that they be cleaned or replaced. The resident was admitted to the facility with diagnoses including myocardial infarction, hypertension, anxiety disorder, and morbid obesity. The resident's Minimum Data Set indicated a Brief Interview for Mental Status score of 14 out of 15, suggesting they were cognitively intact. During a subsequent observation and interview, an LVN confirmed the unclean state of the oxygen concentrator filters and acknowledged that using a dirty concentrator was unacceptable, as it could worsen the resident's respiratory condition. The Director of Nursing also stated that using a dirty oxygen concentrator could potentially cause respiratory infections and emphasized the importance of maintaining cleanliness. The facility's policies and procedures, as well as the oxygen concentrator's user manual, outlined the need for regular cleaning and disinfection of equipment to prevent infection, but these guidelines were not followed in this instance.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in multiple resident rooms, as observed during a survey conducted from May 20 to May 23, 2024. Specifically, rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17, and 18 did not meet the regulatory requirement of at least 80 square feet per resident. Despite this deficiency, the facility maintained that the variations in room size were in accordance with the particular needs of the residents, and that residents had a reasonable amount of privacy, adequate storage space, and sufficient room for nursing care and ambulation. The report noted that wheelchairs and toilet facilities were accessible, and the waiver of the square footage requirement would not adversely affect the health and safety of the residents.
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.
