Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at California Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen sink area not kept sanitary. During observation and interview with the DM, the area under the kitchen sink and prep counter had black residue, dark buildup, flaking, and rusty-brown discoloration. The underside and bottom of the sink had yellow and brown food debris, and the drainpipe contained debris, rust, and old food residue. Review of cleaning logs did not show the area under the sink and prep counter was cleaned daily, and the facility P&P required dietary staff to maintain a sanitary environment by following the routine cleaning schedule.
The facility failed to submit PBJ staffing data for FY quarter 1. Review of the PBJ Staffing Data Report showed no quarter 1 submission, and the CPD stated the data on file reflected quarter 2 instead. The CMS Submission Report also showed Fiscal Quarter 2, confirming the missing required PBJ submission.
Respiratory care was not provided as ordered for three residents with COPD and/or PNA. A resident’s nebulizer bag was labeled for another resident and the tubing/mouthpiece were not properly dated, another resident’s NC was overdue for change, and a third resident’s nebulizer tubing and mouthpiece were left at the bedside after treatments were completed. Staff and the IP stated the supplies should be dated, changed weekly, and removed after use.
An unlocked medication cart was observed left unattended in a hallway while staff and residents passed by. The assigned LVN acknowledged the cart was unsecured and stated medication carts should be locked when unattended. Another LVN stated the cart contained medications, including narcotic drugs, for residents in nearby rooms. The RNS and DON stated medication carts were to be locked when not supervised, and the DON confirmed the facility policy was not followed.
A resident who required partial/moderate assistance with eating was observed being fed lunch by a CNA who stood over the resident rather than sitting at eye level. The CNA stated she preferred to stand while assisting with meals, while another CNA and the DSD stated staff were trained to feed residents while seated at eye level to show respect and promote comfort. The facility policy stated residents must be cared for in a manner that promotes dignity, respect, individuality, and person-centered services.
A resident with depression received an increased sertraline dose after the prior dose was discontinued, but the facility could not produce informed consent for the higher dose. The MAR showed the resident received sertraline 100 mg daily for months, while the care plan called for education about the drug’s risks, benefits, and side effects. The MRD and DON confirmed the consent was missing, and facility policy required written informed consent before psychoactive medication treatment.
Delayed Completion of Admission MDS Assessment: A resident readmitted with palliative care needs, COPD, and immunodeficiency had an incomplete comprehensive admission MDS with multiple sections left blank and no RN completion signature. The MDS-C stated the assessment was overdue and not completed within the required timeframe, and the DON acknowledged that timely MDS completion is needed to avoid delays in care plan development.
Failure to Provide Nail Care and Personal Hygiene: A resident was observed with fingernails extending beyond the fingertips, with yellow buildup and black residue underneath. The resident stated he wanted his nails cleaned and trimmed but said it had not been done since admission. An LVN and the DSD both acknowledged the nails were long and dirty, and the DSD stated CNAs were primarily responsible for nail care with licensed nurses providing oversight.
A resident with stroke-related hemiplegia, hemiparesis, weakness, and contractures had an order for RUE AAROM exercises three times per week or as tolerated and as needed to maintain function. Documentation showed multiple blank entries for the restorative program, and the RNA, RNS, and DON confirmed the services were not documented as provided and that the resident’s care plan and facility policy were not followed.
Controlled substance accountability was inaccurate for two residents when MAR documentation did not match the Individual Narcotic Records for Tramadol and Percocet. An LVN and the DON confirmed that doses were signed out on the narcotic records without corresponding MAR entries or pain assessments, despite facility policy requiring immediate documentation after administration and reconciliation of CS inventory with the MAR and resident record.
A resident receiving Heparin SQ BID for DVT prophylaxis was not adequately monitored for side effects or ADRs, and the MAR lacked documented monitoring for bruising, bleeding, or other adverse reactions. The RNS confirmed there was no documentation of this monitoring, despite facility policy requiring nursing staff to observe for medication-related changes and document findings.
Medication Administration Errors Involving Incorrect Dose and Dosage Form: An LVN administered an incorrect Senna dose and gave OxyContin CR when the physician order was for oxycodone IR 10 mg BID. The MAR, blister card, and narcotic record reflected the CR/ER product, while the MD confirmed the intended order was immediate-release. The DON stated staff were expected to verify the correct medication, dose, and dosage form before administration.
A resident with epilepsy had an order for phenobarbital for seizure control, but the medication supply was exhausted and there was no documented refill request or physician notification when doses were missed. The MAR also documented phenobarbital as given on days when the narcotic record showed no remaining supply, and the DON confirmed there was no evidence of follow-up with the pharmacy or the physician.
The facility failed to follow infection control practices when a sharps container on a medication cart was observed filled past the fill line, and staff confirmed it should have been replaced. The facility also failed to follow EBP when a CNA changed a resident’s incontinent brief without wearing a gown, even though the resident had a PEG feeding tube and was on EBP; the CNA, an LVN, and an RNS all confirmed gown and gloves were required for that high-contact care.
Two residents with significant respiratory and chronic health conditions were not documented as being offered the COVID-19 vaccine, and the facility had no records of vaccine education, refusals, or acceptance for either resident. The IP, MRD, and DON all confirmed the absence of informed consent and vaccination documentation, despite the facility policy requiring annual COVID-19 vaccine education, offering vaccination, and maintaining vaccination status records.
A resident with a history of pulmonary embolism and intact cognition did not receive ordered morning doses of Eliquis and Hydrochlorothiazide. The MAR showed the medications were not administered by the assigned LVN, and there was no documentation explaining the omission or any notification to the physician, despite care plan directives to administer these drugs as ordered and a facility policy requiring timely administration, documentation of held medications, and physician notification.
A resident with a g-tube did not receive a daily stoma dressing change as ordered by the physician. The nurse responsible failed to perform the treatment, did not endorse it to the next shift, and incorrectly documented it as completed in the TAR. Observation revealed the dressing had dried drainage and the site was red and tender. Facility policy required daily care and accurate documentation, which was not followed.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A nurse failed to provide wound care as ordered by the physician for a resident with a chronic leg wound, instead applying dressings from memory of previous treatments without a current order. The nurse did not seek clarification from the physician before changing the treatment, contrary to facility policy and expectations outlined by the DON.
A resident with legal blindness and moderate cognitive impairment was observed smoking without the required smoking apron, as staff failed to provide it during a supervised smoke break. Facility records and staff interviews confirmed that the resident's care plan and facility policy mandate the use of a smoking apron for safety, but this protocol was not followed during the incident.
Five residents experienced severe unplanned weight changes that were not properly addressed, as the facility failed to complete required change of condition assessments, initiate weekly weights, reassess by the RD, communicate with physicians, or update care plans. These residents, with complex medical conditions, were not consistently monitored for meal intake or supplement use, and staff interviews confirmed that expected processes for addressing significant weight changes were not followed.
A facility failed to ensure a Registered Dietitian provided timely monitoring and intervention for several residents experiencing severe unintentional weight changes, did not maintain an updated diet manual or follow approved therapeutic menus, and allowed unsanitary food practices in the kitchen, including a dirty ice machine, unsafe freezer temperatures, and improper dish storage.
Surveyors identified multiple failures in kitchen food safety and sanitation, including an ice machine with visible debris and slime, dish machine sanitizer at excessive concentration, lack of beard nets on staff, improperly cleaned and stored dishes, and the use of soiled oven mitts. These deficiencies were acknowledged by facility leadership and did not meet professional standards or facility policy.
The facility did not have a written QAPI plan addressing systemic issues with weight loss, kitchen and nutrition services, and broken call light systems. The QAPI committee failed to identify and correct problems related to kitchen services and call light repairs, and did not evaluate prior interventions for weight loss, resulting in multiple residents not receiving appropriate care and experiencing delayed call light responses.
Surveyors found that the facility did not maintain the reach-in freezer and ice machine in safe and sanitary condition. The freezer was repeatedly observed at temperatures above freezing, with food items not properly frozen, and the ice machine was found out of service with visible debris and slime inside. Staff acknowledged the issues, and facility records did not accurately reflect the equipment's condition.
The facility failed to maintain a fully functional call light system, as the nurse's station panel lacked an audible alert and a resident with severe cognitive impairment had no call light within reach, relying on yelling for assistance. Staff were either unaware of the system's requirements or had not reported the deficiencies, and facility policy requiring accessible and operable call lights was not followed.
A facility failed to properly secure an opened emergency narcotic kit, and nursing staff did not consistently document the administration of controlled substances on both the count sheet and MAR for two residents. Additionally, staff did not reconcile a pharmacy delivery of a controlled medication that did not match the physician's order, resulting in discrepancies in medication administration and inventory.
Kitchen staff lacked proper training in food safety and sanitation, as demonstrated by incorrect use of chlorine test strips for dish machine sanitizer and inability to calibrate food thermometers. These deficiencies in staff competency exposed all residents consuming food from the kitchen to risks associated with improper food handling and sanitation.
Multiple residents reported that meals were frequently served cold, and a test tray evaluation confirmed that both hot and cold foods were not at the required temperatures. Additionally, food items such as spinach, potato wedges, and garlic bread were found to lack flavor or be difficult to eat, with the Diet Service Manager/Registered Dietitian acknowledging the need for better seasoning and cooking practices.
Staff failed to maintain infection control by allowing entry into the clean laundry area from the hallway with the door open, not properly disinfecting shared BP cuffs and stethoscopes according to manufacturer instructions, and placing meal trays in unsanitary locations such as next to a urinal or on a visitor's chair. These actions did not follow facility policies or infection prevention standards.
A resident with severe cognitive impairment and no capacity to make medical decisions was not provided with a legal representative or conservator, despite facility policy requiring such action. The facility did not follow its process to identify or appoint a surrogate decision-maker, and no referral was made to external agencies, leaving the resident without appropriate representation for medical decisions.
A resident reported missing personal belongings, including a hairbrush, make-up, slippers, pajamas, and $50 cash, after a room transfer. The personal effects inventory was incomplete, and staff failed to update records or notify the Social Service Director as required. The missing items were not promptly investigated, and only the wallet was recovered, with the cash still missing.
A resident with altered mental status, brain disorder, and psychosis was not provided with a required PASARR Level II referral after a positive Level I screening. The state agency closed the case due to the resident's inability to participate, instructing the facility to submit a new Level I screening, but no new screening or referral was documented. The Social Service Director confirmed the follow-up was not completed.
A resident with a history of Peripheral Vascular Disease and documented toenail fungus was observed to have thickened, flaking toenails and painful nail borders. Despite a podiatrist's treatment plan and facility policy requiring care plan updates for new conditions, no care plan was initiated to address the resident's onychomycosis. This was confirmed by an LVN during interview.
Two residents received care that did not meet professional standards when one was allowed to self-administer an Albuterol inhaler without a required assessment or physician's order, and another received Vitamin D3 without the medication strength being clarified in the physician's order. Facility policies regarding medication administration and order completeness were not followed.
A resident was admitted with multiple dry scabs on both forearms, but staff did not refer the condition to a physician or develop a care plan as required. The skin issues were documented on admission, but the treatment nurse and DON confirmed that the facility's process for assessment and physician notification was not followed, resulting in a delay in appropriate treatment.
A resident with COPD and on oxygen therapy was repeatedly found with cigarettes and a lighter in his possession, both in his room and on the smoking patio, despite facility policy requiring staff to securely store smoking materials and only provide them under supervision. Staff confirmed the resident was not allowed to keep these items, but observations showed ongoing non-compliance, creating a safety hazard.
A resident with moderate to severe cognitive impairment and a history of incontinence was identified as a candidate for a scheduled toileting program through multiple MDS assessments and screeners. However, staff did not perform or document the required bowel and bladder assessment or implement scheduled toileting, as outlined in the facility's policy.
A resident with heart failure, asthma, and COPD was given oxygen at 4 LPM via nasal cannula, contrary to the physician's order for 2 LPM. This was confirmed by an LVN and the DON, and the facility's policy required oxygen to be administered as ordered by the physician.
A consultant pharmacist did not identify or report a missing strength on a physician's order for Vitamin D3 during a monthly medication regimen review. As a result, a resident with chronic kidney disease received daily doses of Vitamin D3 without the order being clarified, and nursing staff administered the supplement without confirming the correct dosage. The omission was acknowledged by both nursing staff and the DON, and facility policy required such irregularities to be reported.
Two residents with renal conditions did not receive meals consistent with their prescribed renal diets when kitchen staff substituted white rice for brown rice, contrary to the approved menu. The dietary manager confirmed that staff are expected to follow printed menus to ensure appropriate nutrition for residents with therapeutic diet needs.
A resident with diabetes and renal failure was found with chocolate candies and other non-compliant snacks in his room, brought in by family and known to staff. Despite dietary orders for a diabetic renal diet and a care plan requiring monitoring and education, staff did not document or address the presence of these foods, failing to follow facility policy on outside food.
Physician progress notes failed to document significant weight loss for two residents with multiple comorbidities and cognitive impairment. Despite evidence of notable weight loss and interdisciplinary team awareness, the medical records lacked physician documentation addressing the issue or interventions to prevent further decline, contrary to facility policy.
The facility did not provide the required minimum of 80 square feet per resident in several shared rooms, as four residents were housed in rooms measuring only 310 square feet each. The Administrator confirmed the deficiency, and residents interviewed stated they were comfortable, with no observed negative impact on health or safety.
A resident with moderate cognitive impairment was found to have a shotgun, two airsoft guns, and a chainsaw in their room, violating the facility's policy against weapons. The items were discovered during an unannounced visit following safety complaints. The resident had a history of going out on pass, and it was suspected that the items were brought back during one of these outings. Staff interviews revealed a failure to enforce the policy effectively, as belongings were not checked and recorded upon the resident's return.
The facility failed to adequately supervise and monitor two residents at risk for elopement. One resident, with a history of elopement attempts, successfully left the facility and was later found disoriented by law enforcement. The resident's care plan was not updated, and no additional interventions were implemented. Another resident was observed without a required WanderGuard bracelet, and staff were unaware of its placement and functionality, indicating a lack of proper monitoring.
The facility failed to update care plans for two residents after multiple elopement attempts. Despite being identified as at risk for elopement, the residents' care plans were not revised following incidents, and IDT meetings were either not conducted or documented. The facility's policy requires care plan reviews at the onset of new problems, which was not followed, leading to continued risks for the residents.
A CNA in an LTC facility addressed two residents disrespectfully, violating their rights to dignity and respect. One resident with cognitive impairment was called derogatory names, while another was subjected to profanity and blame for falls. These incidents were reported to the facility administrator.
A resident experienced emotional distress when an unknown visitor was allowed into her room by a CNA without verifying the visitor's identity. The visitor falsely claimed to be the resident's sister to gain access. Facility staff acknowledged the breach of privacy and the failure to follow visitation procedures.
The facility failed to report an alleged abuse involving two residents to CDPH within the required two-hour timeframe. A CNA used inappropriate language towards the residents, who both have moderate cognitive impairments and significant medical histories. The Administrator was aware of the incident in the morning, but the report was not made until later that evening.
Kitchen Sink Area Not Kept Sanitary
Penalty
Summary
The kitchen environment was not maintained in a clean and sanitary condition. During an initial observation tour and interview with the Dietary Manager, the area underneath the kitchen sink and preparation counter was found covered with black residue, dark buildup, and areas of flaking and rusty-brown discoloration. The Dietary Manager confirmed these conditions during the observation. During a concurrent observation and interview, the underside and bottom portion of the kitchen sink were observed coated with stains and spots of scattered yellow and brown food debris, and the sink's white funnel-shaped drainpipe contained debris, rust, and old food residue. The Dietary Manager confirmed that the bottom part and drainpipe of the kitchen sink were coated with stains and spots of scattered food debris and residue and acknowledged that the sink required cleaning. Facility cleaning logs reviewed did not include the area underneath the kitchen sink and preparation counter as being cleaned daily, and the facility policy stated dietary staff would maintain a sanitary environment by complying with the routine cleaning schedule developed by the Dietary Manager.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure its Payroll Based Journal (PBJ) staffing data was submitted for Fiscal Year quarter 1. During review of the PBJ Staffing Data Report, the report showed no submission for FY quarter 1 2026 (October 1-December 31). In a concurrent interview and record review, the Clinical Project Director stated the staffing data that had been submitted reflected quarter 2, and the facility's CMS Submission Report dated 2/13/26 also showed Fiscal Quarter 2. Review of the State Operations Manual indicated the facility is responsible for submitting staffing data through the CMS PBJ system, and the facility's failure to submit PBJ data as required would be reflected on the CASPER report and result in a deficiency citation.
Respiratory supplies were mislabeled, overdue for change, and left at bedside after treatment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents when respiratory supplies were not labeled, not changed as ordered, or were left at the bedside after treatment was completed. Resident 17 had COPD and shortness of breath and was ordered to have nebulizer mask/tubing changed every Sunday night shift or as needed. During observation, the respiratory bag at the bedside was labeled for another resident, and the nebulizer tubing was not labeled with a date while the mouthpiece had a date of 3/30. Staff acknowledged the supplies should have been changed weekly and that bacteria can grow on them. Resident 1 had COPD and pneumonia and was ordered to have oxygen tubing changed every Sunday night shift and to receive oxygen at 2 L/min via NC. During observation, a NC dated 4/24/26 was found on top of the resident’s bed, and the LVN acknowledged the date on the NC. Resident 39 had an order for Ipratropium-Albuterol Solution for pneumonia for 5 days, with the last dose documented on 4/29/26. During observation, the nebulizer tubing and mouthpiece at the bedside were not dated and were left on top of the nebulizer machine, while the respiratory bag was dated 4/26/26. The RNS stated respiratory supplies such as NC, nebulizer tubing, and nebulizer mouthpiece should be labeled with a date and changed every week, and that staff were expected to verify the resident’s identity before labeling and placing supplies at the bedside. The IP stated respiratory supplies and equipment should be removed from the bedside after treatment was completed. The facility policy stated oxygen tubing and mask should be changed at least every 7 days and labeled with the date of change, and the nebulizer set-up bag should be labeled with the resident’s name and date and changed every seven days and as needed.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication Cart 3 was observed in the hallway in front of room [ROOM NUMBER] with its lock not pushed in and the cart left unlocked and unattended. Staff and residents passed by the cart while it was unsecured. During the observation, LVN 4 acknowledged that she was assigned to Medication Cart 3 and confirmed that the cart had been left unlocked and unattended. LVN 4 stated that medication carts should be kept locked when unattended to prevent residents and other people from accessing medications. LVN 5 stated that Medication Cart 3 contained medications, including narcotic drugs, and medical supplies for the residents of Rooms 24-35. RNS 1 stated that medication carts were to be kept organized and locked when not supervised, and that locking the cart when unattended was important to prevent unauthorized access by residents, staff, and visitors. The DON reviewed the facility policy titled, MEDICATION STORAGE IN THE FACILITY, and stated it was the expectation that staff keep the medication cart locked at all times when away from it; the DON also stated the policy was not followed.
Dignified Feeding Care Not Provided
Penalty
Summary
The facility failed to ensure care was provided in a dignified manner for one of 17 sampled residents, Resident 12, when a CNA fed the resident while standing and not at eye level. Resident 12's Face Sheet showed the resident was admitted to the facility on [DATE], and the MDS dated 2/19/26 indicated the resident required partial/moderate assistance for eating. During an observation on 5/4/26 at 1:10 PM, Resident 12 was seated in a wheelchair in the resident's room while CNA 1 stood over the resident and fed lunch with a spoon, remaining standing above the resident's eye level throughout the interaction. During interview, CNA 1 stated she preferred to stand while feeding and assisting Resident 12 with meals. CNA 2 stated staff should establish eye contact and sit at residents' eye level while feeding to convey respect and ensure residents feel valued, and the DSD stated staff received in-services regarding feeding residents at eye level and in a sitting position, with standing discouraged. The facility's policy titled Resident Rights - Quality of Life stated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, individuality, and person-centered services.
Failure to Obtain Informed Consent for Increased Sertraline Dose
Penalty
Summary
The facility failed to obtain informed consent before administering an increased dose of sertraline for one resident with a diagnosis of depression. Resident 16 had physician orders showing sertraline 25 mg was discontinued and the dose was increased to 100 mg daily on 9/5/25 for depression manifested by verbalization of hopelessness and feeling depressed. The resident’s MAR showed sertraline 100 mg was administered daily from 9/6/25 through 3/23/26. The resident’s care plan included an intervention to educate the resident, family, or caregivers about the risks, benefits, and side effects or toxic symptoms of sertraline. During record review and interviews with the MRD and DON, the informed consent for the increased sertraline 100 mg dose could not be found, and the MRD confirmed there was no informed consent for the increased dose initiated on 9/5/25. The facility policy stated informed consent must be obtained prior to proposed treatment and placed in the medical record, and the psychoactive medication policy required written informed consent for treatment using psychoactive drugs.
Delayed Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to ensure timely completion of the comprehensive admission MDS assessment for one resident who was readmitted with diagnoses including encounter for palliative care, COPD, and immunodeficiency. The resident’s comprehensive admission MDS had an ARD of 4/11/26, but multiple sections were left blank, including hearing, speech and vision, functional abilities, bladder and bowel, health conditions, swallowing/nutrition status, oral/dental status, skin conditions, medications, special treatments/procedures/programs, care area assessment summary, and the RN assessment coordinator signature and date verifying completion. During a concurrent interview and record review, the MDS-C stated the assessment was not completed yet and should have been completed within 14 days of admission, identifying it as 24 days overdue. The MDS-C stated this was not acceptable because there would be no baseline assessment needed to develop a comprehensive and individualized care plan for the resident. The DON also stated the MDS must be completed in a timely manner to avoid delays in developing residents’ care plans.
Failure to Provide Nail Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary nail care services and personal hygiene for Resident 97 by not ensuring the resident’s fingernails were cleaned and trimmed. During an initial observation in the resident’s room, Resident 97 was awake, verbally responsive, and lying in bed. Both hands had fingernails extending beyond the fingertips, with a build-up of yellow substance at the base of the nails and black residue underneath. Resident 97 stated he wanted his fingernails cleaned and trimmed but said no one had done it since he was admitted. A review of the resident’s care plan, initiated on 4/28/26, identified a focus on potential impairment to skin integrity related to fragile skin and immobility, with interventions to avoid scratching and keep fingernails short. During a later observation, an LVN acknowledged the fingernails were long and had dirt underneath and stated they needed to be cleaned and trimmed because they could cause skin tears and infections. The DSD also acknowledged the long fingernails with black residue underneath and stated they had to be cleaned and trimmed, adding that CNAs were primarily responsible for cleaning and trimming fingernails and licensed nurses were responsible for oversight to ensure residents were well groomed.
Restorative Nursing Services Not Provided as Ordered
Penalty
Summary
The facility failed to ensure needed restorative nursing services were provided to maintain range of motion for one resident with hemiplegia, hemiparesis, muscle weakness, and contractures. The resident was readmitted with diagnoses including stroke-related left-sided weakness and contractures, had a BIMS score of 7, and was dependent for eating, toileting hygiene, and personal hygiene. The resident’s care plan included right upper extremity assisted active range of motion exercises three times per week or as tolerated and as needed to maintain current function. A review of the resident’s restorative nursing documentation showed blank entries for several dates, with no documented evidence that the ordered RUE AAROM services were provided on those days. During interviews, the RNA stated that blank boxes indicated the treatment was not provided, and the RNS and DON both stated that staff were expected to follow the order and document services after they were provided. The DON acknowledged that the restorative nursing services were not documented on the identified dates and stated that the resident’s plan of care and the facility’s policy and procedure were not followed.
Controlled Substance Documentation Records Did Not Match MARs
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances for two residents, involving Tramadol for one resident and Percocet for another. During review of Medication Cart 2A, the resident’s Tramadol blister card and Individual Narcotic Record showed doses signed out on 4/6/26 at 0500 and 5/2/26 at 0900, but the MAR for April 2026 through May 2026 had no corresponding documentation of administration or pain assessments. The LVN confirmed the records did not match. A second discrepancy was identified on Medication Cart 3 for another resident’s Percocet 10/325 mg. The Individual Narcotic Record showed doses removed and signed out on 4/26/26 at 1330, 4/29/26 at 0700, 1400, and 2050, but the MAR for April 2026 had no documentation that the resident received Percocet at 4/26/26 1:30 PM, 4/29/26 7:00 AM, or 8:50 PM. The LVN and DON both confirmed the discrepancies between the Individual Narcotic Records and the MARs, and the facility policy required immediate documentation after administration and reconciliation of controlled substance inventory with the MAR and the resident’s controlled substance record.
Failure to Monitor Heparin for Adverse Drug Reactions
Penalty
Summary
The facility failed to adequately monitor one resident for side effects and adverse drug reactions related to Heparin Sodium 5000 unit/ml, which was ordered subcutaneously twice daily for DVT prophylaxis. The resident’s MAR showed Heparin was started on 4/18/26 and continued through 5/7/26, but there was no documented evidence in the MAR of monitoring for adverse reactions during that period. During a concurrent interview and record review, the RNS stated there was no documented evidence in the MAR of monitoring for adverse reactions for the resident’s Heparin use. The RNS also stated that residents receiving Heparin should be monitored for bruising, bleeding, and side and adverse effects of the medication. The facility policy on Adverse Drug Reactions required nursing staff to observe for changes in condition associated with medications, including bleeding, and to document findings in the medical record and notify the physician.
Medication Administration Errors Involving Incorrect Dose and Dosage Form
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders when a medication error rate of 8% was identified during medication administration observations for one resident. During an observation of medication administration for Resident 39, an LVN prepared and administered 17 medications, including two tablets of Senna 8.6 mg and one tablet of OxyContin CR 10 mg. The physician's order for Senna specified one tablet daily, but the LVN administered two tablets, and the LVN later confirmed that one tablet should have been given. The resident's physician order for oxycodone specified a 10 mg tablet twice daily, but the medication packaging and narcotic record reflected OxyContin ER/CR 10 mg, and staff documented administration of oxycodone 10 mg twice daily from 4/15/26 through 5/4/26. The primary physician stated the intended order was oxycodone immediate-release 10 mg twice daily, not controlled-release. The DON stated staff were expected to verify the correct medication, dose, and dosage form before administration and that IR and CR discrepancies should have been clarified with the physician or pharmacy prior to administration.
Missed Phenobarbital Doses and Medication Documentation Error
Penalty
Summary
The facility failed to ensure that one sampled resident with epilepsy received phenobarbital as ordered and was free from a significant medication error. Resident 81 had a physician order for phenobarbital 30 mg, 3 tablets by mouth daily for seizures, and the care plan identified the resident’s seizure disorder with an intervention to give medications as ordered. The pharmacy delivered 45 tablets on 4/14/26, and the medication was documented as administered daily through 4/29/26 on the Individual Narcotic Record. After the last documented removal on 4/29/26, there was no documentation that phenobarbital was available or administered from 4/30/26 through 5/4/26. The MAR showed phenobarbital charted with code 9 on 4/30/26, 5/1/26, and 5/2/26, with a progress note on 4/30/26 stating the medication was pending refill delivery from the pharmacy. However, the subsequent progress notes did not document the medication status, follow-up with the pharmacy, or notification to the physician regarding the unavailable medication and missed doses. The pharmacy delivered another supply of phenobarbital on 5/5/26. During interview, the pharmacy technician stated the pharmacy did not receive a refill request from the facility between 4/30/26 and 5/4/26 and had no communication with the facility during that time. The DON confirmed there was no documented evidence that nursing staff notified the physician or followed up with the pharmacy regarding the unavailable phenobarbital, and also confirmed the MAR documented administration on 5/3/26 and 5/4/26 even though the narcotic record showed no remaining supply after 4/29/26.
Infection Control Failures With Overfilled Sharps Container and EBP Noncompliance
Penalty
Summary
The facility failed to implement infection prevention and control measures when the sharps container on Medication Cart 2 was observed filled beyond the fill line indicator. During a concurrent observation and interview, LVN 1 confirmed the container was overfilled and stated it should have been replaced. RNS 1 later stated that a full sharps container has an indicator line and that disposal and replacement are needed once the line is reached, and the Infection Preventionist confirmed the container exceeded the fill line and required replacement. The facility policy titled Sharps Disposal stated contaminated sharps are to be discarded into designated containers and that containers are to be sealed and replaced when they are 75% to 80% full. The facility also failed to follow Enhanced Barrier Precautions for Resident 60 during incontinent care. Resident 60 had a PEG feeding tube and was identified as being on EBP. During observation, CNA 1 was seen changing the resident’s incontinence brief without wearing a gown. CNA 1 stated that gloves and a gown must be worn when changing a resident’s brief and providing direct care for a resident on EBP, and confirmed she did not wear a gown. LVN 2 and RNS 1 both confirmed the resident was on EBP because of the feeding tube and that staff were required to wear gloves and a gown during high-contact care activities. The facility policy on Enhanced Barrier Precautions stated that gown and gloves are to be donned before each high-contact task, including changing briefs and device care for residents with indwelling medical devices such as feeding tubes.
Failure to Document COVID-19 Vaccine Offerings and Consent
Penalty
Summary
The facility failed to ensure that two sampled residents, Resident 17 and Resident 52, were offered the COVID-19 vaccine and failed to maintain documentation of vaccine education, refusals, or acceptance. Resident 17’s admission record showed a readmission with diagnoses including COPD, shortness of breath, and muscle weakness. Resident 52’s face sheet showed a readmission with diagnoses including pulmonary fibrosis, HTN, and adult failure to thrive. During interview and record review, the Infection Preventionist reviewed the residents’ medical records in PCC and the immunization log and stated there was no documented evidence that the COVID-19 vaccine had been offered and informed consent obtained from either resident or their representative for over a year. The Medical Records Director confirmed there was no recent documented evidence of COVID-19 informed consent and vaccination for these residents. The Infection Preventionist later acknowledged there was no documented evidence of COVID-19 vaccination and no documentation of vaccine education, refusals, or acceptance for the two residents. The DON stated it was the facility’s policy to annually offer the COVID-19 vaccine to residents and obtain informed consent so the benefits and risks could be explained. The facility’s IPC406 Management of COVID-19 policy stated residents are encouraged to receive COVID-19 vaccination and boosters and that the facility will maintain documentation of resident and staff vaccination status.
Failure to Administer Ordered Morning Medications and Notify Physician
Penalty
Summary
A resident with a diagnosis of pulmonary embolism and no cognitive impairment, as evidenced by a BIMS score of 15, did not receive ordered morning medications on February 20, 2026. Physician orders for that morning included Eliquis 5 mg and Hydrochlorothiazide 25 mg. Review of the Medication Administration Record (MAR) for that date showed that the morning medications were not administered by the assigned LVN. The resident reported during interview that she did not receive her 9:00 a.m. medications on that date and stated she did not experience any adverse side effects from missing them. Record review revealed no progress note or other documentation explaining why the medications were not given and no indication that the physician was notified of the missed doses. The resident’s care plans directed staff to administer Hydrochlorothiazide and anticoagulant medications, including Eliquis, as ordered. The DON confirmed that facility policy requires medications to be administered within one hour before or after the scheduled time and that, when medications are not administered, the nurse must notify the physician and document the reason. The LVN acknowledged being the medication nurse that morning, confirmed the medications were not administered, could not recall the reason, and verified that the physician was not notified and no progress note was entered, despite facility policy requiring both actions when medications are held.
Failure to Provide and Document Daily G-Tube Stoma Dressing Change
Penalty
Summary
A deficiency occurred when a treatment nurse failed to provide a daily gastrostomy tube (g-tube) stoma dressing change for a resident as ordered by the physician. The resident, who had a history of stroke and dysphagia and was cognitively intact, reported that the dressing change was not performed on the previous day. During observation, the nurse removed a dressing with a moderate amount of dried brown drainage and noted redness at the stoma site, which was also tender to touch. The nurse was unable to determine if the drainage was from the g-tube nutrition or the site itself and acknowledged the redness could be due to irritation from the drainage. Record review revealed that the treatment administration record (TAR) had been initialed by the nurse, indicating the dressing change was completed, even though the treatment was not provided. The nurse admitted to not performing the dressing change due to being occupied with rounds with the wound doctor and also failed to endorse the missed treatment to the next shift or notify the charge nurse, contrary to facility policy. The care plan for the resident required local care to the g-tube site as ordered and monitoring for infection, and facility policy mandated that treatments be provided as ordered and documented accurately.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when a nurse failed to provide wound care treatment in accordance with the physician's order for a resident with peripheral vascular disease and a chronic leg wound. The resident's treatment order specified cleansing the wound with normal saline, patting it dry, applying oil emulsion gauze, wrapping with Kerlix, and securing with retention tape every other day. However, during an observation, the nurse was seen removing a different set of dressings, including Coban, Kerlix, a 4x4 gauze pad, calcium alginate, and Xeroform, which were not part of the current physician's order. The nurse admitted to applying these dressings based on memory of past treatments rather than the current order and confirmed there was no physician order for the calcium alginate and Xeroform dressings used. Further interviews revealed that wound treatments are sometimes changed based on wound condition, but the nurse did not seek clarification or new orders from the physician before altering the treatment. The Director of Nursing stated that the nurse should have either applied the current ordered treatment or contacted the physician for clarification upon discovering a change in the wound's condition. Facility policy requires treatments to be administered as ordered by a physician, and any changes to orders must be clarified and documented before implementation.
Failure to Provide Required Smoking Apron for Visually Impaired Resident
Penalty
Summary
During an unannounced visit, it was observed that a staff member failed to provide a required smoking apron to a resident who was smoking on the facility patio. The Activity Assistant, responsible for supervising the smoking area, admitted to forgetting to give the apron to the resident, who was nearly finished with his cigarette before the omission was noticed and corrected. The resident, who is legally blind and has moderate cognitive impairment as indicated by a BIMS score of 12, confirmed that he is supposed to wear a smoking apron while smoking and did not have one on during the observed incident. Record review showed that the resident's care plan and smoking safety assessment both required the use of a smoking apron due to his blindness. Facility policy also mandates that residents assessed as needing a smoking apron must wear one during smoking, and that staff are responsible for ensuring compliance. Interviews with the Activities Director and Director of Nursing confirmed that the expectation is for staff to provide and ensure the use of smoking aprons for residents who require them, and both verified that the policy was not followed in this instance.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to implement a comprehensive and systematic approach to monitor and maintain acceptable nutritional status for five residents, resulting in severe unplanned weight changes that were not properly addressed. For each of the five residents, significant weight loss or gain was documented over a period of months, but required actions such as completing a change of condition assessment, initiating weekly weights, reassessment by the Registered Dietitian (RD), communication with the physician, and updating the care plan were not performed. In several cases, the Interdisciplinary Team (IDT) did not address the weight changes, and the care plans did not reflect the interventions needed to address the residents' nutritional needs. The residents affected had complex medical histories, including diagnoses such as uncontrolled diabetes mellitus, hyperlipidemia, chronic kidney disease, hypothyroidism, dysphagia, and hemiplegia. Despite documented weight losses ranging from 5.78% to 12.3% over three months, and one case of a 10.26% weight gain, the facility did not follow its own policies for timely notification of physicians, reassessment by the RD, or implementation of appropriate interventions. In some cases, meal intake records and supplement consumption data were missing or incomplete, and the facility failed to provide requested documentation to surveyors. Observations and interviews revealed that residents were not consistently monitored for meal intake, and their preferences and needs were not always accommodated. Staff interviews confirmed that the expected processes for addressing significant weight changes were not followed. The RD and DON acknowledged that nutrition interventions and care plans should have been updated, and that communication with the physician and IDT was lacking. Facility policies required prompt evaluation and intervention for significant weight changes, but these procedures were not consistently implemented, resulting in compromised nutritional status for the affected residents.
Removal Plan
- Notify the Physicians for Residents 23, 43, 51, 58, and 673 of significant and severe weight change.
- Re-weigh all five residents and place on weekly weights.
- Review labs, weights, physician visits, PO intake, and therapy orders for the five identified weight loss residents 23, 43, 51, 58, and 673.
- The RD will re-assess and re-evaluate Residents 23, 43, 51, 58, and 673 nutrition status.
- Immediate training for Certified Nursing Assistants and Licensed Vocational Nurses on monitoring and recording meal intake percentages and supplement orders.
- The RD will monitor the weekly weights and residents with significant weight loss and residents who are under 100 pounds were reevaluated by the Senior Regional Registered Dietitian and followed up by the Facility RD, as well as the Weight Variance and Nutrition Condition Interdisciplinary team.
- IDT will monitor for sustainable compliance to determine weight variances/significant weight losses and accuracy of assessments to meet weight loss resident's nutritional needs and goals of care such as improved PO intake or weight goals are met. Identified concerns will be addressed and reported to the DON and Administrator for follow-up as warranted.
- Senior Regional Registered Dietitian provided one to one re-education to the Registered Dietitian on Evaluation of Weight & Nutritional Status Policy and Procedures and an RD competency with current facility's RD.
- Regional Quality Management Compliance and Senior RD completed education on Evaluation of Weight and Nutritional Status policy with IDT members.
- The Medical Director was notified by the Administrator and Director of Nursing of the concerns related to Weight Loss and Nutritional Assessments and presented and discussed the action plan for implementation.
- Pharmacy medication regimen review completed for the five identified weight loss residents 23, 43, 51, 58, and 673 for review of weight change related medications.
Failure to Ensure Adequate Nutrition Services and Food Safety
Penalty
Summary
The facility failed to ensure that a Registered Dietitian (RD) carried out essential nutrition and food service functions, resulting in multiple deficiencies. Five residents experienced severe, unintentional weight changes, including significant weight loss and one case of weight gain, over a three-month period. These residents had complex medical conditions such as uncontrolled diabetes, hyperlipidemia, hypothyroidism, chronic kidney failure, and dysphagia. The RD did not implement weekly weight monitoring, failed to reassess residents to determine appropriate interventions, and did not communicate significant weight changes to physicians. Documentation of nutrition goals and interventions was lacking, and the interdisciplinary team was not adequately involved in addressing these issues, as confirmed by interviews with the RD, corporate RD, DON, and medical director. The facility's diet manual was found to be outdated and not reviewed or signed off for the current year by the RD and medical director. Additionally, the facility did not consistently follow approved menus for therapeutic diets, such as renal diets. During meal service observations, staff substituted menu items without regard to dietary requirements, and the RD acknowledged the importance of adhering to approved menus to ensure residents received appropriate nutrition. The facility's policy required annual review and approval of the diet manual and adherence to planned menus, but these standards were not met. Multiple unsanitary and unsafe food practices were observed in the kitchen. The ice machine contained visible debris and slime, and was cleaned only monthly. The reach-in freezer repeatedly registered temperatures far above safe levels, with food items such as ice cream found soft and partially thawed. Kitchen equipment, including pans and strainers, was found with food debris and stored while still wet, and cutting boards were heavily marked. The RD and other staff acknowledged these conditions were unacceptable and not in compliance with infection control and food safety policies. These failures were documented in monthly kitchen inspection reports and were not adequately addressed.
Failure to Maintain Food Safety and Sanitation in Kitchen Operations
Penalty
Summary
The facility failed to maintain food safety and sanitation practices in the kitchen as required by professional standards and facility policy. Surveyors observed that the ice machine was not properly maintained or cleaned according to manufacturer guidelines, with visible dark brown and black debris, as well as a slimy substance inside the bin and on internal parts. The Maintenance Supervisor was using dish soap and an unspecified solution for cleaning, which did not align with the manufacturer's recommended cleaning agents and procedures. The ice machine was marked out of service, and both the Director of Nursing and the Dietary Service Manager-Registered Dietitian acknowledged the unacceptable condition and the risk it posed to residents, especially those with weakened immune systems. Additionally, the dish machine sanitizer solution was found to be outside the correct chemical range, testing at 300-400 ppm, which is higher than the recommended level. Kitchen staff confirmed the sanitizer concentration was too high and acknowledged the need for adjustment. Observations also revealed that kitchen staff did not consistently wear beard nets while working, with one staff member admitting to forgetting this mandatory requirement. Furthermore, dishes and large metal pans with food debris and dripping water were stacked together in storage, and other utensils and cutting boards were found with dried residue and markings, indicating they were not properly cleaned or dried before being put away. Surveyors also noted that kitchen staff were using cloth oven mitts that were wet, soiled, and had food build-up and residue. The Dietary Service Manager-Registered Dietitian confirmed that these mitts should not be used due to the accumulation of dirt and potential bacteria. These findings were corroborated by facility policies and the 2022 Federal Food Code, which require proper cleaning, sanitizing, and personal hygiene practices in food service areas. The facility census at the time was 72.
Failure to Implement Comprehensive QAPI Plan for Systemic Issues
Penalty
Summary
The facility failed to maintain a written Quality Assurance Performance Improvement (QAPI) plan that addressed systemic process issues related to weight loss, kitchen and nutrition services, and the repair of broken call light systems. During the survey, it was found that the QAPI committee, which included the Administrator, DON, Medical Director, Radiology, Pharmacy, Laboratory, and department heads, did not have a program in place to identify, correct, and improve issues concerning the broken call light system and kitchen and nutrition services. Although the QAPI program identified issues with weight loss, it did not evaluate the effectiveness of interventions implemented prior to December 2024. As a result of these deficiencies, multiple residents did not receive appropriate care and treatment for weight loss and experienced delayed responses to call lights. The lack of a comprehensive and data-driven QAPI plan also placed other residents at risk of not achieving their highest physical, mental, and psychosocial well-being. The facility's documentation indicated that each department was supposed to review and report on performance and outcomes, but these processes were not effectively implemented for the identified issues.
Failure to Maintain Safe and Sanitary Food Service Equipment
Penalty
Summary
The facility failed to maintain essential food and nutrition services equipment, specifically the reach-in freezer and the ice machine, in safe operating condition. During multiple observations, the reach-in freezer was found to have internal temperatures significantly above the required freezing point, with readings ranging from 41.9 to 55 degrees Fahrenheit. Food items such as ice cream were noted to be soft, and there was water condensation inside the freezer. Staff interviews confirmed awareness of the temperature issues, and temperature logs did not reflect the actual elevated temperatures observed by surveyors. Additionally, the ice machine was found to be out of service and in an unsanitary condition. Observations revealed dark brown and black debris, as well as a slimy substance inside the bin and on the ice cubes. The machine was being cleaned by the maintenance supervisor using dish soap and another cleaning solution, but the presence of debris and slime was confirmed by both the Director of Nursing and the Dietary Services Manager-Registered Dietitian. Both acknowledged that the condition of the ice machine was unacceptable and could pose a risk to residents, especially those with weakened immune systems. A review of facility policies indicated that both the freezer and ice machine were to be maintained and cleaned regularly according to manufacturer guidelines. However, the observed conditions and staff interviews demonstrated that these procedures were not consistently followed, resulting in equipment that was not safe for food storage or preparation.
Non-Functional Call Light System and Inaccessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that the call light system was fully functional and accessible to residents, as observed during a survey. The call light panel at the nurse's station did not emit an audible sound when activated from a resident's room, despite the light indicator being on. Multiple staff members, including the Registered Nurse Supervisor, Maintenance Supervisor, and Director of Nursing, confirmed that the audible alert had not been working since early January, and the issue had not been documented in the equipment log or discussed in the QAPI meeting. The Maintenance Supervisor had received an estimate for repair, but the deficiency persisted, and some staff were unaware that an audible alert was required for the system to function properly. Additionally, a resident was found in bed, alert but confused, and yelling for assistance, with no call light within reach or visible in the room. The resident, who had a history of severe cognitive impairment, psychosis, altered mental status, and incontinence, was unable to use the call light system and relied on yelling to communicate needs. A CNA confirmed that the resident's call light was not present and stated that facility policy requires call lights to be within reach of all residents, regardless of their ability to use them. Facility policies reviewed indicated that a functioning call system must be available to all residents in their rooms and toileting/bathing areas, and that call cords should be placed within reach and reported for immediate repair if defective. These requirements were not met, as evidenced by the non-functional call light panel and the absence of a call light for the resident, resulting in the potential for residents not to receive timely assistance from staff.
Deficient Handling and Documentation of Controlled Substances
Penalty
Summary
The facility failed to ensure proper provision of pharmaceutical services, specifically regarding the handling and documentation of controlled substances (CS). An emergency narcotic kit (E-kit) containing CS medications was found opened and unsealed in the medication room, without the required yellow lock. The Registered Nurse Supervisor (RNS) confirmed that after the kit was accessed, it should have been resealed and the pharmacy notified for replacement, as per facility policy. However, the kit remained unsealed, and the necessary procedures for securing and documenting the use of the E-kit were not followed. Additionally, there were multiple instances of incomplete or inconsistent documentation for the administration of CS medications to two residents. For one resident, several doses of hydrocodone-acetaminophen were signed out on the individual narcotic record (count sheet) but not documented on the Medication Administration Record (MAR), and vice versa. In some cases, doses were documented as administered on the MAR but not signed out on the count sheet. The Director of Nursing (DON) acknowledged that these discrepancies resulted in unaccounted doses and that the facility's policy required immediate and concurrent documentation on both the count sheet and MAR when CS medications are administered. Furthermore, the facility did not ensure that CS medications received from the pharmacy matched the current physician's orders. For one resident, the pharmacy delivered hydrocodone-acetaminophen with a frequency of every 8 hours, while the physician's order specified every 6 hours. Nursing staff failed to reconcile this discrepancy upon receipt, as required by facility policy. The DON and pharmacy representatives confirmed that the medication delivered should have matched the physician's order and that the discrepancy should have been identified and clarified at the time of delivery.
Deficient Staff Training in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that kitchen staff in the food and nutrition services department were adequately trained in accordance with standards of practice for food safety, sanitation, and facility policy. Specifically, one cook and a dietary aide demonstrated a lack of knowledge regarding the correct use of chlorine test strips to test sanitizer concentration in the dish machine. The cook misread the test strip results, and the dietary aide was unaware of the correct sanitizer concentration range, as well as the proper method for testing. The Dietary Service Manager-Registered Dietitian confirmed that both staff members did not know how to correctly test the sanitizer, which should be within the 50-100 ppm range as per facility policy and the 2022 Federal Food Code. Additionally, another dietary aide was observed to be unsure of how to calibrate a food thermometer, stating that this task was typically performed by the cook. The Dietary Service Manager-Registered Dietitian acknowledged this lack of knowledge. Facility job descriptions and policies require staff to maintain a safe and sanitary work environment and to calibrate thermometers periodically to ensure proper food temperatures. These deficiencies in staff competency exposed all 72 residents who consume food from the kitchen to practices associated with foodborne illness and potential cross-contamination.
Failure to Serve Food at Safe Temperatures and with Adequate Palatability
Penalty
Summary
The facility failed to ensure that food was served at acceptable temperatures and with adequate palatability, as required by facility policy. During a Resident Council meeting, multiple residents anonymously reported that food was served cold. An individual resident also stated that breakfast meals were cold almost every day. A test tray evaluation of both regular and pureed diets revealed that food items, such as roast beef and orange juice, were not at the recommended serving temperatures when measured with both the facility's and the surveyor's thermometers. The temperatures recorded for hot foods were below the facility's policy standard of greater than 140 degrees Fahrenheit, and cold beverages were above the required maximum of 41 degrees Fahrenheit. Additionally, the palatability of the food was found to be lacking. The spinach was described as having no flavor, the potato wedges were hard, and the garlic bread was dried out and tough to chew. The Diet Service Manager/Registered Dietitian acknowledged these issues, stating that improvements were needed in seasoning and cooking temperatures. These deficiencies were observed during meal service and confirmed through interviews, direct observation, and review of facility policies.
Infection Control Failures in Laundry, Equipment Disinfection, and Meal Service
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several key areas. In the laundry room, staff were observed entering the clean area from the resident hallway while the laundry door was open, and there was no signage indicating the clean area. The Housekeeping Supervisor and Infection Preventionist both acknowledged that leaving the door open and allowing staff to pass through the clean area increased the risk of contamination, which was contrary to facility policy requiring a clean and safe environment for linen handling. Nursing staff did not properly clean and disinfect shared blood pressure cuffs and stethoscopes between residents. Observations showed that staff used Sani-Cloth disposable wipes but did not adhere to the manufacturer's required two-minute contact time, and in some cases, alcohol pads were used instead of appropriate disinfectant wipes. The Infection Preventionist and Director of Nursing confirmed that staff were expected to follow the manufacturer's instructions for disinfection, which was not done, and that alcohol pads were not effective for this purpose. Facility policy required cleaning and disinfection of reusable resident care equipment according to CDC recommendations and manufacturer instructions, which was not followed. Additionally, meal trays were placed in unsanitary locations in residents' rooms. One resident's meal tray was observed on a bedside table next to a urinal, and another resident's tray was placed on a visitor's chair due to the absence of a bedside table. Staff acknowledged that these practices were not sanitary, and the Dietary Service Manager/Registered Dietitian stated that meals were expected to be served in a sanitary manner. Facility policy and the Federal Food Code require food to be protected from contamination and handled according to sanitary practices.
Failure to Appoint Legal Representative for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked capacity to make medical decisions was appointed a legal resident representative (RR) or conservator. The resident, who had diagnoses including altered mental status, a brain disorder, and psychosis, was documented as being able to make needs known but unable to make medical decisions, with a BIMS score indicating severe cognitive impairment. Despite this, records showed that the resident had no family or friends on file willing or able to serve as a legal representative, and the facility did not initiate the process to appoint a legal RR or conservatorship as required by their own policy. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that the facility's process for residents lacking decision-making capacity was not followed. The SSD acknowledged that a Bioethics Committee should have been convened to address the lack of legal representation, but this was not done. The facility's policy required efforts to identify a surrogate decision-maker and, if unsuccessful, to refer the case to the Office of Long Term Care Patient Representatives, but these steps were not documented or completed for the resident.
Failure to Protect Resident's Personal Property During Room Transfer
Penalty
Summary
The facility failed to exercise reasonable care for the protection of a resident's personal property, resulting in the loss of several items. A resident, who was alert and oriented with a history of hypertension and anxiety disorder, reported missing personal belongings including a hairbrush, expensive make-up, house slippers, pajamas, and $50 in cash after being transferred from one room to another. The resident stated she informed staff about the missing items but could not recall the exact date or the staff members involved. The personal effects inventory completed at admission listed some, but not all, of the missing items, and the wallet was documented as given to the charge nurse. Interviews with staff revealed that personal inventory lists should be updated upon room transfers and that missing property should be reported to the Social Service Director (SSD) for follow-up. However, the SSD was not aware of the missing items until interviewed by surveyors, and the resident's name was not on the facility's list of residents with missing property. Upon investigation, the SSD located the resident's wallet but found the $50 missing. The facility's policy required reasonable steps to protect residents' property, including securing valuables in the business office, but these procedures were not effectively followed, resulting in the loss of the resident's belongings.
Failure to Complete Required PASARR Level II Referral and Follow-Up
Penalty
Summary
The facility failed to ensure that a follow-up with the local authority for the completion of a Level II Preadmission Screening and Resident Review (PASARR) was performed for one resident. The resident was admitted with diagnoses including altered mental status, a disorder of the brain, and psychosis. Documentation showed that the resident's Level I PASRR screening was positive, indicating the need for a Level II referral. However, there was no evidence that a Level II referral was completed. Further review revealed that the state agency had closed the case after determining the resident was unable to participate in the Level II evaluation, and instructed the facility to submit a new Level I screening to reopen the case. There was no documentation that a new Level I screening was performed or submitted. The Social Service Director confirmed that the necessary follow-up and referral for Level II screening were not completed, and acknowledged that this step was missed for the resident.
Failure to Initiate Care Plan for Toenail Fungus
Penalty
Summary
The facility failed to initiate a care plan for a resident with toenail fungus, despite clear evidence of the condition and related complications. During an observation, the resident was found to have dry, flaking skin and hypertrophic toenails on both feet. The resident's medical record indicated a diagnosis of Peripheral Vascular Disease and a recent podiatry evaluation documented onychomycosis, onychohypertrophy, and painful nail borders on all toenails. The podiatrist's treatment plan included trimming and electrical debridement of the affected toenails. Despite these findings and the facility's policy requiring care plan updates for new problems or changes in condition, no care plan was initiated to address the resident's toenail fungus. This omission was confirmed during an interview with a treatment nurse, who acknowledged that a care plan should have been started for the condition. The lack of a care plan had the potential to result in ineffective treatment of the resident's foot care needs.
Failure to Meet Professional Standards in Medication Administration and Order Clarification
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for two residents. For one resident with a history of Chronic Obstructive Pulmonary Disease (COPD), an Albuterol Sulfate inhaler was observed on the resident's nightstand. The resident reported self-administering the inhaler, and nursing staff were aware of this practice. However, there was no assessment for self-administration, no physician's order permitting self-administration, and no documentation in the medical record or care plan regarding the resident's ability to self-administer medication or bedside storage, as required by facility policy. For another resident with chronic kidney disease, a physician's order for Vitamin D3 supplementation did not specify the strength of the medication. Despite this, nursing staff administered one tablet daily over multiple days without clarifying the order with the physician. During medication administration observation, a nurse identified the missing strength and withheld the dose, but review of the medical record confirmed that the order had not been clarified and the medication had been given without a complete order. Facility policies require that all medications brought in by residents or family members be properly labeled, stored, and assessed for self-administration, and that all physician orders for medications include the name, dosage, frequency, duration, and route. In both cases, these policies were not followed, resulting in medication administration practices that did not meet professional standards.
Failure to Refer Resident's Skin Condition for Physician Orders and Care Planning
Penalty
Summary
The facility failed to ensure that a resident with multiple dry scabs on both forearms was referred to a physician for treatment orders upon admission. Observation and interviews revealed that the resident was admitted with these scabs, which were noted during the initial skin check. However, there was no documented evidence that the scabs were reported to a physician or that a care plan was developed and initiated to address the skin condition at the time of admission. The resident and a family member confirmed the presence of the scabs prior to admission, and the family member reported using Neosporin during visits. Further review and interviews with the treatment nurse and DON confirmed that the facility's process for skin assessment and physician notification was not followed. The treatment nurse was not involved until several days after admission, and the required care plan was not developed until that time. The facility's policy required licensed nurses to complete a skin evaluation and obtain physician orders for treatments, but this process was not adhered to in this case.
Failure to Enforce Safe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to ensure safe smoking practices for a resident who was observed with cigarettes and a lighter in his possession, despite being on oxygen therapy via nasal cannula. Multiple observations confirmed that the resident kept cigarettes in his nightstand and wheelchair pocket, and was seen handing a lighter to another resident on the smoking patio. The resident's roommate was also on oxygen, increasing the potential for safety hazards. Staff interviews revealed that the resident was not permitted to have smoking materials in his possession, and facility policy required that such items be stored securely by staff and only provided during supervised smoking times. Record review indicated that the resident had a history of chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, and stimulant dependence. The care plan noted the resident's non-compliance with the smoking policy and the need for ongoing reeducation and monitoring for safety issues. Despite these measures, the resident continued to have access to cigarettes and a lighter, contrary to facility policy and individualized care planning, resulting in a failure to prevent potential accident hazards.
Failure to Implement Scheduled Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to ensure that a bowel and bladder assessment and evaluation were performed for a resident identified as a candidate for a scheduled toileting program. Despite the resident's care plan indicating a risk for bladder incontinence and the goal for continence during waking hours, there was no documented evidence that a bowel and bladder evaluation or scheduled toileting was implemented. The resident, who had moderate to severe cognitive impairment and was admitted with diagnoses including altered mental status and diabetes mellitus, was observed to use incontinence pads and required nursing assistance for changes. Multiple Minimum Data Set (MDS) assessments and Bowel and Bladder Program Screeners identified the resident as a suitable candidate for scheduled toileting on several occasions. However, interviews and record reviews confirmed that the required assessments and interventions were not documented or carried out as per facility policy. The facility's own procedures required licensed nurses to conduct assessments and document progress, but this process was not followed for the resident in question.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of heart failure, asthma, and COPD was observed receiving oxygen therapy at 4 liters per minute (LPM) via nasal cannula, despite a physician's order specifying oxygen at 2 LPM. This discrepancy was confirmed during observations and interviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the physician's order was not followed. Review of the resident's medical record and the facility's oxygen therapy policy further substantiated that oxygen should have been administered as per the physician's directive.
Consultant Pharmacist Failed to Identify and Report Missing Medication Strength
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported an irregularity during the monthly Medication Regimen Review (MRR) for a resident with chronic kidney disease. Specifically, the physician's order for Vitamin D3 did not specify the strength of the supplement, yet nursing staff administered one tablet daily over multiple days without clarification of the correct dosage. During medication administration observation, a licensed vocational nurse (LVN) noted the missing strength and stated the order required clarification, which had not been done at the time. Record reviews confirmed that the physician's order lacked a specified strength and that the medication administration record (MAR) documented daily administration of Vitamin D3. Both nursing staff and the Director of Nursing (DON) acknowledged the omission and the need for order clarification. The CP's MRR for the relevant month did not include any recommendations or identification of the missing strength as an irregularity, and the CP later acknowledged this oversight. Facility policy required the CP to identify and report such irregularities, but this was not done in this instance.
Failure to Follow Therapeutic Renal Diet Menus
Penalty
Summary
The facility failed to ensure that the therapeutic menu was followed for two residents on renal diets. Both residents had significant medical conditions, including chronic kidney disease, dependence on renal dialysis, and other comorbidities such as COPD, diabetes, hypertension, and hyperlipidemia. The prescribed diets for these residents required specific restrictions and modifications, including regulated protein, sodium, potassium, and fluid intake. However, during meal service, it was observed that the kitchen staff substituted white rice for brown rice on the renal diet tray, despite the menu specifying brown rice. The cook stated that white rice was the same as brown rice and served it due to the unavailability of brown rice. Interviews with the Dietary Services Manager-Registered Dietitian confirmed that it was the facility's expectation for kitchen staff to follow the printed menus to ensure residents receive appropriate nutrition according to their therapeutic needs. Documentation and menu reviews indicated that the renal diet was designed to regulate certain nutrients to protect kidney function. The failure to follow the approved menu resulted in the two residents receiving foods that did not meet their prescribed nutritional requirements.
Failure to Enforce Policy on Outside Food for Diabetic Resident
Penalty
Summary
The facility failed to implement its policy and procedure regarding food brought in from outside sources for a resident with diabetes and renal failure. During an observation, a resident was found with bite-size chocolate candies in his nightstand drawer, which he stated were brought by a family member and that staff were aware of their presence. The resident's medical record indicated he was on a diabetic renal diet and could not make medical decisions. The care plan included dietary restrictions and monitoring, but there was no documentation of staff addressing the non-compliant food items with the resident or family. Further review and interviews with staff, including an LVN and the DON, confirmed that the resident had additional non-compliant snacks at his bedside and that the facility's policy was not followed. The staff acknowledged that there was no documentation in the progress notes, physician orders, or resident/family education regarding the inappropriate snacks. The facility's policy required staff to ensure that outside food was compatible with the resident's care plan, to educate the resident and family if not, and to document and notify the physician, none of which occurred in this instance.
Failure to Document Significant Weight Loss in Physician Progress Notes
Penalty
Summary
The facility failed to ensure that physician progress notes in the medical records were accurately completed for two residents who experienced significant weight loss. For one resident with severe cognitive impairment and multiple diagnoses, including chronic kidney disease and malnutrition, a review of the medical record showed a weight loss of seven pounds (5.8%) over one month. However, the physician's progress notes during this period only addressed complaints of generalized pain and did not mention the resident's weight loss or any interventions to prevent further decline. Another resident, who had moderate cognitive impairment and diagnoses including COPD, chronic kidney disease, and lung cancer, experienced a six-pound (7%) weight loss over three months. The resident reported not having discussed her weight loss with her physician or the registered dietitian, and her medical record lacked any physician progress notes addressing the weight loss or monitoring efforts. Interdisciplinary team notes indicated that the physician was aware and that monitoring was ongoing, but this was not reflected in the physician's own documentation. Interviews with facility staff, including the DON, RD, and physicians, confirmed that the physician progress notes did not document the residents' weight loss. Both the DON and RD acknowledged the importance of including this information in the medical record for effective monitoring by the interdisciplinary team. The facility's policy required standardized and accurate completion of medical records, but this was not followed in these cases.
Failure to Meet Minimum Square Footage Requirements in Shared Resident Rooms
Penalty
Summary
The facility failed to ensure that bedrooms occupied by multiple residents met the required minimum of 80 square feet per resident. Specifically, rooms 3, 17, 20, and 33 each housed four residents but measured only 310 square feet per room, which is less than the required space per resident. This deficiency was confirmed through observation, interview, and record review, with the facility Administrator acknowledging that these rooms did not meet the space requirement. Residents interviewed in these rooms reported being comfortable with the space provided, and no negative impact on health and safety was observed during the survey.
Resident Found with Weapons in Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when a resident was found to have a shotgun, two airsoft guns, and a chainsaw in his room. This incident was discovered during an unannounced visit following anonymous complaints about resident safety. The Director of Nursing (DON) confirmed that these items were found while the resident was at the hospital, and the local police were notified to take custody of the weapons. The resident had a history of going out on pass, and it was suspected that he brought these items back into the facility during one of these outings. The facility's policy prohibits weapons on the premises, and staff are required to check and record residents' belongings upon their return from passes. Interviews with facility staff, including the DON, a social worker, a licensed vocational nurse, and a nursing assistant, revealed that the staff were aware of the policy against weapons but failed to enforce it effectively. The resident involved had a history of anxiety, altered mental status, and depression, with a BIMS score indicating moderate cognitive impairment. Despite the facility's policy and procedures, there was a lapse in monitoring and recording the resident's belongings, leading to the presence of dangerous items in the resident's room, which posed a potential risk to the safety of other residents and staff.
Failure to Monitor and Supervise Residents at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for two residents identified as at risk for elopement. Resident 1, who had a history of multiple elopement attempts, was not placed under one-on-one supervision or frequent visual checks despite being identified as high risk. On one occasion, Resident 1 successfully eloped from the facility during the night shift, and staff were unable to bring him back. The resident was later found by law enforcement in a disoriented state, highlighting the facility's failure to implement effective interventions to prevent elopement. Resident 1's care plan and elopement risk assessments were not updated or revised following multiple elopement attempts, and there was no documented interdisciplinary team meeting to address the ongoing risk. Despite having a WanderGuard and being on probation with an ankle monitor, the facility did not take additional measures to ensure Resident 1's safety, such as implementing a 1:1 supervision or conducting more frequent checks. The facility's policy required immediate interventions and care plan updates after an elopement attempt, which were not followed in this case. Resident 2, also identified as at risk for elopement, was observed not wearing a WanderGuard bracelet as ordered by the physician. The staff, including licensed nurses, were unaware of the WanderGuard's placement and functionality, indicating a lack of proper monitoring and adherence to the facility's policy. The failure to ensure Resident 2 was wearing the WanderGuard as prescribed further demonstrated the facility's inadequate supervision and monitoring of residents at risk for elopement.
Removal Plan
- Resident 1 was taken to the hospital for evaluation.
- The DON/Designee reviewed and audited residents with multiple attempts to leave the facility. Resident 2 was identified and placed under one-on-one supervision for safety.
- The Maintenance Supervisor inspected all exit doors and the WanderGuard system to ensure the alarms were working. All alarms and systems were functioning properly.
- New orders to monitor WanderGuard placement and function were added to the medication administration records for the five residents who were at risk. All wander guards were in place as ordered. IDT and care plans were updated based on elopement risk assessments.
- The Administrator and DON provided in-service training to facility staff on the facility's wandering and elopement policies, focusing on interventions for residents attempting to leave the facility and monitoring the WanderGuard system. The Administrator initiated an in-service with facility staff regarding Adequate Supervision and providing the appropriate level of oversight for all residents based on their needs.
- The Administrator conducted an in-service to licensed nurses on using the transmitter tester for WanderGuard, including proper usage, storage, extra supplies, and battery changes.
- The elopement binder was updated, and residents are being monitored and supervised according to their care plans.
- The licensed nurses will conduct room rounds every 2 hours during their assigned shifts to ensure all residents are accounted for and safe.
- DON/Designee checked that all residents identified as risk for elopement had orange arm bands.
Failure to Update Care Plans After Elopement Attempts
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and updated after they attempted to elope from the facility. Resident 1, who was admitted with dementia and identified as at risk for elopement, had multiple elopement incidents documented in his care plan. Despite these incidents, there were no documented updates or revisions to his care plan after several elopements, including the most recent one on November 18, 2024. The interdisciplinary team (IDT) meetings were either not conducted or not documented following these incidents, and the care plan remained ineffective as Resident 1 continued to elope. Resident 2, also diagnosed with dementia and identified as at risk for elopement, had similar issues with the lack of care plan updates. Despite having a Wander Guard order and being placed on a 1:1 observation at times, there were no documented IDT meetings or care plan revisions after Resident 2's elopements on August 23 and September 6, 2024. The facility's Social Service Director (SSD) and Director of Nursing (DON) acknowledged the lack of documentation and IDT meetings, attributing some of the issues to staffing changes and orientation periods. The facility's policy requires care plans to be reviewed and revised by the IDT at the onset of new problems or changes in condition, which was not adhered to in these cases. The DON stated that IDT meetings should occur the day after an elopement incident, but this was not consistently practiced or documented. The failure to update and revise care plans after elopement incidents resulted in continued risks for the residents involved.
Disrespectful Conduct by CNA Towards Residents
Penalty
Summary
The facility failed to uphold resident rights for dignity and respect for two residents when a Certified Nurse Aide (CNA) addressed them in a disrespectful manner. Resident 1, who has moderate cognitive impairment and a history of brain disorder and anxiety, was reportedly called a 'pimp' by CNA 4 in the main lobby. Although Resident 1 may not have understood the comment due to his cognitive status, the language used had the potential to cause emotional distress. Additionally, the receptionist observed CNA 4 addressing Resident 1 with derogatory language, calling him a 'f*****g pig,' and reported this to the facility administrator. Resident 2, diagnosed with cerebral infarction and dysarthria, was also subjected to disrespectful language by CNA 4. The Activity Assistant reported hearing CNA 4 express frustration towards Resident 2, using profanity and blaming the resident for frequent falls. This incident was also reported to the administrator. The facility's policy on resident rights, which mandates treating all residents with kindness, respect, and dignity, was not adhered to in these instances.
Breach of Resident Privacy Due to Unverified Visitor Access
Penalty
Summary
The facility failed to ensure the personal privacy of a resident when an unknown visitor was allowed into the resident's room. The incident involved a resident who was cognitively intact and had the capacity to understand and make decisions. The resident reported that a Certified Nurse Aide (CNA) escorted an unknown female into her room, who then hugged her and began talking to her. The visitor falsely claimed to be the resident's sister to gain access. This encounter caused the resident to feel uncomfortable and emotionally distressed. The CNA admitted to not verifying the visitor's identity and assumed the visitor and the resident knew each other. The facility's policy requires visitors to check in at the front desk, sign in, and state their business, which was not followed in this case. Interviews with facility staff, including a Registered Nurse and the Director of Staff Development, confirmed that the proper procedure was not adhered to, and the incident was acknowledged as a violation of the resident's privacy. The facility's Administrator also recognized the potential for abuse and emotional distress caused by allowing unknown visitors access to residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse involving two residents to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved inappropriate language used by a Certified Nurse Aide (CNA) towards the residents. The CNA referred to one resident as a 'pimp' and used offensive language in the presence of another resident. The facility's Administrator became aware of the allegations on the morning of September 25, 2024, but the report to CDPH was not made until later that evening, at 7:02 p.m. Resident 1, who has a moderate cognitive impairment and cannot make medical decisions, was subjected to inappropriate language by the CNA. Resident 2, also with moderate cognitive impairment and similar decision-making limitations, was present during the incident. Both residents have significant medical histories, including brain disorders and mental health issues. The delay in reporting the incident to CDPH could have resulted in a delayed investigation and corrective actions, potentially placing the residents at further risk.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Palm Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Desert Regional Medical Center D/p Snf | 0.8 mi | ★★★★★ | 6 | 0 |
| Palm Springs Healthcare & Rehabilitation Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Premier Care Center For Palm Springs | 3.3 mi | ★★★★★ | 32 | 1 |
| Bayshire Rancho Mirage | 9 mi | ★★★★★ | 1 | 0 |
| Rancho Mirage Health And Rehabilitation Center | 10.7 mi | ★★★★★ | 2 | 0 |
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