Kern River Transitional Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 5151 Knudsen Drive, Bakersfield, California 93308
- CMS Provider Number
- 555912
- Inspections on file
- 75
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Kern River Transitional Care during CMS and state inspections, most recent first.
A resident developed small, pink/red, pea-sized raised bumps on the scalp near both ears that were documented on an SBAR form and remained present several days later per progress notes, though the resident did not appear to be in pain. During an interview and record review, the DON confirmed there was no documentation that the physician had been notified of this ongoing skin condition, despite facility policy requiring nurse supervisors/charge nurses to notify the attending or on-call physician of significant physical status changes that do not normally resolve without intervention.
A resident developed small, raised, pink/red, tender bumps on the scalp near both ears, documented on an SBAR form, and a care plan was created the same day identifying risk for infection, worsening condition, and pain or discomfort with an intervention to moisturize dry, flaky skin. Review of the TAR for two consecutive months showed no documentation that this moisturizing intervention or any treatment for the scalp bumps was provided. In an interview and record review, the DON confirmed there was no documentation that the care plan intervention was implemented, despite facility policy requiring that care plan interventions be designed and carried out based on identified problem areas and their causes.
A resident whose primary language was Spanish did not receive vital admission documents in their preferred language. The facility lacked a Spanish version of the Admissions Agreement and did not provide written or oral translation, despite policy requirements and staff acknowledgment that such translation was necessary.
The facility did not ensure that care and services provided met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident who did not have a bowel movement for six days was not provided with the required bowel management protocol, as the DON confirmed that no medications were administered and the facility's policy for assessment and intervention was not followed.
Three LVNs lacked documented competency training for CPAP and BIPAP care, resulting in inconsistent application of respiratory devices for residents. A resident reported variable effectiveness of her BIPAP mask depending on which LVN applied it, and the DON confirmed that several residents required these therapies without staff having received proper training.
A resident at high risk for falls was not wearing non-skid socks as required by their care plan and facility policy, and after an unwitnessed fall, an LVN and CNA transferred the resident without waiting for an RN assessment as mandated by the facility's fall protocol. The resident complained of hip pain and was later sent to the hospital for further evaluation.
A resident's responsible party was not given the opportunity to participate in the selection of a hospice provider, nor was there documentation that the hospice process or available providers were explained. The DON confirmed the lack of documentation, and facility policy requires residents and their representatives to be informed and involved in care decisions.
A resident's transition to hospice care was not properly coordinated, as no initial IDT conference was held and the first conference lacked a facility nurse. Only two care plans were updated to reflect hospice involvement, contrary to facility policy requiring comprehensive, interdisciplinary care planning.
The facility did not consistently obtain or document informed consent for psychoactive medications and bed alarms, as required by its own policies. In multiple cases, consent forms were missing physician or nurse signatures, or were not signed by the resident or responsible party, even though medications or interventions were administered. This included residents with varying levels of cognitive impairment and involved both medication and restraint interventions.
Nursing staff failed to demonstrate and document competency in providing specialized care, including dialysis site assessment, suprapubic catheter care, and management of midline and PICC lines for several residents. Required skills were not validated or documented as per facility policy, and assessments were not consistently performed or recorded.
Staff failed to adhere to infection control protocols, including not wearing required PPE during close contact with a resident on Enhanced Barrier Precautions, exiting a resident's room with contaminated PPE, improper disposal of wound dressings, lack of hand hygiene between glove changes, use of non-sterile instruments for wound care, and accessing disinfectant wipes from an open container. These deficiencies were observed during care of residents with wounds and confirmed through staff interviews and policy review.
The facility did not ensure that all CNAs completed the required annual dementia-specific in-service training, as attendance records showed that only a portion of the CNA staff participated in each session, and none met the full five-hour requirement. This was confirmed through record reviews and interviews with the DSD.
Two residents and their responsible parties did not receive completed Baseline Care Plan (BCP) summaries within 48 hours of admission, as required by facility policy. Documentation and signatures confirming receipt of the BCP summaries were missing, and staff interviews confirmed that the summaries were not provided in a timely manner.
Multiple residents were found with unlabeled and unsecured medications at their bedsides without proper assessment for self-administration, and a controlled substance destruction record lacked the required second nurse signature, in violation of facility policy.
The facility did not ensure its Social Services Director was qualified or fulfilled essential duties, resulting in missed Advance Directive information for several residents, lack of timely dental and podiatry referrals, incomplete social history assessments, and failure to notify the Ombudsman of a resident's transfer. The SSD also did not conduct in-room visits or timely documentation, and some residents were not properly assessed or referred for PASRR, as confirmed by the DON.
The QAPI committee did not identify or address ongoing deficiencies in infection prevention, control practices, and social services. Meeting minutes showed a focus on new resident assessments, with no discussion of the specific issues found by surveyors. The Social Services Director was replaced due to incompetence, and the DON took over those duties, but only weekly reviews of admission records were conducted. These failures left all residents at risk for infectious diseases and unmet medically necessary services.
The facility did not ensure that the Infection Preventionist attended two out of three required QAPI committee meetings, as verified by sign-in sheets and administrator review. The IP's attendance was only confirmed for one meeting, while the other two meetings lacked documentation of the IP's presence.
A resident's personal belongings were lost after staff failed to complete the required inventory of personal effects upon admission, contrary to facility policy. The resident reported the missing items to nursing staff, but they were not returned or replaced, and the Social Services Director was not aware of the loss.
The facility did not accurately complete PASARR screenings for three residents, resulting in missed Level II evaluations for individuals with documented mental health diagnoses and psychotropic medication use. The DON acknowledged that the screenings were not done correctly, and the required referral process was not followed according to facility policy.
Surveyors found that the facility did not develop or implement individualized care plans for four residents with specific needs, including foot care, respiratory failure, and IV site management. Staff interviews and record reviews confirmed the absence of required care plans, despite clear evidence of medical conditions and facility policy requiring comprehensive, person-centered planning.
Two residents had IV catheters that were not managed according to facility policy, including failure to flush, change, or remove the IVs as ordered. One resident's IV remained in place and unchanged for over the recommended period, while another resident's IV site was not cared for or discontinued as directed, with no documentation or staff awareness of the IV. These actions did not meet professional standards for IV catheter care.
Two residents dependent on staff assistance did not receive necessary personal and oral hygiene care. One resident had untreated dry, flaky feet with overgrown, discolored toenails and debris between the toes, while another had poor oral hygiene with dental caries and missing teeth, and did not receive consistent mouth care. Staff interviews and record reviews confirmed lapses in care and documentation, contrary to facility policies.
A resident with significant visual impairment was not provided with individualized activities that matched their abilities and preferences. The care plan included activities the resident could not perform due to blindness, and staff did not offer alternatives or assistance, resulting in the resident having nothing to do except remain in bed.
A resident with visibly dry, flaky skin, swollen toes, and overgrown, discolored toenails did not receive appropriate foot care or a podiatry referral, despite a physician's order and clear signs of foot disorders. Nursing staff acknowledged the need for intervention but did not act, and documentation in nursing and social services records failed to address the resident's foot condition or the need for specialist care.
A resident with a suprapubic catheter did not have documented catheter changes for several months, and staff could not provide evidence of competency or proper documentation for catheter care. The facility's policy lacked clear guidelines on which clinical personnel were qualified to change suprapubic catheters and did not meet current professional standards.
A resident requiring dialysis did not have documented assessments of their dialysis access site on several occasions, as the post-dialysis treatment sections of the communication forms were left blank. An LVN stated that the facility would call the dialysis center if information was missing, but the required documentation was not present as per facility policy.
A resident with multiple missing and discolored teeth, as well as reported cavities, was not assisted by staff in obtaining a dental appointment despite a physician's order and the resident's request. The Social Services Director did not make or document a dental referral, and the social history assessment was incomplete, lacking necessary information about the resident's dental needs.
Two residents had incomplete and inaccurate medical records, including one whose weekly nursing summaries did not match observed skin and toenail conditions, and whose hemodialysis communication assessments were left incomplete on several occasions. Another resident's initial social history assessment was started but not finished, with both the DON and SSD confirming the documentation lapses.
The facility did not ensure that two residents fully understood the Binding Arbitration Agreements they signed. One resident with moderate cognitive impairment and a dementia diagnosis was asked to sign without adequate assessment of their understanding, while another resident, whose responsible party should have signed and who required language assistance, signed without a translator or responsible party involvement. Facility policy requires clear explanation and language access, which was not provided in these cases.
A resident in an LTC facility did not have a care plan developed for their refusal of showers and baths over 13 days, nor for their significant respiratory conditions, including asthma and COPD. The DON confirmed these omissions during a review, which violated the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to obtain a physician's order and document the removal of a midline IV catheter for a resident receiving Meropenem for a bacterial infection. The catheter was removed without proper documentation or a physician's order, contrary to facility policy, leading to incomplete medical records and potential risks for the resident.
A facility failed to implement a fall prevention care plan for a resident at risk for falls. The care plan included the red star program, requiring a red star on the resident's nameplate after multiple falls. However, the resident was observed attempting to get out of bed unassisted without the red star in place, as confirmed by the DON. The facility's policy emphasizes resident-centered fall prevention, which was not followed.
A facility failed to follow its Fall Management policy for a resident with a history of falls, resulting in an incomplete post-fall assessment. The resident experienced multiple falls, and the Post Fall Review (PFR) assessment did not include a review of medications, as required by the facility's policy. The DON and Administrator confirmed the assessment's incompleteness, acknowledging the omission of the medication review.
A facility failed to report a suspicion of financial abuse to a resident's attending physician, as required by their policy. The incident involved a resident discovering missing money from their bank account during a bank visit with the Administrator. Despite the policy's requirement for immediate reporting to the attending physician, the Director of Nursing and the Administrator confirmed that this notification did not occur.
A resident reported being raped by two men multiple times, but the facility failed to report the allegation to the CDPH within 24 hours and did not complete an investigation within five business days. The DON was informed of the allegations and instructed staff to call 911, but did not report to CDPH, citing a change in the resident's story. The facility's policy requires immediate reporting and thorough investigation of abuse allegations.
A resident experienced two unwitnessed falls, and the facility failed to notify the attending physician and responsible party as required by their policy. The first fall was documented with notifications, but the second fall lacked documentation of any notifications. This deficiency was confirmed through interviews and record reviews.
A resident identified as high risk for falls experienced two separate falls, but the facility failed to revise the fall risk care plan after each incident. The Director of Nursing confirmed that the care plan should have been updated according to the facility's policy, which was not adhered to, resulting in a deficiency.
A resident experienced two unwitnessed falls, and the facility failed to conduct the required neurological checks. An LVN stated that such checks should be initiated and last for 72 hours, but the resident's medical records showed no documentation of these assessments. The DON confirmed the oversight, despite the facility's protocol for monitoring vital signs and neurological status after falls.
A facility failed to follow its policy on documentation accuracy, resulting in an inaccurate medical record for a resident. The Director of Nursing confirmed that the resident's discharge summary incorrectly listed another resident as the responsible party, despite the admission record indicating the correct emergency contact. This discrepancy highlights a deficiency in maintaining accurate clinical records.
A resident's grievance about being left in the bathroom for an extended period was not addressed or resolved by the facility, violating the resident's rights. The grievance involved a CNA's inappropriate response during a shift change and was documented but not acted upon according to the facility's grievance policy.
A resident experienced a change in cognitive status, becoming confused and severely impaired, but the facility failed to notify the primary care physician as required by policy. Staff interviews indicated a lack of awareness of the resident's baseline status, and the resident was eventually sent to the hospital after family concerns.
A facility failed to notify a physician of a resident's elevated blood pressure, recorded at 184/82, which exceeded the facility's threshold for reporting. The Director of Nursing confirmed there was no documentation of reassessment or physician notification. The facility's policy requires prompt notification of changes in a resident's condition, but this was not adhered to, potentially impacting the resident's care needs.
A facility failed to implement a care plan for a resident with moderate cognitive impairment who was non-compliant with using the call light, often yelling for assistance instead. Despite reminders from staff, the resident continued this behavior, and the ADON acknowledged the absence of a care plan addressing this issue, contrary to the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to ensure complete communication and coordination with a dialysis center for a resident requiring dialysis. The Pre and Post-Dialysis Communication Form was incomplete, with post-dialysis assessments left blank on several occasions. The Director of Nursing confirmed the oversight, which contradicted the facility's policy requiring detailed documentation of dialysis-related care and observations.
A resident experienced an unwitnessed fall and was identified as high risk for falls, but the facility failed to update the care plan as required by their policy. The Assistant Director of Nurses confirmed the oversight during a review, noting that the care plan should have been revised following the incident.
A resident's call light was found on the floor and not within reach, contrary to the facility's policy. The resident, who had severe cognitive impairment and required assistance for daily activities, was unable to access the call light. Both a CNA and an LVN acknowledged that the call light should have been accessible.
A facility failed to monitor and document behavioral episodes for a resident with bipolar disorder, risking untreated worsening behavior. The care plan required documentation of behavioral symptoms, but this was not done, as confirmed by the DON.
The facility failed to document medication administration immediately for two residents, leading to inaccurate medical records. Despite timely administration, staff did not adhere to the policy requiring immediate documentation, as confirmed by the ADON and LVNs.
The facility failed to ensure medication carts and the medication room were free from expired medications and did not follow their policy on medication labeling. Expired medications and improperly labeled medications were found during observations, and an insulin was not dated as required.
Failure to Notify Physician of Resident’s Ongoing Skin Condition Change
Penalty
Summary
Surveyors found that nursing staff failed to notify a resident’s physician and family of a change in the resident’s condition involving new skin findings on the scalp. On 2/24/26, an SBAR Communication Form documented that the resident was noted in the morning with small raised bumps on the scalp near the ears on both sides of the head, described as pink/red, pea-sized lumps under the skin that were slightly tender when pressed. A subsequent progress note dated 2/27/26 indicated that the red bumps on the resident’s head were still present and that the resident did not appear to be in pain, with no facial grimacing or moaning observed. During an interview and concurrent record review on 4/29/26 at 4:04 p.m., the DON confirmed she was unable to find documentation that the physician had been notified about the ongoing presence of the red bumps and stated that the condition should have been followed up with the MD. The facility’s policy on change in a resident’s condition or status, dated November 2015, required the nurse supervisor/charge nurse to notify the attending or on-call physician when there was a significant change in the resident’s physical condition, defined as a change that would not normally resolve without staff intervention or standard disease-related clinical interventions.
Failure to Implement Care Plan Interventions for Skin Condition
Penalty
Summary
The facility failed to implement a care plan for a resident who was noted on an SBAR Communication Form to have small, raised bumps on the scalp near both ears, described as pink/red, pea-sized lumps under the skin that were slightly tender to pressure. Review of the resident’s Treatment Administration Records for February and March 2026 showed no documentation of any treatment for these scalp bumps. The resident’s care plan, dated the same day as the SBAR, identified the bumps and the resident’s risk for infection, worsening condition, and pain or discomfort, and included an intervention to moisturize dry and flaky skin to rehydrate the skin. During interview and concurrent record review, the DON confirmed there was no documentation that the moisturizing intervention was carried out and stated that the care plan was not followed or implemented, despite facility policy stating that care plan interventions are to be designed and implemented after consideration of the resident’s problem areas and their causes. This failure resulted in the resident not receiving treatment and created a potential for worsening skin condition, as documented in the findings.
Failure to Provide Vital Documents in Resident's Primary Language
Penalty
Summary
The facility failed to provide vital documents in the primary language of a resident whose preferred and primary language was Spanish. Review of the resident's admission record and social history assessment confirmed Spanish as the resident's primary language. However, the Admissions Agreement provided to the resident was in English, and the facility did not have a Spanish version available. The Admissions Coordinator confirmed that the facility does not have an Admissions Agreement in Spanish. Additionally, the resident's hospital record indicated a need for an interpreter, and the Director of Nursing acknowledged that vital documents should have been provided in Spanish. The facility's policy on translation and interpretation services requires that individuals with limited English proficiency (LEP) have meaningful access to information and services, including written translation of vital information such as admission agreements. The policy also specifies that when written translation is unavailable, oral translation should be provided, and that family members should not be relied upon for interpretation unless explicitly requested by the resident. In this case, the facility did not provide the required written or oral translation of vital documents to the resident in their primary language.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the nursing facility did not consistently provide care and services in accordance with accepted standards, but does not specify particular residents, staff actions, or detailed events leading to the deficiency.
Failure to Initiate Bowel Management Protocol for Resident with Constipation
Penalty
Summary
A deficiency occurred when the facility failed to follow its Bowel Management Protocol for one resident who did not have a bowel movement for six consecutive days. The resident's Task: Bowel Continence record showed no bowel movement from 6/24/25 to 6/30/25. During an interview and record review, the DON confirmed that the bowel protocol, which includes administering medications to treat and prevent constipation, was not initiated for this resident. No medications were given, and the necessary steps outlined in the facility's policy were not followed. The facility's policy requires daily review of residents' bowel movement records, identification of those who have not had a bowel movement in three days, and administration of appropriate medications as ordered by a physician. In this case, the required assessment, tracking, and treatment were not performed, resulting in the resident not receiving needed medication to address constipation.
Lack of Staff Competency for CPAP and BIPAP Care
Penalty
Summary
The facility failed to ensure that three sampled Licensed Vocational Nurses (LVNs) possessed the necessary competencies to provide care for residents requiring continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) therapy. During interviews and record reviews, it was found that there was no documented skills training for CPAP or BIPAP for these LVNs. A resident reported that the effectiveness of her BIPAP mask application varied depending on which LVN applied it, indicating inconsistency in staff competency. The Staffing Coordinator confirmed the absence of skills training records for the involved LVNs. The Director of Nursing acknowledged that there were seven residents with physician orders for CPAP and BIPAP and stated that training should be provided for these therapies to ensure proper application and resident comfort. Review of the facility's policy indicated that nursing staff are required to demonstrate skills and competencies based on the needs of the resident population, but this requirement was not met for CPAP and BIPAP care. The lack of appropriate training and competency assessment for these devices led to the deficiency.
Failure to Ensure Use of Non-Skid Socks and Proper Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was wearing non-skid socks as required by the care plan. The resident, who had a documented high fall risk score and a care plan intervention specifying the use of non-skid socks, was found not wearing them at the time of an unwitnessed fall. Staff interviews confirmed that the non-skid socks had been removed prior to the incident, and the resident was not wearing them when found on the floor. The facility's policy required the use of proper footwear to prevent falls, but this was not followed in the resident's case. Additionally, the facility did not follow its in-service protocol on falls, which required an RN to assess any resident found on the floor before moving them. After the resident was found on the floor complaining of left hip pain, an LVN and a CNA transferred the resident to a wheelchair and then to bed without waiting for the RN's assessment. The RN supervisor arrived shortly after and, upon assessment, suspected a hip fracture and sent the resident to the hospital. Staff interviews confirmed awareness of the protocol but acknowledged it was not followed in this instance.
Failure to Involve Responsible Party in Hospice Provider Selection
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for one resident was able to participate in treatment decisions, specifically regarding the initiation of hospice care. The resident's family member, who was identified as the RP in the admission record, reported that while she agreed to start hospice care for the resident, she was not given a choice of hospice providers and did not consent to the specific hospice company assigned. Review of the resident's medical record with the DON confirmed there was no documentation that the RP was educated about the hospice process or informed of the available hospice companies. The facility's policy states that residents have the right to be informed and to participate in decisions and care planning, including choosing a physician and treatment.
Failure to Coordinate Hospice Care in Resident's Plan of Care
Penalty
Summary
The facility failed to ensure that a resident's plan of care was properly coordinated with hospice services. Upon review of the resident's medical record and interviews with the DON, it was found that when the resident began hospice care, no interdisciplinary team (IDT) conference was held at the start of hospice, as required. The first IDT conference that did occur included dietary, activities, social services, a hospice nurse, and the resident's representative, but did not include a facility nurse. Additionally, only two of the resident's care plans were updated to reflect the initiation of hospice care, rather than a comprehensive update as expected. Facility policies require that a coordinated plan of care be developed and maintained between the facility, hospice agency, and the resident or their family, with updates as necessary to reflect the resident's current status. The care planning process is intended to be interdisciplinary, involving multiple disciplines including the resident's physician and a facility nurse. The failure to hold a timely and fully staffed IDT conference and to comprehensively update the care plans resulted in a lack of proper coordination for the resident's hospice care needs.
Failure to Obtain and Document Informed Consent for Psychoactive Medications and Bed Alarms
Penalty
Summary
The facility failed to follow its own policies and procedures regarding informed consent for psychoactive/psychotropic medication use and the use of bed alarms for multiple residents. In several cases, consent forms for psychoactive medications such as escitalopram, amitriptyline, alprazolam, venlafaxine, bupropion, sertraline, Seroquel, lorazepam, and clonazepam were either missing required physician signatures, lacked verification by a licensed nurse, or were not signed by the resident or their responsible party. In some instances, documentation of informed consent was entirely absent, despite the medications being administered. The facility's policy required that the prescribing clinician obtain and document informed consent, and that a licensed nurse verify and sign the consent form prior to medication administration, but these steps were not consistently followed. The report details that for several residents, including those with varying levels of cognitive impairment as measured by the Brief Interview for Mental Status (BIMS), informed consent forms were incomplete or missing. For example, one resident with a BIMS of 12 had consent forms for two psychoactive medications that were not signed by a physician. Another resident with a BIMS of 3 had an incomplete consent for alprazolam, and a resident with a BIMS of 7 had no documentation of consent for lorazepam, despite receiving the medication on multiple occasions. In other cases, the responsible party's signature was present, but there was no verification by a nurse or physician, as required by policy. Additionally, the facility failed to obtain and document informed consent for the use of bed alarms for two residents. The consent forms for these interventions were incomplete, lacking signatures from a nurse or physician, and in one case, the responsible party's signature was not clearly documented. The facility's policy required that the physician provide education to the resident or responsible party about the risks, benefits, and alternatives of such interventions, and that informed consent be properly documented, but this was not done consistently.
Failure to Validate Nursing Staff Competency for Specialized Resident Care
Penalty
Summary
Nursing staff at the facility failed to demonstrate and document appropriate competencies for specialized care required by several residents. Specifically, three licensed vocational nurses (LVN 2, LVN 3, and TN 2) did not have documented competency in providing care for a resident undergoing dialysis, including assessment of the arterio-venous fistula site for bruit and thrill before and after dialysis treatments. The Director of Nursing (DON) and Director of Staff Development (DSD) confirmed that the competency forms for these nurses did not include dialysis care, and the required assessments were not performed as indicated in the residents' records. Additionally, the same three nurses lacked documented competency in the care and replacement of suprapubic catheters for another resident who returned from the hospital with this device. Although the nurses indicated prior experience or education in suprapubic catheter care, there was no evidence of return demonstration or validation of their skills by the facility. The DSD was unable to provide documentation of competencies in all areas related to suprapubic catheter care, assessment, and replacement for these nurses. Furthermore, two registered nurses (RN 1 and RN 3) did not have documented competencies for the care and management of midline catheters and peripherally inserted central catheters (PICC) for several residents receiving intravenous antibiotics. The competency forms reviewed did not include specific skills related to midline or PICC line care, and the DSD could not provide evidence of validated skills or knowledge for these procedures. The facility's policy required that nurses be competent in skills related to their assigned duties, with competencies validated prior to independent performance and annually thereafter, but this was not followed for the specialized care in question.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Multiple failures to follow infection prevention and control protocols were observed among staff members during resident care activities. One nurse provided care to a resident on Enhanced Barrier Precautions (EBP) for a right ankle wound without wearing the required isolation gown, despite signage and physician orders indicating the need for EBP. The nurse acknowledged awareness of the requirement but did not comply during close contact with the resident. An X-ray technician, while performing imaging for a resident on EBP, exited the resident's room into the hallway wearing contaminated gloves and an isolation gown to answer a phone call. The technician then returned to the room, removed the PPE, and failed to perform hand hygiene before touching equipment and leaving the room. Facility policy required removal of PPE inside the room and hand hygiene after glove removal, which was not followed. During wound care for another resident, a treatment nurse disposed of contaminated dressings in a regular trash bin instead of a biohazard container, did not perform hand hygiene between glove changes, and used non-sterile scissors to cut a sterile gauze strip for wound packing. The same gloves were used throughout the procedure, and the nurse stated the scissors were disinfected after use. Additionally, a central supply staff member accessed disinfectant wipes from a container without a lid, contrary to facility expectations. These actions were directly observed and confirmed through staff interviews and policy review.
Failure to Ensure Annual Dementia Training for All CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received at least five hours of dementia-specific in-service training annually, as required. Record reviews and interviews with the Director of Staff Development (DSD) revealed that out of 108 sampled CNAs, attendance at various one-hour dementia training sessions ranged from 33 to 68 CNAs per session, with no evidence that all CNAs completed the required training hours. The DSD confirmed during multiple interviews that only a portion of the CNAs attended each session, and none of the sessions individually or collectively ensured that every CNA met the five-hour annual requirement. Additionally, the facility's policy and procedure on in-service training, which mandates annual training in dementia management and resident abuse prevention for all staff, was not followed. The deficiency was identified through a review of attendance sheets for multiple training sessions, all indicating incomplete participation by the CNA staff. There were no specific residents mentioned as being directly affected in the report, but the lack of comprehensive training for all CNAs was established through documentation and staff interviews.
Failure to Provide Baseline Care Plan Summaries Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide completed Baseline Care Plan (BCP) summaries to two of six sampled residents or their responsible parties within 48 hours of admission. During interviews and record reviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was found that there was no documentation indicating that the BCP summaries were given to the residents or their representatives. Specifically, for one resident, the DON could not locate a signed document or any evidence that the BCP summary was provided within the required timeframe. Similarly, for another resident, the ADON confirmed that although the BCP summary indicated participation in the review, there was no documentation or signature showing that a copy was provided to the resident or their representative within 48 hours. The facility's policy and procedure require that a baseline plan of care be developed and a summary provided to the resident and their representative within 48 hours of admission. This summary should include initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information based on the comprehensive care plan. The lack of documentation and signatures for the two residents demonstrates that the facility did not meet its own policy requirements for timely communication of the baseline care plan upon admission.
Failure to Securely Store and Properly Dispose of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly labeled and securely stored, as required by professional standards and facility policy. During observations, multiple residents were found with medications, such as micronazole nitrate, eye drops, antifungal cream, and nystatin powder, left unsecured on their bedside tables. None of these residents had been assessed for self-administration of medications, and there were no orders or documentation supporting their ability to self-administer. Additionally, some of the medications were not labeled with the resident's name, and at least one resident denied ownership of the medication found at their bedside. Further review revealed that the facility did not follow its own policy for the destruction of controlled substances. A controlled substance destruction record was missing the required second nurse signature, as mandated by facility policy, which states that two licensed nurses must be present and sign off during the disposal of controlled substances. The DON acknowledged that the process was not followed as the ADON forgot to sign the record.
Unqualified Social Services Director and Failure to Provide Required Social Services
Penalty
Summary
The facility failed to ensure that the Social Services Director (SSD) met the required qualifications to manage and coordinate social services for its 126 residents. The SSD held a Bachelor of Science in Psychology and was working toward a master's in social work, but this was her first experience in a skilled nursing facility. During interviews and record reviews, it was found that the SSD had not facilitated several required social services, including providing Advance Directive information to six sampled residents or their representatives, making dental and podiatry referrals as ordered, and completing initial social history assessments. The SSD also reported not conducting resident visits in their rooms, instead waiting for care conferences, and delayed documentation for up to two days. Further review revealed that the SSD did not notify the Ombudsman regarding a resident's transfer and discharge, believing it was not her responsibility, and failed to appropriately assess and refer three residents for Pre-admission Screening and Resident Review (PASRR). The facility's policies and job descriptions outlined responsibilities for the SSD that were not being met, such as maintaining adequate records, making necessary referrals, and providing supportive visits. The Director of Nursing confirmed awareness of these occurrences during the survey.
QAPI Committee Failed to Identify and Address Infection Control and Social Services Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify ongoing issues and did not develop or implement corrective action plans for deficiencies in Infection Prevention and Control practices and Social Services. Review of QAPI meeting minutes revealed that meetings were focused on reviewing new resident assessments, but did not address or identify the specific deficiencies related to resident assessment and care planning. The Administrator confirmed that these issues were not discussed in recent QAPI meetings, and that the facility had not recognized the assessment deficiencies identified by the survey team. Additionally, the Social Services Director was found to be incompetent in job duties and was terminated, with the Director of Nursing assuming those responsibilities. Despite this change, the facility's admission records were only reviewed weekly, and the Administrator asserted full compliance. The facility's policy required an ongoing, data-driven QAPI program focused on care outcomes and quality of life, but the observed practices did not align with these requirements, resulting in unaddressed deficiencies that placed all residents at risk.
Infection Preventionist Absent from Required QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) attended two out of three Quality Assessment and Performance Improvement (QAPI) committee meetings during 2024 and 2025, as required. During a review of QAPI committee sign-in sheets for meetings held in September 2024, January 2025, and April 2025, it was found that the IP's attendance could only be verified for the January 2025 meeting. The sign-in sheets for the September 2024 and April 2025 meetings did not include the IP's signature, and the Administrator was unable to confirm the IP's presence at those meetings. The QAPI committee meetings were attended by various staff members, but the absence of the IP was specifically noted in two of the three meetings reviewed.
Failure to Document and Safeguard Resident Personal Property
Penalty
Summary
The facility failed to follow its policy and procedure regarding the documentation of personal property for a resident upon admission. Specifically, staff did not complete the inventory of personal belongings for the resident when she was readmitted, as confirmed by the Director of Nursing during a record review. The resident reported the loss of two sets of pajamas and a pair of pants, stating she informed nurses and nursing assistants, but the items were not returned or replaced. The Social Services Director was unaware of the lost belongings and had not been informed or spoken with the resident about the issue. The facility's policy requires that residents' personal belongings and clothing be inventoried and documented upon admission and updated as necessary.
Failure to Accurately Complete PASARR Screenings for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to accurately review and complete the annual Pre-Admission Screening Assessment and Resident Review (PASARR) for three of sixteen sampled residents. For one resident, the Level I PASRR screening was positive for serious mental illness, intellectual disability, developmental disability, or related condition, but no Level II PASRR was completed as required. The Director of Nursing (DON) confirmed that the Level I screening was positive and acknowledged that it was their responsibility to ensure the PASRR process was completed, but this did not occur. For two other residents, the PASRR Level I screenings were marked negative despite both residents having documented mental health diagnoses and being prescribed psychotropic medications. The admission records and order summaries indicated diagnoses such as unspecified psychosis, depression, and anxiety disorder, along with medications like Risperidone, Valium, and Lexapro. The DON acknowledged that the PASRR Level I screenings were not completed accurately, which resulted in the screenings not triggering the required Level II PASRR evaluations. The facility's policy stated that positive Level I screens should be referred for Level II evaluation, but this process was not followed.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents with specific and documented care needs. For one resident, observations revealed significant foot issues, including dry, flaky skin, red and swollen toes, thick and discolored toenails, and wounds, yet there was no care plan addressing foot care. Another resident with a history of respiratory disorders and acute respiratory failure with hypoxia did not have an individualized care plan for managing their respiratory condition. In both cases, staff interviews and record reviews confirmed the absence of appropriate care plans. Additionally, two residents with peripheral intravenous (IV) lines did not have individualized care plans for IV site care and management. One resident had an IV inserted with orders to change the site every 96 hours, but the site was never changed, and no care plan was in place. The other resident was observed with an IV and a gauze dressing, but again, no documented care plan was found. Review of the facility's own policy confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timetables, which was not met for these residents.
Failure to Follow IV Catheter Care and Removal Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for preventing intravenous (IV) catheter-related infections for two residents. For one resident, an IV was observed in place despite the last dose of IV medication being administered three days prior, and the resident reported that the IV had not been flushed since then. Review of the medical record showed the IV was inserted eleven days earlier and had not been changed or removed as ordered, contrary to the facility's policy requiring peripheral IV sites to be changed every 96 hours. The registered nurse confirmed that the IV should have been removed and that the site had not been changed as required. For another resident, an IV site was present in the left upper arm, and the resident stated that no treatment or dressing change had occurred since admission. The resident also reported providing a physician's order to discontinue the IV to a nurse, but there was no documented evidence of a physician order for care or removal of the IV in the medical record. Nursing staff were unaware of the presence of the IV, and the facility was unable to provide documentation of appropriate orders or care for the IV site. The facility's policy requires prompt removal of IV catheters that are no longer essential and mandates that peripheral catheters be changed every 96 hours.
Failure to Provide Adequate Personal and Oral Hygiene Care
Penalty
Summary
The facility failed to provide necessary personal and oral hygiene care for two residents who were dependent on staff assistance. One resident was observed with dry, flaky skin on both feet, overgrown and discolored toenails, and blackish debris between the toes. Interviews with nursing staff confirmed the presence of thick, discolored nails and possible fungal infection, as well as dry, red, and swollen toes. Although a CNA reported attempting to clean the resident's feet, the care was not completed due to the resident's pain, and the CNA did not return to finish the task. Facility policy required routine foot care in accordance with professional standards, but this was not followed. Another resident was found to have yellowish, gray teeth, multiple dental caries, and missing teeth, and reported not receiving mouth care on two consecutive days. Review of the resident's ADL documentation showed inconsistent oral care, with gaps in care and documentation. The ADON acknowledged that oral care was not consistently provided and that documentation did not always reflect when care was rendered. Nursing weekly summaries lacked adequate assessment of the resident's oral condition, contrary to facility policy, which required thorough documentation and assessment of oral care.
Failure to Provide Individualized Activities for Visually Impaired Resident
Penalty
Summary
The facility failed to provide individualized activities to a resident with significant visual impairment, as required by their policy and procedure for activity programs. During observation and interviews, it was noted that the resident, who was blind in one eye and losing vision in the other, reported having nothing to do except sit in bed. The resident's care plan listed activities such as reading materials, TV, radio, and arts and crafts, but did not account for his inability to participate in these due to his blindness. Staff acknowledged that the resident could not engage in the listed activities without assistance, such as having someone read to him, but this support was not provided. Record reviews and staff interviews further revealed that the resident's preferences included listening to music, keeping up with the news, and spending time outdoors, but these interests were not addressed in the activity plan. The Social Services Director confirmed that the activities were not individualized to maximize the resident's participation. The facility's own policies require activity programs to be tailored to each resident's needs and to encourage maximum participation, but these were not followed in this case.
Failure to Provide Appropriate Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to provide appropriate foot care and follow its own policies and procedures for a resident who exhibited significant foot and toenail issues. Observations revealed that the resident had dry, flaky skin on both feet, red and swollen toes, long, thick, discolored, and brittle toenails, as well as wounds and blackish debris between the toes. Despite these visible issues, there was no evidence that foot care was provided or that a referral to a podiatrist was completed, even though a physician's order for a podiatry consult was present upon admission. Interviews with nursing staff confirmed that the resident's toenails were overgrown, thick, and discolored, with possible fungal involvement, and that the resident had wounds and very dry skin. Staff acknowledged the need for a podiatry referral but admitted that no action was taken to initiate the referral or provide necessary foot care. Additionally, a CNA reported that while attempting to clean the resident's feet, the resident complained of pain, and the cleaning was not completed. No further attempts were made to address the resident's foot hygiene. Record reviews showed that nursing assessments and weekly summaries did not document the condition of the resident's skin, toes, or toenails, and there was no follow-up or progress notes from social services regarding the need for podiatry or foot care. The facility's policies required referral to qualified professionals for foot disorders and regular documentation and follow-up by social services, but these procedures were not followed, resulting in the resident's ongoing foot issues.
Deficient Suprapubic Catheter Care and Documentation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate competency in assessing and changing a suprapubic catheter for a resident with a neuromuscular bladder dysfunction. The resident was admitted with a suprapubic catheter, and physician orders specified that the catheter should be changed as needed for dislodgement, malfunction, or leakage. However, there was no written documentation of any catheter changes over a four-month period, despite a nurse recalling a change due to leakage two months prior. The Director of Nursing was unable to provide evidence of the procedure or documentation, and the Director of Staff Development could not produce records of nurse competencies related to suprapubic catheter care and changes. Additionally, the facility's policy and procedure for suprapubic catheter care did not specify which clinical personnel were qualified to change the catheter, nor did it outline the required qualifications or competencies for performing this task. The policy also failed to align with current standards set by the Society of Urologic Nurses and Associates, which require clear protocols regarding personnel qualifications and training for suprapubic catheter changes. These deficiencies were identified through interviews, record reviews, and policy examination.
Incomplete Documentation of Dialysis Site Assessment
Penalty
Summary
The facility failed to ensure complete communication and coordination with the dialysis center regarding the assessment of a resident's dialysis access site. During review of the resident's Hemodialysis Communication Observation/Assessment forms for multiple dates, it was found that the post-dialysis treatment sections were left blank. An LVN confirmed that if the dialysis center does not complete the form, the facility typically calls the center to obtain the necessary post-dialysis information. The facility's policy requires staff to be trained in the care of residents with end-stage renal disease and to gather specific assessment data about the resident's condition on a daily or per shift basis. However, there was no documented assessment of the dialysis site for the resident on the reviewed dates.
Failure to Assist Resident with Dental Appointment and Referral
Penalty
Summary
The facility failed to assist a resident with obtaining a dental appointment, despite clear indications of dental issues and a physician's order for a dental consult and treatment. Upon admission, the resident had multiple missing teeth, yellowish/gray teeth, and reported cavities, specifically noting a cavity in a molar and expressing an urgent need to see a dentist. The resident's Admission Record and Order Summary Report documented the need for dental care, and the Interdisciplinary Team Conference Summary noted the resident's request for a referral to a dentist. However, interviews and record reviews revealed that the Social Services Director (SSD) did not make the necessary dental referral or document any notification to dental services to ensure the resident would be seen. The SSD also had not met with the resident to discuss dental needs. Additionally, the social history assessment was incomplete, with no documentation under the dental section regarding the resident's dental condition or the need for a referral. The facility's policy required social services to make appropriate referrals and maintain documentation, but these steps were not followed in this case.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Nursing Weekly Summary (NWS) did not accurately reflect the actual condition of the resident's skin, toes, and toenails. Observations revealed significant issues such as dry and flaky skin, red and swollen toes, long and discolored toenails, wounds, and black debris between the toes. However, the NWS entries for several weeks either indicated no new skin issues, marked the skin section as not applicable, or stated the skin was clear and intact, which did not match the resident's observed condition. The Director of Nursing (DON) confirmed that the documentation was not accurate and did not reflect the true condition of the resident's skin and nails. Additionally, the same resident's Nursing Hemodialysis Communication Observation/Assessments (NHCOA) were not completed on multiple dates. The forms were missing critical information such as assessments of the dialysis access site, documentation of medications administered, pain levels, and post-dialysis assessments. In several instances, both pre- and post-dialysis sections were left blank, and the Dialysis Center documentation was incomplete. The DON stated that licensed nurses should complete these assessments before and after dialysis and that the Dialysis Center staff should also document following treatment, but this was not done. For another resident, the Initial Social History Assessment was started but not completed. The Social Services Director (SSD) acknowledged that the assessment was initiated but left unfinished. Facility policy requires the social services department to obtain pertinent social data related to the resident's illness and care, and documentation policies require clinical records to accurately reflect care provided to ensure continuity and coordination of services. These failures resulted in incomplete records for both residents.
Failure to Ensure Understanding of Binding Arbitration Agreements
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the explanation and execution of Binding Arbitration Agreements (BAA) for two residents. In the first instance, the Admission Coordinator (AC) had a resident with a diagnosis of dementia and a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment sign a BAA. The AC relied on basic questions and a review of nursing notes and diagnoses to determine the resident's understanding but did not identify documented episodes of confusion or the dementia diagnosis. The resident was considered their own responsible party, but the documentation showed cognitive impairment and confusion, raising concerns about the resident's ability to fully comprehend the legal implications of the BAA they signed. In the second instance, the AC had another resident sign a BAA even though the resident's admission record indicated that their son was the responsible party and that the resident's spoken language was not English. The AC did not document the use of a translator, and the responsible party did not sign the BAA. The facility's policies require that residents or their representatives be informed of the nature and implications of binding arbitration agreements in a manner they can understand, and that language access services be provided for individuals with limited English proficiency. These requirements were not met in either case, resulting in the residents not fully understanding the legal documents they signed.
Failure to Develop Care Plans for Refusal of Care and Respiratory Needs
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who consistently refused showers and baths over a 13-day period. During an interview and record review, the Director of Nursing (DON) confirmed that the resident's refusal of care was documented on several dates, yet no care plan was created to address these refusals. This oversight was contrary to the facility's policy and procedure, which mandates the development of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet each resident's needs. Additionally, the facility did not develop a respiratory care plan for the same resident, who had multiple respiratory diagnoses, including asthma, interstitial pulmonary disease, chronic obstructive pulmonary disease, respiratory disorders, and atelectasis. The DON confirmed that despite the resident's significant respiratory conditions, no care plan was in place to monitor and manage these issues. This lack of a respiratory care plan was also in violation of the facility's policy, which requires care plans to be derived from a thorough analysis of the resident's comprehensive assessment.
Failure to Document and Obtain Order for IV Catheter Removal
Penalty
Summary
The facility failed to obtain a physician's order and document the removal of a midline intravenous catheter for one of the residents. The resident was receiving Meropenem intravenously every six hours for a bacterial infection, with the last dose administered on February 11, 2025. However, by February 13, 2025, the resident's medication administration note indicated that there was no IV line access, suggesting the catheter had been removed without proper documentation or a physician's order. During an interview and record review, the Director of Nursing confirmed that there was no physician's order for the removal of the midline IV catheter and no documentation of its removal in the resident's progress notes. The facility's policy requires a physician's order for the removal of any IV catheter and documentation of the removal process, including measuring the catheter, ensuring the tip is intact, assessing for bleeding, and recording the intervention in the medical record. These steps were not followed, leading to incomplete medical records and potential risks for the resident.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to consistently implement care plans for a resident at risk for falls. The care plan for the resident, revised on December 2, 2024, included the red star program, an intervention for residents who have experienced two or more falls within 30 days. This program requires a red star to be placed on the nameplate outside the resident's room. However, during an observation on December 31, 2024, the Director of Nursing (DON) confirmed that the resident was attempting to get out of bed unassisted and did not have a red star on their nameplate, despite being care planned for the red star program. The facility's policy on managing falls and fall risk, revised in March 2018, emphasizes the need for staff to implement resident-centered fall prevention plans based on specific risk factors, which was not adhered to in this case.
Incomplete Post-Fall Assessment for High-Risk Resident
Penalty
Summary
The facility failed to implement its Fall Management policy and procedure for a resident with a history of falling, resulting in an incomplete post-fall assessment. The Director of Nurses (DON) confirmed that the resident experienced a fall in the bathroom and an unwitnessed fall, indicating a high risk for falls. During a review of the resident's Post Fall Review (PFR) assessment, it was found to be incomplete, lacking an evaluation of the resident's medications. The facility's policy requires a comprehensive PFR assessment after each fall, including a review of medications, cognition, behavior, and incontinence to determine the cause of the fall. Both the DON and Administrator acknowledged the incompleteness of the PFR assessment, confirming that the resident's medications were not assessed as required by the facility's policy.
Failure to Report Financial Abuse to Attending Physician
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of suspected abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not report a suspicion of financial abuse to the attending physician of a resident. This incident involved a resident who discovered missing money from their bank account during a visit to the bank with the Administrator. Despite the facility's policy requiring immediate reporting of such suspicions to the resident's attending physician, the Director of Nursing and the Administrator confirmed that this notification did not occur. The facility's policy, revised in September 2022, explicitly states that the administrator or the individual making the allegation must report suspicions to the resident's attending physician, among other persons or agencies.
Failure to Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the California Department of Public Health (CDPH) within the required 24-hour timeframe and did not complete an investigation within five business days. The incident involved a resident who reported being raped by two men on multiple occasions. The resident's progress notes indicated that the charge nurse was informed of the allegation, but there was no documentation of a completed investigation in the resident's clinical record. During an interview, the Director of Nursing (DON) acknowledged that staff had reported the resident's allegations to her, and she instructed them to call 911 and follow the abuse protocol. However, the DON did not report the allegation to the CDPH, citing that the resident had changed her story. The facility's policy and procedure require all allegations of abuse to be reported to local, state, and federal agencies and thoroughly investigated, with findings documented and reported. The failure to adhere to these procedures resulted in a deficiency.
Failure to Notify Physician and Family of Resident's Falls
Penalty
Summary
The facility failed to notify the attending physician (AP) and responsible party (RP) of a change of condition (COC) for a resident who experienced two unwitnessed falls. The first incident occurred when the resident was found sitting on the floor between his wheelchair and toilet, with no obvious injuries noted, and the nurse documented notifying the medical doctor (MD) and family. However, during the second incident, the resident was found on the floor again, and there was no documentation of notification to the MD or family. This lack of communication was confirmed during a review of the resident's medical records and interviews with the Director of Nursing (DON). The facility's policy and procedure for notifying changes in a resident's condition or status, revised in February 2021, requires prompt notification of the resident's AP and RP in the event of an accident or incident. The policy also mandates detailed observations and information gathering before notifying the physician, using tools like the Interact SBAR Communication Form. Despite these guidelines, the facility did not document the required notifications for the resident's falls, leading to a deficiency in communication and potential unmet care needs.
Failure to Revise Fall Risk Care Plan
Penalty
Summary
The facility failed to revise the fall risk care plan for a resident who was identified as high risk for falls, scoring an 18 on the Fall Risk Observation/Assessment. The resident experienced two separate falls, one while attempting to transfer from the toilet to a wheelchair and another incident where the resident was found on the floor. Despite these incidents, the care plan was not updated to reflect the increased risk or to implement new interventions to prevent further falls. The Director of Nursing confirmed that the care plan should have been revised following each fall incident, as per the facility's policy and procedure on falls. The policy requires staff to evaluate and document falls, categorize them, and identify interventions to prevent future occurrences. However, this process was not followed, leading to a deficiency in the care provided to the resident.
Failure to Conduct Neurological Checks After Unwitnessed Falls
Penalty
Summary
The facility failed to conduct neurological checks for a resident who experienced two unwitnessed falls. During an interview, a Licensed Vocational Nurse (LVN) stated that neurological checks should be initiated if a fall is unwitnessed and should last for 72 hours. However, upon reviewing the resident's medical records, it was found that no neurological checks were completed for the incidents on the specified dates. The Director of Nursing (DON) confirmed that the resident had two separate unwitnessed falls and that the required neurological checks were not performed. The facility's Neurological Flow Sheet outlines the procedure for conducting these checks, which includes monitoring vital signs and neurological status at specified intervals for 72 hours. Despite this protocol, the necessary assessments were not documented for the resident following the falls.
Inaccurate Documentation in Resident's Medical Record
Penalty
Summary
The facility failed to adhere to its own policy and procedure titled 'Documentation Accuracy In The Health Record' for one of the sampled residents. During an interview and record review with the Director of Nursing (DON), it was found that the Admission Record (AR) for a resident indicated the emergency contact as the resident's wife, with no other responsible party listed. However, the Discharge Summary (DS) for the same resident incorrectly included the name of another resident, who was not affiliated with the first resident, as the responsible party. The facility's policy emphasizes the importance of accurate clinical records for ensuring continuity of care, assisting staff in coordinating services, and serving as a legal document. The discrepancy in the resident's records, confirmed by the DON, highlights a failure to maintain accurate documentation, which is crucial for the facility's operations and legal responsibilities. This inaccuracy in the medical record was identified as a deficiency during the survey.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address and resolve a grievance raised by a resident, which resulted in a violation of the resident's rights. The grievance involved an incident where a Certified Nursing Assistant (CNA) told the resident that they should not call for help during a shift change. Subsequently, the resident was left in the bathroom with the call light on for one and a half hours. This grievance was documented in the Grievances Interview Record (GIR) dated August 25, 2023. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that the grievance regarding the call light was not addressed or resolved. The facility's policy and procedure for the Resident Concern/Grievance Program, updated in December 2006, outlines that grievances should be communicated to the Administrator within one business day and resolved within five business days. However, in this case, the grievance was not resolved as per the facility's policy, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to communicate a change in condition to the primary care physician for a resident, which had the potential to delay care and worsen the resident's condition. The resident was initially assessed as alert and oriented, but subsequent evaluations noted confusion and severe cognitive impairment. Despite these changes, there was no documentation indicating that the primary care physician was notified of the resident's new onset of confusion. Interviews with staff revealed a lack of awareness regarding the resident's baseline cognitive status, and the facility's policy required prompt notification of changes in a resident's condition to the physician. The resident was eventually sent to the hospital for altered mental status after a family member expressed concern about the resident's behavior. The failure to notify the physician was a deviation from the facility's policy and procedure.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for one of the sampled residents, identified as Resident 1. During an interview and record review with the Director of Nursing (DON), it was found that on 5/25/2024, Resident 1 had a recorded blood pressure of 184/82, which is significantly higher than the normal range. The facility's policy requires that any blood pressure reading over 160 should be reported to a physician. However, there was no documentation indicating that Resident 1 was reassessed or that the physician was notified of the high blood pressure. The facility's policy, titled 'Change in a Resident's Condition or Status,' mandates prompt notification of the resident, their attending physician, and the resident representative of any changes in the resident's medical or mental condition. Notifications are to be made within 24 hours, except in medical emergencies. The failure to notify the physician of Resident 1's elevated blood pressure had the potential to result in unmet care needs for the resident.
Failure to Implement Care Plan for Call Light Non-Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive person-focused care plan for a resident who was non-compliant with using the call light. The resident, identified as having moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12, was noted to frequently yell for assistance instead of using the call light. Despite staff reminding the resident to use the call light, the resident continued to be non-compliant, which was documented in the nurse's notes. The Assisted Director of Nursing (ADON) acknowledged during a review that there should have been a care plan addressing the resident's non-compliance with the call light. The facility's policy and procedure on comprehensive person-centered care plans, dated 2022, requires the interdisciplinary team to develop a care plan with input from the resident and their family or legal representative. The policy also mandates that the care plan be reviewed and updated when there is a significant change in the resident's condition. However, the facility did not have a care plan in place for the resident's non-compliance with the call light, which placed the resident at risk of not having their care needs met.
Incomplete Dialysis Communication and Assessment
Penalty
Summary
The facility failed to ensure proper communication and coordination between the facility and the dialysis center for a resident requiring dialysis services. Specifically, the Pre and Post-Dialysis Communication Form (PDCF) for a resident was found incomplete, with the post-dialysis assessment sections left blank on multiple occasions. During an interview and record review, the Director of Nursing acknowledged that the post-dialysis assessments were not completed as required. The facility's policy and procedure for hemodialysis catheters, dated February 2023, mandates documentation of the catheter location, dressing condition, dialysis occurrence, post-dialysis report from the dialysis nurse, and post-dialysis observations in the resident's medical record every shift. The lack of documentation had the potential to result in complications due to the absence of an assessment of the dialysis site.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident following an unwitnessed fall, as required by their policy. The incident occurred on 6/8/24 when the resident was found lying supine on the floor by the right side of the bed after sliding off. The resident was identified as high risk for falls, but the fall care plan was not updated post-incident. During a review on 7/16/24, the Assistant Director of Nurses confirmed the absence of an updated care plan, acknowledging that it should have been revised following the fall. The facility's policy mandates that the interdisciplinary team reviews and updates care plans when there is a significant change in a resident's condition.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within easy reach, which could potentially impact the resident's ability to have their activities of daily living needs met. During an observation and interview, it was noted that the call light button was on the floor and not accessible to the resident. Both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) confirmed that the call light should have been within the resident's reach, either clipped to the sheet or the resident's clothes. The resident in question had a care plan indicating a decline in activities of daily living and mobility, requiring assistance due to behavioral symptoms, cognitive impairment, non-ambulatory status, pain, recent hospitalization, and weakness. The resident's Minimum Data Set (MDS) showed severe cognitive impairment and complete dependence on helpers for various tasks, including putting on footwear, toileting hygiene, bathing, and transfers. The facility's policy on answering call lights stated that the call light should be within easy reach of residents confined to bed or a chair, which was not adhered to in this instance.
Failure to Monitor and Document Behavioral Episodes
Penalty
Summary
The facility failed to monitor and document behavioral episodes for a resident diagnosed with a mental disorder, specifically bipolar disorder, which led to a potential risk of untreated worsening behavior. During an observation, the resident was noted to be agitated and upset while sitting in a wheelchair outside a conference room. The resident's care plan, dated 6/20/2024, indicated a risk for behavioral symptoms such as striking out, grabbing others, and being verbally or physically abusive. The care plan included interventions to document and record behavioral episodes, which were not followed. During a review of the care plan and an interview with the Director of Nursing (DON), it was confirmed that there was no documentation of behavioral monitoring for the resident. The facility's policy and procedure for comprehensive, person-centered care plans emphasized the need to describe services to assist residents in maintaining their physical, mental, and psychosocial well-being. However, the required documentation and monitoring of the resident's behavior were not conducted, leading to a deficiency in care.
Failure to Document Medication Administration Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the immediate documentation of medication administration for two residents. For Resident 1, the Medication Administration Audit Report (MAAR) showed discrepancies in the timing of medication administration and documentation. Medications such as Atorvastatin Calcium and Doxycycline Hyclate were scheduled for administration at 9:00 p.m. but were documented as administered at 10:58 p.m. Additionally, Humalog was scheduled for 9:00 p.m. but was documented as administered at 2:10 a.m. the following day. Similarly, for Resident 2, the MAAR indicated that medications like Empagliflozin and Losartan Potassium were administered later than scheduled, with documentation times not aligning with the scheduled administration times. Interviews with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurses (LVN) revealed that while medications were administered on time, the staff failed to document the administration immediately, as required by the facility's policy. The ADON confirmed that the investigation into the late administration times showed that the medications were given timely but not documented promptly. Both LVN 1 and LVN 2 acknowledged that medications should be documented immediately after administration, aligning with the facility's policy titled 'Documentation of Medication Administration' dated November 2022.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that medication carts and the medication room were free from expired medications, which had the potential for residents to receive expired medications. During an observation and interview with the Director of Nursing (DON), an expired emergency drug supply box was found in the medication room refrigerator. Additionally, an insulin labeled with a discard date of 5/14/24 was found in a medication cart, and the Licensed Vocational Nurse (LVN) confirmed it was expired. The facility's policy and procedure (P&P) on medication storage indicated that outdated medications should be immediately removed from stock and disposed of according to procedures, which was not followed in these instances. The facility also failed to follow their P&P on medication labeling, which had the potential to result in medication errors. During observations and interviews with LVNs, several medications were found without proper labeling, including the resident's name, medication name, specific directions for use, strength of medication, prescriber's name, date filled, and quantity of medication filled. Additionally, an insulin in a medication cart was not dated, and the LVN did not know when it was placed in the cart. The facility's P&P indicated that insulin bottles/pens should be dated when opened and discarded as per manufacturer recommendations, which was not adhered to in this case.
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.
