Asistencia Villa Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Redlands, California.
- Location
- 1875 Barton Rd, Redlands, California 92373
- CMS Provider Number
- 555379
- Inspections on file
- 39
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Asistencia Villa Healthcare Center during CMS and state inspections, most recent first.
A resident with mobility and gait issues left the facility without staff knowledge and was missing for five hours before being found at a nearby building. The resident did not have authorization to leave, and staff interviews confirmed that required supervision was not maintained, resulting in the resident's unsupervised exit.
A resident with a history of cardiac arrest received a double dose of Metoprolol Tartrate when two LVNs each administered the medication, due to a lack of immediate documentation and failure to verify assignments. The medication was present in both nurses' carts, and only one administration was recorded in the MAR, contrary to facility policy requiring immediate documentation.
Two residents with significant medical needs, including respiratory failure and paralysis, experienced delays in receiving assistance with ADLs such as changing and personal hygiene. Both residents reported waiting extended periods for help, particularly during night shifts, and staff interviews confirmed that care was sometimes delayed due to insufficient staffing. Facility policy requires timely ADL support, but this was not consistently provided.
A resident with acute respiratory failure did not receive a scheduled dose of Pirfenidone due to a medication error at the facility. An LVN mistakenly disposed of the medication, believing it was discontinued, leading to its unavailability for administration. The DON confirmed the error, acknowledging that staff did not follow the facility's policy on medication error reporting.
The facility failed to maintain a sanitary kitchen, with observations of sticky residues, food crumbs, and trash in various areas, including a juice dispenser cabinet and under the steam table. An industrial mixer had food residue, and the ice machine had brown buildup. Staff acknowledged these areas should be clean, aligning with facility policies and FDA codes.
The facility failed to track and document staff COVID-19 vaccination status, as required by its policy. The ICP nurse was unaware of the responsibility to maintain such documentation until reviewing the facility's policy. The DON confirmed the lack of tracking, which could increase the risk of COVID-19 exposure to the 95 residents.
A leaking countertop water dispenser in the facility was not repaired, leading to standing water accumulation. Staff acknowledged the issue, and dietitians expected prompt repair. The facility's maintenance policy and FDA guidelines emphasize the need for equipment to be in good repair to prevent health risks.
A resident experienced a significant change in condition, transitioning from gastric tube feeding to an oral diet, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within the required 14-day period. The MDS nurse did not update the assessment, resulting in a 68-day delay, leaving the resident's care plan outdated and not reflective of their current needs.
A facility failed to accurately complete the MDS assessment for a resident using mittens and an abdominal binder as restraints. Despite physician orders and observations confirming the use of these restraints, the Quarterly MDS assessment did not reflect this, violating the facility's policy on assessment accuracy. The DON and MDS Nurse acknowledged the oversight.
A medication cart in the 200's hall was found unsanitary with a yellow moist buildup in the bottom drawer containing over-the-counter medications. Both an LVN and the ICP nurse confirmed the unsanitary condition, which violated the facility's policy requiring clean and safe medication storage. The DON acknowledged the policy was not followed.
A facility failed to implement its antibiotic stewardship policy for a resident, as the ICP nurse did not accurately assess and collect necessary data to ensure appropriate antibiotic use. The resident, admitted with metabolic encephalopathy and ventilator-associated pneumonia, was prescribed Merrem and Zyvox for sepsis. However, the Surveillance Data Collection Form was incomplete, and the Loeb's criteria were not filled out, leaving it unclear if the antibiotics were used for a true infection. Interviews revealed the facility did not follow its policy, resulting in a deficiency.
A resident with polyneuropathy was mistakenly given Methocarbamol after it was discontinued, due to the facility's failure to remove the medication from the cart as per policy. The error was identified by an LVN and the resident's grandson. The facility's policy requires immediate removal of discontinued medications to prevent such errors.
Two residents with chronic conditions reported significant delays in call light response times, ranging from 10 minutes to two hours, affecting their daily living activities. Despite care plans indicating the need for prompt assistance, the facility failed to adhere to its policy, leading to residents waiting in soiled diapers and experiencing false documentation of care refusals.
A resident with a history of falls, seizures, and dementia fell and sustained a subdural hematoma due to inadequate supervision. The resident was found unsupervised at the nurse's station and fell from his wheelchair, hitting his head. The facility's policies on accident prevention and resident safety were not followed, as confirmed by the ADON.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for one of four sampled residents when the resident left the facility without staff knowledge and was missing for five hours. The resident, who had diagnoses including spinal stenosis of the cervical region and abnormalities of gait and mobility, was last seen by an LVN in the hallway around 5:00 AM. Shortly after, staff noticed the resident was not in his room during rounds, prompting a search and notification of the supervisor. The resident was eventually found at an adjacent facility and taken to the hospital. Record review and interviews revealed that the resident did not have authorization or a physician's order to leave the facility. The facility's policy requires constant supervision for residents not authorized to leave, and elopement assessments are conducted for those at risk. The administrator acknowledged that insufficient supervision contributed to the incident, as the resident was able to exit the building without staff awareness.
Double Dosing of Blood Pressure Medication Due to Documentation and Assignment Errors
Penalty
Summary
A deficiency occurred when a resident with a history of cardiac arrest was administered a double dose of Metoprolol Tartrate, a blood pressure medication, by two different licensed vocational nurses (LVNs). The first LVN administered the medication but was interrupted before documenting the administration. Upon returning, the LVN discovered that a second LVN had also administered the same medication, mistakenly believing the resident was assigned to him. The second LVN did not verify his assignment prior to giving the medication, and both LVNs found that the medication was present in both of their medication carts. Review of the Medication Administration Record (MAR) showed that only one administration was documented, and the facility's policy required immediate documentation after medication administration. Both the Administrator and the Director of Nursing confirmed that the policy was not followed, and the staff failed to adhere to the five rights of medication administration and proper documentation procedures.
Delayed Assistance with ADLs for Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who were clinically compromised and dependent on staff for care. Resident 1, with diagnoses including chronic respiratory failure, morbid obesity, dependence on a respirator, and quadriplegia, reported having to wait a long time to be changed on multiple occasions. The care plan for this resident identified problems with ADL decline and set goals for improvement in grooming, dressing, and toileting. Resident 2, diagnosed with chronic respiratory failure, COPD, paraplegia, and respirator dependence, also reported waiting a long time for help with changes, particularly at night. The care plan for this resident noted a self-care performance deficit and total dependence on staff for personal hygiene and oral care. Interviews with staff confirmed that delays in providing care occurred, especially when staffing was insufficient. A CNA acknowledged that it sometimes took a while to attend to residents' needs due to lack of help. The DON stated that nursing staff are expected to provide timely assistance and confirmed that residents' needs should have been met promptly. Review of the facility's policy indicated that residents should receive care to prevent decline in ADLs unless clinically unavoidable, and that appropriate care should be provided in accordance with the care plan.
Medication Error Due to Miscommunication and Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication error and adverse drug reaction reporting, resulting in a significant medication error for one resident. The resident, who was admitted with a diagnosis including acute respiratory failure, did not receive a scheduled dose of Pirfenidone, a medication prescribed for interstitial lung disease, on December 21, 2024. This omission occurred because a Licensed Vocational Nurse (LVN) mistakenly disposed of the medication, believing it had been discontinued. The error was realized later that day, but the medication was not available for administration. The Director of Nursing (DON) confirmed that the medication was not administered due to its unavailability, as it had been accidentally discarded. Another LVN corroborated this account, stating that the medication was not available for the scheduled dose. The facility's policy defines a medication error as an omission of a vital medication due to an error in prescribing, dispensing, or administering. The DON acknowledged that the staff did not follow the established policy, leading to the medication error.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by several observations. A cabinet storing a juice dispenser had a sticky residue on its handle, and inside the cabinet, there was a red juice spill. Additionally, the area under the steam table contained food crumbs and trash, and there was food residue around the floor sink. These conditions were noted during observations and confirmed through interviews with staff, who acknowledged that these areas should be kept clean. Further observations revealed that the industrial mixer was stored with white food residue on its exterior, which was covered by a black plastic bag. This was confirmed during an interview with the Registered Dietitian Nutritionists, who stated that the mixer should be cleaned thoroughly before being covered. The facility's policy on sanitization, as well as the FDA Federal Food Code, emphasize the importance of maintaining non-food contact surfaces in a clean state to prevent the accumulation of soil residues. Additionally, the ice machine in the kitchen had a brown buildup in the area where ice is formed. This was observed and confirmed by the facility's Maintenance Director, who stated that the area should be kept clean. The facility's policy on ice machines and the FDA Federal Food Code require regular cleaning to prevent the development of slime, mold, or soil residues. These deficiencies had the potential to attract pests and cause foodborne illness to the residents consuming meals prepared in the facility.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement its infection control program to prevent the spread of COVID-19 by not maintaining any tracking and documentation of staff COVID-19 vaccination status. During an interview and record review, the Infection Control Preventionist (ICP) nurse was unable to provide documentation indicating a tracking system for staff members' COVID-19 vaccination status. The ICP nurse admitted to being unaware of her responsibility to maintain such a system until she reviewed the facility's Policy and Procedure on COVID-19 Vaccination for Staff. The Director of Nursing (DON) confirmed that there was no tracking and documentation of staff COVID-19 vaccination status. The facility's policy, revised in January 2024, required the infection preventionist to maintain a tracking worksheet of staff members and their vaccination status, including specific details such as staff name, job title, vaccination status, and documentation of informed consent. The DON acknowledged that the facility did not follow this policy, which had the potential to cause harm to the 95 residents by increasing the risk of exposure and spread of the COVID-19 virus.
Leaking Water Dispenser Not Repaired
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as evidenced by a leaking countertop water dispenser. During an observation, it was noted that the water dispenser was leaking and collecting standing water in the drain beneath it. This issue was confirmed during an interview with a staff member who acknowledged that the dispenser was not in use and required repair. Further interviews with two Registered Dietitian Nutritionists revealed that there was an expectation for the water dispenser to be fixed promptly. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring all equipment is kept in a safe and operable condition. Additionally, the FDA Federal Food Code emphasizes the importance of maintaining equipment in good repair to prevent health risks to consumers.
Failure to Complete SCSA for Resident After Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period following a significant change in the resident's condition. The resident, who was initially receiving nutrition through a gastric tube, had the tube removed and transitioned to an oral diet. This change in the nutrition route and the level of eating assistance required an updated assessment to reflect the resident's current status. However, the MDS nurse did not complete the SCSA, which was due by August 10, 2024, resulting in a delay of 68 days without the assessment being completed. The deficiency was identified during a review of the resident's records and interviews with the Director of Nursing (DON) and the MDS nurse. The resident's clinical records indicated a change from dependent gastric tube feeding to oral partial/moderate assistance for eating, but the last MDS assessment was a quarterly assessment completed on July 18, 2024. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, but this was not adhered to, leading to the resident's care plan not being updated to reflect the current status.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed accurately for a resident, specifically regarding the use of restraints. Resident 68, who was admitted with diagnoses including metabolic encephalopathy and a tracheostomy, was observed wearing mittens and an abdominal binder to prevent interference with medical equipment. However, the Quarterly MDS assessment did not reflect the use of these physical restraints, as it was not coded under the relevant section for restraints and alarms. Interviews with the Director of Nursing (DON) and the MDS Nurse confirmed that the orders for the use of mittens and an abdominal binder were present, but the MDS assessment failed to capture this information. The facility's policy on certifying the accuracy of resident assessments was not followed, as the assessment did not accurately reflect the resident's status during the observation period. The MDS Nurse acknowledged that the restraints should have been coded, and the facility's failure to adhere to the policy was confirmed during the review.
Unsanitary Medication Cart Found in Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in accordance with currently accepted professional principles and its own policies and procedures. During an observation on October 16, 2024, a medication cart on the 200's hall was found to be unsanitary. Specifically, the left bottom drawer of the cart, which contained as-needed over-the-counter medications, had a yellow moist buildup. This was confirmed by a Licensed Vocational Nurse (LVN 2) who acknowledged the unsanitary condition of the drawer. Further inspection by the Infection Control Preventionist (ICP) nurse confirmed the presence of the yellow buildup. The ICP nurse emphasized the importance of keeping medication carts clean to maintain medication efficacy and prevent contamination. The Director of Nurses (DON) reviewed the facility's policy on medication storage, which mandates that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. The DON acknowledged that the policy was not followed, leading to the deficiency.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its policy and procedure on antibiotic stewardship for one of the residents, identified as Resident 47, who was reviewed for antibiotic use. The Infection Control Preventionist (ICP) nurse did not accurately assess and collect data to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for this resident. This oversight had the potential to place Resident 47 at risk for adverse events, including the development of antibiotic-resistant organisms, due to unnecessary or inappropriate antibiotic use. Resident 47 was admitted to the facility with diagnoses including metabolic encephalopathy and ventilator-associated pneumonia. A review of the resident's physician's orders revealed that antibiotics Merrem and Zyvox were prescribed for sepsis. However, during the review, it was found that the Surveillance Data Collection Form used to monitor and collect data on antibiotic use was incomplete. Key fields such as the diagnosis, culture, and type of infection were left blank, and the Loeb's minimum criteria for initiating antibiotics were not filled out, leaving it unclear whether the antibiotics were used for a true infection. Interviews with the ICP nurse and the Director of Nursing (DON) revealed that the facility's policy on antibiotic stewardship was not followed. The policy required that all clinical infections treated with antibiotics undergo review by the infection preventionist, and that antibiotic usage and outcome data be collected and documented. However, the ICP nurse admitted to not conducting the necessary analysis and review to confirm whether Resident 47 had a true infection, which was a critical step in ensuring the appropriate use of antibiotic therapy. The facility's failure to adhere to its own policy and procedure resulted in a deficiency in antibiotic stewardship practices.
Failure to Remove Discontinued Medication Leads to Administration Error
Penalty
Summary
The facility failed to adhere to its policy and procedure for the removal of discontinued medication from the medication cart, leading to a medication error involving a resident. The resident, who was admitted with a diagnosis of polyneuropathy, was administered Methocarbamol, a muscle relaxant, despite the medication having been discontinued. The error was identified when a licensed vocational nurse (LVN) administered the medication and later realized the mistake, which was also pointed out by the resident's grandson. The registered nurse supervisor and the facility administrator confirmed that the medication should have been removed from the cart immediately upon receiving the discontinuation order. However, the medication remained in the cart due to oversight, contributing to the error. The facility's policy, as outlined in their Discontinued Medications - Disposal policy and procedure manual, mandates the immediate removal of discontinued medications to prevent such errors, but this protocol was not followed in this instance.
Delayed Call Light Response for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for answering call lights in a timely manner, which affected two residents. Resident 1, who has chronic obstructive pulmonary disease and no mental impairment, reported that the average response time for assistance was 20 minutes. Additionally, Resident 1 mentioned instances of false documentation by staff regarding his refusal to shower. Resident 2, diagnosed with chronic respiratory failure with hypoxia and also without mental impairment, reported that call light response times ranged from 10 minutes to two hours, with longer delays during nighttime and shift changes. Resident 2 experienced waiting in soiled diapers for up to two hours. The care plans for both residents indicated deficits in activities of daily living, requiring prompt assistance with tasks such as personal hygiene, dressing, and toilet use. Despite these documented needs, the facility did not ensure that call lights were answered promptly, as confirmed by interviews with the residents and a Certified Nursing Assistant. The assistant director of nursing acknowledged the issue but did not provide comments on the findings. The facility's policy, revised in October 2010, emphasized the importance of responding to residents' requests and needs, which was not followed in these cases.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent avoidable accidents, resulting in a resident falling and sustaining a subdural hematoma. Resident 4, who had a history of repeated falls, seizures, dementia, and gait abnormalities, was found unsupervised and fell from his wheelchair, hitting his head. The incident occurred while the resident was sitting at the nurse's station, and the fall was unwitnessed. Following the fall, the resident reported head pain and dizziness and was subsequently transferred to the emergency department, where a CT scan revealed bilateral subdural hematomas. Interviews with staff and review of the resident's care plan and clinical records indicated that the resident had not been adequately supervised, despite being identified as at risk for falls. The facility's policies on accident prevention and resident safety were not followed, as acknowledged by the Assistant Director of Nursing (ADON). The ADON confirmed that more supervision should have been provided to the resident to prevent the accident, highlighting a failure to adhere to established safety protocols and procedures designed to protect residents from avoidable accidents.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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