Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crescent City Care Center during CMS and state inspections, most recent first.
A resident with anxiety, PTSD, claustrophobia, and shoulder pain was showered by a CNA despite repeatedly refusing care and telling staff to stop. The resident reported feeling angry, fearful, and distrustful afterward, and the facility’s investigation confirmed the shower occurred despite her refusal. The SSD acknowledged the resident’s rights and psychological protections were not appropriately recognized during the incident.
A resident with multiple pressure-related skin conditions, including an unstageable pressure sore, deep tissue injuries, and moisture-associated skin damage, had care plans requiring that treatments and medications be administered as ordered and that skin care be provided per facility guidelines. Review of the Treatment Administration Record showed that an ordered zinc and foam dressing treatment to the bilateral buttocks was not provided by the afternoon shift on 11 days in the month. The DON confirmed these missed treatments and acknowledged that failure to administer the treatment as ordered posed a danger of infection and delayed healing, and that this was not in accordance with the facility’s medication administration policy requiring licensed nurses to follow physician orders and professional standards.
A resident with Parkinson's disease, dementia, PTSD, and corticobasal degeneration reported during a telepsych visit that people working in the facility were trying to hurt him. The ADON, who was present, heard the allegation, informed the Administrator, and completed the SOC 341, which the Administrator then submitted electronically to the state agency. However, the allegation was made at 11:30 a.m. and the SOC 341 was not sent until 3:17 p.m., exceeding the facility policy requirement to report alleged abuse to the state and other agencies immediately, but no later than two hours after the allegation is made.
Oxygen therapy equipment was not maintained for multiple residents receiving O2. Several residents had no humidifier in use, multiple concentrator filters were visibly dusty or dirty, and many residents had no physician orders for oxygen despite actively receiving it. The DON stated dirty equipment was concerning for respiratory injury and that no water in the humidifier could dry out the respiratory tract and make breathing uncomfortable.
Insufficient staffing led to missed resident care needs, including meal assistance, turning, nail care, getting residents out of bed, and keeping call lights within reach. Residents with malnutrition, diabetes, cognitive impairment, Parkinson's disease, and other conditions were observed sleeping through meals, remaining in bed for repeated observations, and having long or dirty nails, while staff said they were assigned too many residents and did not have time to complete all required care.
The facility failed to maintain current dietary preference documentation for most residents and relied on an outdated Diet Type Report for meal service. Only five of 85 lunch tray tickets had documented preferences, and dining room staff used a report that was two weeks old to verify current diet type and texture orders. The IP confirmed the report was outdated, and the DON acknowledged that using outdated diet information could result in residents receiving incorrect diets.
Inadequate dietary staff competency for dishwashing operations: A new Dishwasher operated the dishwashing machine at 108 degrees F but could not state the required operating temperature or explain how to test for chlorine sanitation. The CDM stated the employee had worked at the facility for three weeks and had not completed required competency checks, and the DON stated dietary staff were expected to be competent in their assigned duties. Facility policy required the machine to run at 120 degrees F to 140 degrees F and chlorine to read 50-100 ppm in the final rinse.
A facility failed to accurately identify and communicate residents’ food allergies and meal preferences on tray tickets. One resident repeatedly requested Raisin Bran with specific additions but was served oatmeal instead, another resident had no preferences documented, and a third resident’s life-threatening Macadamia Nut Oil allergy was listed as a dislike. The CDM stated the software did not print allergies directly on tray tickets, and the DON stated allergies should be indicated on tray tickets; Medical Records reported there was no current allergy policy.
Food items were found expired, unlabeled, or improperly stored in the kitchen and resident refrigerator. The RD found multiple items in the walk-in cooler past their use-by dates, and the kitchen tour identified additional expired dry goods plus a scoop left inside a flour container. Facility-prepared snacks in the resident refrigerator were also found with outdated or missing dates, and the CDM and DON acknowledged these practices were a persistent safety concern.
Unlabeled and Uncovered Resident Food Stored Improperly: Staff stored resident food in the clean utility room without proper labeling, dating, or covering. An uncovered bowl of bread was left exposed on a cabinet shelf, and a commercially wrapped cheeseburger was stored nearby without a room number or date. US H confirmed the items were not labeled or dated, and the CDM stated staff were expected to label resident food per facility policy.
Medical Director Failed to Coordinate Care and Address GDR Reviews. The Medical Director did not effectively coordinate medical care or respond to GDR recommendations for residents receiving psychotropic medications. The DON, Administrator, Consultant Pharmacist, and family members reported poor communication and limited responsiveness, and records showed no documented Medical Director response to pharmacist GDR recommendations for multiple residents. The Medical Director stated he reviewed GDR documents monthly and usually attended meetings by phone, but he could not describe QAPI work and was described by facility leadership as disconnected and inconsistent in his involvement.
Kitchen equipment was not kept in safe operating condition when the low temp dishwasher was observed running at 108 to 110 degrees F instead of the facility’s required 120 to 140 degrees F range, and food thermometers were not readily available and did not calibrate correctly. A CK I found one thermometer reading 203 degrees F in boiling water, and a second thermometer read 208 degrees F. The CDM and DON stated staff should know the correct dishwasher operating temperature and have working thermometers to verify food and sanitation temperatures.
Failure to Provide ADR/POLST Consultation on Admission: The facility did not honor the rights of three residents when it failed to provide ADR/POLST consultation on admission. One resident with a history of breast cancer, falls, osteoarthritis, osteoporosis, and bipolar disorder, one resident with Parkinson's disease, dysphagia, and dementia, and one resident with encephalopathy and repeated falls had no POLST or ADR on file. Medical Records could not locate the documents, SSD notes showed no ADR consultation until the survey, and the DON stated ADR/POLST should be completed on admission.
The facility failed to timely report abuse allegations involving a resident who reported staff argued with her and spit in her face, and a separate resident-to-resident altercation involving two residents. The DON and ADM acknowledged the incidents were not reported within required timeframes, and the record showed no completed investigation for the resident allegation and no assessment or 72-hour monitoring for the resident-to-resident event.
A resident with dementia, falls history, and difficulty walking had a fall followed by general care plan updates that did not clearly match the specific interventions identified in the IDT meeting. The same resident repeatedly refused Seroquel, but the care plan did not address the refusals, physician notification, or follow-up. Another resident with dementia, major depression, and diabetes had fluctuating bedbound, wandering, and activity patterns, but the care plan did not clearly reflect individualized interventions, and a documented plan to take her outside on sunny days was not observed being carried out.
Failure to Provide Adequate Fall Supervision, Post-Fall Assessment, and Care Plan Updates: Three residents with significant fall risk factors experienced falls with injuries, but the records did not show complete post-fall assessments, neurological checks, or timely individualized care plan updates. One resident with dementia and a high fall risk score was later diagnosed with a T12 compression fracture after a fall, another resident with encephalopathy and dementia sustained a femoral neck fracture and later required 1:1 supervision without a corresponding care plan update, and a third resident with myopathies, osteoporosis, and moderate cognitive impairment fell, reported severe pain, and was later diagnosed with a humerus fracture. The record also did not show IDT root-cause review after the falls.
Delayed Initial Nutrition Assessments A facility failed to ensure timely initial nutrition assessments for four residents with significant medical conditions, including DM with foot ulcer, cellulitis, protein-calorie malnutrition, osteomyelitis, and severe obesity. The clinical record lacked evidence that the RD completed an admission nutrition assessment at or shortly after admission to identify weight history, diet orders, allergies, swallowing risks, and nutrition-related diagnoses. The CDM and DON stated that these assessments are expected on admission or within the first week and are used to identify dietary needs and texture requirements.
Inadequate Pain Assessment and Management for Two Residents: Two residents with significant pain conditions did not have pain adequately assessed, monitored, or managed. One resident had a fall, later a T12 compression fx, and repeated refusals of scheduled analgesics without documented reassessment or individualized non-pharmacological interventions; the other resident had extensive trauma-related injuries, constant pain rated 7/10 despite scheduled meds and PRN Tramadol, and no documented physician response or chronic pain plan.
Incomplete Physician Response to Pharmacist GDR Reviews: The facility did not document physician agreement or disagreement with multiple pharmacist GDR and medication review recommendations for several residents. The DON reported missing responses for antipsychotic and other psychotropic medication reviews, including recommendations for discontinuation, lab monitoring, and an AIMS test, while the consultant pharmacist stated physician responses were not always received and the Medical Director could not explain why some reviews were not signed or documented.
Missed hand hygiene and glove change during med passes. An LPN and the IP failed to perform hand hygiene before and after resident contact and before med prep/admin for multiple residents, and one LPN continued a tube-feeding med pass after handling a soiled towel without changing gloves or cleaning hands. The facility policy required hand hygiene before and after direct resident contact and that meds only contact the medication cup.
Failure to Timely Report and Investigate Abuse Allegation: The facility did not thoroughly investigate an abuse allegation involving a resident and two staff members. A family member reported that the resident said staff argued, got into her face, and spit on her, but the ADM did not believe the report, did not timely notify CDPH, and did not start immediate follow-up actions when the allegation was first made. The EMR did not show timely reporting, and the facility policy required immediate investigation and prompt reporting of alleged abuse.
Incomplete Transfer and Discharge Documentation: A resident was transferred to the hospital, but the medical record lacked a physician order, nursing progress note, Ombudsman notification, and documentation of the disposition of personal belongings. MR and the DON confirmed that only a Social Services note reflected the transfer, and required transfer/discharge documentation was missing from the chart.
Enteral feeding for a resident with chronic kidney disease was observed running by pump, but the Glucerna bottle label was smudged and showed a rate that did not match the physician order, and a later observation found the bottle completely unlabeled for the resident, time, date, or rate. The DON and an LPN stated the unlabeled bottle meant staff could not know when it was hung and raised concerns about the feeding being old and potentially contaminated; facility policy required feeding tubes to be used according to physician orders and infusion labels to include key identifying information.
Failure to provide behavioral health services for a resident with MDD, delusional disorder, and trauma history. The resident’s care plan identified disturbed thought processes, depression, and suspected trauma history, and included a referral to Psychiatry or a mental health provider, but the record showed no psych consult or referral. The resident reported a home invasion and said a prior hospital psychiatrist did not believe the trauma was real; the DON stated psych services should be provided if indicated on the care plan.
Medication storage and security were not maintained when an LPN left a packet requiring disposal on top of a med cart and left the cart unattended, loose pills were found in multiple carts, an open date on a medication was illegible, and one LPN did not know how to dispose of wasted meds. Surveyors also observed an unlocked, unattended med cart in the hallway and an open, accessible E-kit with no access log; the DON confirmed the kit had been opened without documentation and inventory showed missing IV fluids.
Missed Medical Appointment Due to Lack of Transportation: A resident with injuries from an MVA, multiple fractures, and ongoing pain missed a needed pain management-related nerve conduction study because facility transportation was not arranged when the van was unavailable. The SSD said the appointment was cancelled due to the van being inoperable and waiting for new registration tags, and there was no documentation that the missed appointment was addressed or rescheduled.
A physician conducted medical examinations in a group setting in the dining area, rather than in a private location, resulting in a resident with morbid obesity, depression, and epilepsy feeling embarrassed and dissatisfied with the physician’s services. The physician acknowledged performing several examinations among groups of residents due to only visiting monthly and needing to locate residents wherever they were. Anonymous complaints to a resident advocate and resident council minutes reflected concerns about the physician’s practices and interest in a new physician. These actions conflicted with facility policies requiring review of each resident’s total program of care at each visit and guaranteeing residents’ rights to privacy and confidentiality during medical treatment.
A resident with malnutrition, mobility issues, and little to no cognitive impairment repeatedly expressed suicidal ideation, including to a mobile crisis team and at a GACH evaluation, where he stated he would kill himself if he returned to the facility. Despite these statements and an OTA reporting that the resident said, “It’s hospice or suicide,” facility records showed no suicide-focused safety or monitoring care plan was initiated. The DON and ADM acknowledged that a suicidal ideation safety care plan should have been started and that expected interventions, such as enhanced supervision and removal of potential hazards, were not care planned, even though facility policies required assessment, care plan development, immediate reporting, continuous presence, and documentation when suicidal ideation is expressed.
A resident with severe cognitive impairment and a history of elopement attempts exited the facility unsupervised after being left alone in the dining room. Required safety devices, including a Wander Guard and sit-stand alarm, failed to function—one due to an expired battery and the other because it was removed by the resident. Staff did not follow protocols for escorting the resident, and door monitoring was inconsistent, leading to the resident being found outside by neighbors.
An unlicensed staff member admitted to vaping in a resident's room, violating the facility's non-smoking policy, which only permits smoking in designated areas. This was confirmed through staff interviews and review of the staff member's written statement.
Two residents experienced delays in receiving their medications, with one resident's Parkinson's medication and another's scheduled morning medications administered late on multiple occasions. The facility's policy requires medications to be given within one hour of the scheduled time, which was not followed.
The facility failed to provide adequate supervision and effective care plan revisions for residents at risk of falls, resulting in multiple incidents of falls with injuries. A resident with a history of falls experienced numerous falls, including one leading to a major injury requiring surgery, without consistent care plan updates or increased supervision. Another resident suffered a fracture from a fall, and a third resident with severe cognitive impairment experienced falls without appropriate care plan updates, leading to a major injury and subsequent death. Additionally, a fourth resident experienced multiple falls without a fall care plan until after the third fall.
The facility failed to provide adequate nutritional care for residents, leading to significant weight loss and potential health risks. The RD's infrequent visits resulted in minimal assessments, while the unqualified Dietary Manager handled dietary progress notes and care plans, leading to incorrect MDS coding and inadequate monitoring. Residents, including one who was legally blind and Spanish-speaking, did not receive proper meal assistance or fluid intake monitoring, and care plans were not updated despite ongoing weight loss.
The Administrator failed to ensure effective oversight and resources, leading to 134 falls, nutritional issues, and inadequate staffing affecting 81 residents. The QAPI Committee did not implement a fall reduction plan, and the RD's infrequent visits led to dietary errors. Inadequate staffing resulted in unmet care needs and inconsistent charting, compromising residents' well-being.
The facility's kitchen was found in unsanitary conditions, with moldy and spoiled food items, improper labeling, and incomplete documentation of food thermometer calibration. The walk-in refrigerator and freezer were disorganized, and the kitchen had dirty surfaces and equipment. These issues had the potential to cause foodborne illness and spread infections to residents.
The facility failed to uphold the dignity and respect of 15 residents, with incidents including a resident left in a soiled sweater, another moved to a new room without proper notice, and long wait times for assistance. Residents reported discomfort due to untrimmed toenails, cold meals, and lack of dining assistance. Multiple residents expressed dissatisfaction with staff attitudes and long wait times, highlighting a failure to treat residents with dignity and respect.
The facility failed to provide residents with the necessary contact information for the California Department of Public Health, preventing them from filing complaints about potential abuse, neglect, or other violations. During a Resident Council meeting, none of the residents knew how to contact the State, indicating a lack of compliance with regulatory requirements to inform residents of their rights and procedures for reporting grievances.
The facility failed to maintain a clean and homelike environment, with pervasive offensive odors of feces, urine, and body odors noted throughout the building, particularly in the North Hall. Observations revealed stained carpets and soiled linens, with staff and residents confirming the persistent smell. The DON acknowledged the odor, and the facility's policy on cleanliness was not followed.
A facility failed to accurately code the MDS for a resident on a physician-prescribed weight loss plan, marking it incorrectly as not on such a regimen. The resident had a complex medical history, and the error could have affected care planning. The Dietary Manager completed Section K of the MDS, but there was no oversight for accuracy, and the DON's signature only verified completion. Job descriptions lacked clarity on responsibility for accurate MDS completion.
The facility failed to develop individualized care plans for residents, leading to potential health risks. A resident with shortness of breath lacked a care plan for oxygen administration, another resident who choked did not have aspiration precautions, and a resident with respiratory failure and constipation issues lacked appropriate care plans. Additionally, a resident at risk for falls did not have a fall prevention plan after multiple falls.
The facility failed to update care plans for two residents after multiple falls, as required by their policy. One resident experienced numerous falls, including a major injury, without timely updates to their care plan to include necessary interventions like increased supervision. Another resident's care plan was not updated with preventive measures after falls, and no fall risk assessment was conducted after the first fall. This failure to adhere to the facility's policies potentially compromised resident safety.
The facility failed to follow physician orders and its constipation protocol for two residents, resulting in extended periods without bowel movements. Despite having a bowel care program in place, it was not consistently implemented, especially when residents refused oral medications. Staff interviews revealed communication gaps and non-adherence to the protocol, leading to the oversight.
The facility failed to provide adequate ADL assistance, resulting in severe deficiencies. A resident was left in a soiled brief for an extended period, causing severe skin damage and pain. Another resident reported being left in a wet brief and not repositioned frequently, corroborated by ADL flow sheets. Additionally, two residents were not provided with adequate hydration, and three residents did not receive scheduled showers, highlighting a failure to adhere to facility policies.
The facility failed to provide adequate staffing, resulting in significant delays in responding to call lights and providing necessary care. Residents experienced discomfort and neglect due to extended wait times for assistance with ADLs and incontinence care. Insufficient staff during meal times led to delays in feeding, causing meals to become cold and raising concerns about cross-contamination. The lack of prompt incontinence care resulted in severe skin damage for some residents, highlighting the impact of staffing shortages on the quality of care.
A facility failed to provide correct diets to 18 residents, with errors in fortified and mechanical soft diets. Dietary staff did not correct these errors before meal distribution. LPNs checked trays only in the social dining room, while CNAs delivered meals without verifying tray tickets. The DON acknowledged the risk of choking due to incorrect diet consistency.
The facility failed to ensure kitchen staff were knowledgeable about food safety processes, including cooling, thawing, and dishwashing. Interviews revealed that Dietary Aids R, S, T, and U lacked understanding of these processes, despite claims of prior training. The facility's policy on dishwashing was not followed, and a contradiction was found regarding leftover food storage. These deficiencies posed a risk of foodborne illnesses to residents.
The facility failed to provide palatable and appropriately heated meals to most residents, with reports of cold, flavorless food and mismatched entrees. Observations confirmed that meal temperatures were below acceptable levels, and vegetables were overcooked and lacking flavor, contrary to facility policy.
The facility failed to maintain complete and accurate documentation of meal consumption for two residents, leading to significant weight loss. One resident lost over 20% of their weight in six months, with incomplete meal records for May. Another resident experienced a 15.86% weight loss over six months, with inadequate monitoring of meal intake from March to June. The facility's policy required CNAs to document food intake, but this was not consistently followed, impacting the residents' care and healthcare goals.
The facility failed to maintain an effective QAPI program, with the DON responsible for its development but lacking documentation and involvement from leadership. Department heads did not provide necessary reports, leading to untracked interventions for falls and weight loss issues. Despite recording numerous falls, including major injuries, the facility did not have a specific plan to address these issues.
The facility's ineffective QAPI program resulted in several deficiencies, including inadequate monitoring of infection prevention, ADLs, falls, nutrition, and resident dignity. The QAPI meetings lacked consistent attendance and were too brief to address issues. The DON reported that department heads failed to provide necessary data, leaving key areas unaddressed. Despite discussions on falls and weight issues, there was no comprehensive analysis to prevent future incidents, compromising resident safety and care quality.
Resident Showered Despite Refusal
Penalty
Summary
The facility failed to maintain dignity for one resident when a CNA showered her despite her clear refusal of care. The resident was admitted with diagnoses including muscle weakness, unsteadiness on feet, difficulty walking, anxiety disorder, PTSD, and claustrophobia. During an interview, the resident stated that on 5/27/26 she was forced to shower by facility staff even though she repeatedly told them to stop and yelled multiple times, leaving her angry, fearful, and distrustful of caregivers. She also reported chronic shoulder pain and a history of childhood trauma related to bathing, and said she had previously developed trust with a specific CNA and had told nursing staff she preferred only that CNA to shower her. The facility’s investigation report stated that after the resident reported being showered against her wishes, the DON and Administrator interviewed the resident and notified the Department and local law enforcement. The report indicated the resident said she had refused the shower, and a CNA confirmed the resident was heard shouting during the incident. The report also stated that multiple witnesses, including the CNA who performed the shower, substantiated that the resident was showered despite her refusal. During interviews, the new DON stated that when a resident refuses showering or bathing, staff should immediately stop, honor the refusal, report it to the charge nurse, and document the incident for follow-up. The Social Services Director stated that every person has the right to autonomy over their body and to refuse care, and acknowledged that the resident’s rights, consent, and psychological protections were not recognized, assessed, and acted upon appropriately during the incident. A psychiatry note documented follow-up for the shower-care complaint and described anxiety and frustration related to persistent shoulder pain and painful handling during care.
Failure to Provide Ordered Skin Treatments for Resident with Pressure Injuries
Penalty
Summary
The facility failed to provide ordered skin treatment and care in accordance with a resident's goals of care and professional standards. A resident admitted with diagnoses including bleeding between the brain and its surrounding membrane, heart and lung failure, and infectious diseases had documented skin issues on admission, including one unstageable pressure sore, two deep tissue injuries, and moisture-associated skin damage. The resident’s care plans for deep tissue injury on the coccyx, an unstageable pressure injury on the right sacrum, and potential for impaired skin integrity included interventions such as administering medications and treatments as ordered and providing skin care per facility guidelines. Review of the Treatment Administration Record for the month showed that an ordered treatment to the bilateral buttocks with zinc and a 3x3 foam dressing was not provided by the afternoon shift on 11 specific days. The DON confirmed that 11 of the resident’s zinc treatments had not been completed as ordered and stated that not giving the treatment as ordered poses the danger of infection and delay of healing. Review of the facility’s Medication Administration policy indicated that medications are to be administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, which the DON stated the facility failed to do.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the California Department of Public Health within the required two-hour timeframe. A resident with Parkinson's disease, dementia, PTSD, and corticobasal degeneration was admitted on an unspecified date and participated in a telepsychiatry visit on 4/7/26. During this telepsych appointment at 11:30 a.m., the resident stated that some people in the facility tried to hurt him. This allegation was documented on a SOC 341 form, which indicated that the report "the people that work here try to hurt me" was made during the telepsych appointment at 11:30 a.m. The Assistant Director of Nursing was present with the resident during the telepsych visit and heard the allegation that some people in the facility tried to hurt him. The ADON then informed the Administrator and prepared the SOC 341, which the Administrator sent electronically to the Department. The Director of Nursing confirmed that the SOC 341 reflected the allegation time as 11:30 a.m. on 4/7/26 and that the Administrator electronically submitted the SOC 341 to the Department at 3:17 p.m. on the same day, more than three hours after the allegation was made. The facility’s Abuse, Neglect and Exploitation policy, dated 12/19/22, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately, but not later than two hours after the allegation is made.
Oxygen therapy equipment not maintained and orders missing
Penalty
Summary
Provide safe and appropriate respiratory care for residents when needed was not maintained for multiple residents receiving oxygen therapy. During observation and record review, 13 of 15 residents observed on oxygen therapy did not have humidifiers in use as required for their oxygen delivery systems, seven residents had visibly soiled or dirty oxygen concentrator filters, and 11 residents did not have physician orders for oxygen therapy despite actively receiving oxygen during the survey. Resident 18 was admitted for pneumonia and was observed on 3/24/26 with no humidifier on the concentrator, and the record showed no oxygen therapy order. Resident 20, admitted for orthopedic aftercare following surgical amputation, was observed with no humidifier on the concentrator. Resident 23, admitted for intervertebral disc degeneration, was observed with no humidifier and a dirty concentrator filter, and the record showed no oxygen therapy order. Resident 22, admitted for dysphasia, was observed with a dusty concentrator and no oxygen therapy order. Resident 25, admitted for an unspecified open wound of the left thigh, was observed with no humidifier on the concentrator. Additional findings included Resident 31, admitted for cellulitis of the left lower limb, with no humidifier and no oxygen therapy order; Resident 40, admitted for surgical aftercare following digestive system surgery, with no humidifier, a dusty filter, and no oxygen therapy order; Resident 41, admitted for the same type of surgical aftercare, with no humidifier; Resident 98, admitted for fracture of the neck of the right femur, with no humidifier, a dusty filter, and no oxygen therapy order; Resident 48, admitted for acute respiratory failure, with no humidifier and a dusty filter; Resident 51, admitted for chronic obstructive pyelonephritis, with a concentrator and no oxygen therapy order; Resident 55, admitted for acute respiratory failure, with a dusty filter and no oxygen therapy order; Resident 76, admitted for Huntington's disease, with no humidifier and a dusty filter; Resident 81, admitted for myopathies, with no humidifier and no oxygen therapy order; Resident 83, admitted for cellulitis of the right lower limb, with no humidifier and no oxygen therapy order; and Resident 86, admitted for acute and chronic respiratory failure, with no humidifier and no oxygen therapy order. During interviews, the DON stated that dirty equipment was concerning for respiratory injury, that no water in the humidifier could dry out the respiratory tract and make breathing uncomfortable, and that all residents on oxygen therapy should have a physician order. The DON and FMM also reviewed rooms with concentrators, and the DON noted dirty equipment and lack of water in humidifiers, while the FMM stated he bought and maintained the units but did not clean them.
Insufficient staffing led to missed meals, unmet ADL care, and inaccessible call lights
Penalty
Summary
Staffing was not sufficient to meet the needs of multiple sampled residents, and the report documents several instances where resident care needs were not met. Three residents with diagnoses including malnutrition, adult failure to thrive, diabetes, and, for one resident, cellulitis and cognitive impairment, were observed during meals without adequate assistance. One resident stated she needed help cutting her food, but no staff were available in the hallway or at the nursing station to assist. Two other residents were observed sleeping or positioned away from their meal trays, and their lunches were left untouched or removed with 0% consumed. A staff member stated he normally helped residents cut food right away, while another staff member later stated he was in a rush and could not help residents with meals, turn them every two hours, change briefs, give showers, assist with meals, or get residents out of bed because he was assigned 12 to 16 residents daily. The report also documents that residents did not receive care related to activities, nail care, and mobility. One resident with Parkinson's disease and mild cognitive impairment stated staff did not do what he asked and never got him out of bed, and he was bored and wanted to go outside. The Activities Director stated the resident did not refuse activities but became frustrated and liked company the most, and that activities staff could not move him without help from other staff, who were unavailable. Several residents had long, thick, discolored, or dirty fingernails and toenails during observation, including residents with paraplegia, paralytic syndrome, acute respiratory failure, dementia, and repeated falls. One resident stated staff did not have time to do nail care, another said staff had a hard time getting to brushing teeth and nail care, and another stated staff said they did not have time. A nurse confirmed one resident's nails were long and dirty and offered nail care during the observation. The report further shows that several residents remained in bed for repeated observations across multiple days. Residents with severe cognitive impairment and other diagnoses were seen in bed throughout the day on multiple occasions, and one resident stated she was in bed all day and was only out of bed once a week for showering if a lift was available. Staff stated they did not have time to get residents out of bed and that transfers often required two people and a lift that was not often available. In addition, call lights were not consistently within reach: one resident's call light was on the floor and wrapped around the bed rail, another resident's call light was on the floor on multiple observations, and another resident's call light was found on a neighboring resident's bedside table. The Infection Preventionist and ADON confirmed the call lights were not properly accessible to the residents.
Incomplete Dietary Preferences and Outdated Diet Orders
Penalty
Summary
The facility failed to provide a census of 87 residents with a well-balanced diet that met daily nutritional and special dietary needs because current and complete dietary preference documentation was not maintained. During review of 85 lunch tray tickets, only five had documented preferences. The report also noted that dining room staff were offering residents hot drinks such as coffee or tea and chicken soup during a meal observation, while the facility did not have complete preference documentation available for most residents. The facility also failed to provide staff with accurate and up-to-date diet order information. Dining room staff were instructed to use a Diet Type Report to verify current diet type and texture orders, but the report available at the time of review was dated two weeks earlier than the observation. The Infection Preventionist Nurse confirmed the report was outdated and stated she would notify the Certified Dietary Manager that a current report was needed immediately. The Director of Nursing stated residents were expected to receive meals according to current diet orders and acknowledged that using an outdated Diet Type Report placed residents at risk of receiving incorrect diet types and textures.
Inadequate dietary staff competency for dishwashing operations
Penalty
Summary
The facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 87 residents when the Dishwasher operated the dishwashing machine at 108 degrees Fahrenheit and could not identify the required operating temperature or describe how to test for chlorine sanitation. During an interview, the Dishwasher stated he was a new employee and remained in training, and he was unable to specify the temperature at which the dishwashing machine should operate or explain how to test for chlorine sanitation. During an observation, the Dishwasher operated the dishwashing machine while the temperature gauge showed 108 degrees Fahrenheit. The Certified Dietary Manager stated the Dishwasher had been employed for three weeks and had not completed the required competency checks. The DON stated she expected all dietary staff to prove competent in their assigned positions and agreed that anyone operating the dishwashing machine should know the correct operating temperature and how to check for proper sanitation. The facility policy titled Dishwashing stated the machine should be used at 120 degrees F to 140 degrees F and chlorine should read 50-100 ppm on dish surfaces in the final rinse, and the Sanitation policy stated no Food & Nutrition Services employee shall operate any major piece of equipment without knowing how to operate it correctly.
Food Allergies and Preferences Not Properly Documented on Tray Tickets
Penalty
Summary
The facility failed to ensure an effective system was in place to accurately identify and communicate residents’ food allergies, preferences, and substitutes for a census of 87 residents. Tray tickets listed residents’ allergies under the dislikes section rather than under a clearly defined allergies designation, and preferences were not assessed, documented on meal tickets, or honored for three residents. During interviews and record review, Resident 35 stated he repeatedly asked for Raisin Bran cereal with two non-sugar sweeteners and more milk, but staff kept bringing oatmeal and did not offer anything else. A review of his meal ticket showed Raisin Bran was not included under preferences. Resident 86 stated her breakfast was not what she liked, and her meal ticket had nothing documented under preferences or dislikes. During observation, Resident 35 did not receive Raisin Bran for breakfast, and lunch tray preference cards for Resident 35 and Resident 86 did not have any preferences or dislikes documented. Resident 89 stated her tray ticket listed Macadamia Nut Oil under dislikes, but it was actually a life-threatening allergy. A review of 85 lunch tray tickets showed all listed allergies as NONE. The Certified Dietary Manager stated the dietary software did not allow allergies to print directly on tray tickets and that when allergies are not accurately displayed, dietary staff may mistake a true allergy for a preference. The DON stated residents’ food allergies should be indicated on tray tickets, and Medical Records stated the facility did not currently have a policy on allergies.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety. During a concurrent observation and interview in the walk-in refrigerator, several items were found past their use-by dates, including liquid whole eggs, soy sauce, and opened lettuce, and an opened bag of red seedless grapes was unlabeled. The Registered Dietitian confirmed the items were past their dates and removed them, placing them directly into the garbage can. During the initial kitchen tour, additional expired or improperly dated items were observed in the dry storage area, including hamburger buns dated 3/9, individually packaged saltine crackers with a use-by date of 1/20/25, individually packaged diet cookies dated 12/15/25, an opened container of seasoning with an open date of 7/15/25 and a use-by date of 10/15/25, and a container of honey with a use-by date of 6/15/25. A blue scoop was also observed stored inside the large container used for flour, rather than being stored separately. In the resident refrigerator, facility-prepared sandwiches and pudding-like items were observed with printed or handwritten dates of 3/20/26, and other facility-prepared sandwiches and dessert bowls were observed without any date labels. The CDM stated expired food items and unlabeled foods had been a persistent issue in the kitchen and confirmed the outdated snacks should have been discarded no later than three days after preparation, while unlabeled snacks should have been discarded immediately because staff could not verify freshness or safety. The DON stated expired, unlabeled, and improperly dated foods posed a significant safety concern and should not be available to residents.
Unlabeled and Uncovered Resident Food Stored Improperly
Penalty
Summary
The facility failed to store resident food in a safe and sanitary manner for a census of 87 when staff kept several perishable food items unlabeled and undated in the pantry designated for resident food. During an observation on 3/24/26 at 8:23 a.m. in the clean utility room, which contained cabinets for resident personal food items, one clear plastic scalloped-edge bowl containing three large porous pieces of bread was found sitting directly on the cabinet shelf with no cover, leaving the bread exposed to the environment. At the same time and location, a large red-and-white commercially wrapped food item labeled "JACK CHEESEBURGER" was on the same shelf about two inches from the uncovered bread, but the package did not include a room number or a date showing when staff received it. During an interview on 3/24/26 at 8:28 a.m., Unlicensed Staff H stated that only foods for residents were to be stored in the clean utility room and confirmed that the bread and cheeseburger were not labeled or dated. During an interview on 3/26/26 at 5:30 p.m., the Certified Dietary Manager stated he expected staff to label all resident food items according to facility policy. Facility policies titled "Food For Residents From Outside Sources" and "Bringing In Food For A Resident," both dated 2018, stated that opened food must be sealed and dated to the date opened, and that food or beverages should be labeled and dated to monitor for food safety; unlabeled containers would be marked with the current date and the resident's name.
Medical Director Failed to Coordinate Care and Address GDR Reviews
Penalty
Summary
The facility failed to ensure the Medical Director effectively performed his responsibilities for coordination of medical care and implementation of resident care policies. Interview and record review showed that Gradual Dose Reduction (GDR) recommendations were not being addressed by the Medical Director, and communication between the Medical Director and the care team was ineffective. The Medical Director Agreement stated that the physician was responsible for standards, coordination, surveillance, and planning for improvement of medical care in the facility, including apprising the Administrator of recommendations and proposed plans through dated and signed reports. During interviews, the legal decision maker for two residents stated she had to repeatedly call and request to speak with the Medical Director about the medical care for those residents and that he seldom returned her calls. A family member of another resident stated she had tried to speak with the Medical Director but could never get through to him. The DON stated the facility monitored the anti-psychotic medication program monthly with the Consultant Pharmacist, Medical Director, and herself, but the GDR documentation for the last 3 months showed no documented response by the Medical Director to pharmacist recommendations for mandated GDRs for three residents. The DON stated the Medical Director should have approved the GDR recommendations and that there was no monitoring of GDR medications by him. The Consultant Pharmacist stated she reviewed medications, including GDRs, and collaborated with the Administrator and DON, but the Medical Director was non-compliant and did not always respond in a timely manner. The Medical Director stated he reviewed GDR recommendations once a month and usually attended committee meetings by phone, but he could not describe what projects the QAPI team was working on. The Administrator and DON stated he attended only a few QAPI meetings a year, did not consistently review pharmacy recommendations for GDRs, and they did not feel supported by him. Facility policy stated residents receiving psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, and the QAPI committee, which includes the Medical Director, is responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction.
Kitchen Equipment Not Operating Within Required Temperatures
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was in safe operating condition for a census of 87 residents. During observation, the low temp dishwasher was operated multiple times while the temperature gauge showed 108 degrees to 110 degrees Fahrenheit. During interview, the Certified Dietary Manager stated the low temp dishwasher should be operated between 120 to 140 degrees Fahrenheit, and the Director of Nursing stated staff who operated the dishwashing machine should know the correct operating temperature and how to check for proper sanitation. During a concurrent observation and interview, the CK I was calibrating food thermometers per facility policy and found that a thermometer immersed in boiling water was not reading the required 212 degrees Fahrenheit, instead reading 203 degrees Fahrenheit. The thermometer continued to read 203 degrees Fahrenheit during a later observation, and a different thermometer brought in by the CK I read 208 degrees Fahrenheit. Review of the facility's dishwashing policy stated the machine should be used at 120 degrees F to 140 degrees F, and the weekly thermometer calibration procedure stated thermometers should read 212 degrees Fahrenheit in boiling water.
Failure to Provide Advance Directive Consultation on Admission
Penalty
Summary
The facility failed to honor the rights of three residents to request, refuse, or discontinue treatment and to formulate an advance directive when it did not provide consultation regarding POLST or ADR on admission. Resident 81 was admitted with a history of breast cancer, repeated falls, osteoarthritis, osteoporosis, and bipolar disorder, and her clinical record showed no POLST or ADR on file. Resident 34 was admitted with Parkinson's disease, dysphagia, and unspecified dementia, and his record also showed no POLST or ADR on file. Resident 54 was admitted with encephalopathy and repeated falls with unsteadiness on feet, and her clinical record likewise showed no POLST or ADR on file. Medical Records stated during interview that they could not find the POLST or ADR records for Residents 81, 34, and 54 and had asked the SSD to make notes about why the records were not available. Resident 81's record showed she had signed a POLST declination form and was not offered an ADR at that time, with SSD follow-up noted quarterly, but SSD progress notes showed no ADR consultation had been provided until the survey date. SSD progress notes for Residents 34 and 54 also showed no ADR consultation had been provided until the survey date. The DON stated that ADR and/or POLST should be completed on admission and that the resident and/or representative should have had consultation.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report two allegations of abuse to the Department for three sampled residents. For Resident 99, the facility was made aware through a Social Services progress note that the resident reported two staff members were arguing, got into her face, and spit in her face. The resident had been admitted to the facility and later died on 3/13/26. The record did not show a completed investigation after the allegation was made, and documentation of the interdisciplinary team meeting reportedly scheduled for about 2/04/26 was not found in the EMR. The Administrator stated no investigation had been conducted and that she believed the resident may have been experiencing confabulations or delusions; she also stated she could not locate documentation of the IDT meeting. The Administrator and Infection Prevention Nurse later stated they would begin identifying staff who cared for the resident and attempt to obtain additional information, and the Administrator stated she submitted the SOC 341 during the survey. The facility also failed to report a resident-to-resident altercation between Resident 12 and Resident 84. A nursing note documented a verbal altercation related to miscommunication between the two residents, with staff notified and the Administrator informed. Resident 12’s record showed a diagnosis of chronic kidney disease and no memory impairment on the MDS, and Resident 84’s record showed a diagnosis related to surgical aftercare following nervous system surgery and no memory impairment on the MDS. IQIES entries confirmed the altercation was not reported to the Department. The DON stated Resident 84 grabbed Resident 12’s arm while Resident 12 was walking out of the room, and also acknowledged that no assessment or 72-hour monitoring checks were completed. The Administrator stated she did not report the incident because she believed it was unsubstantiated, and confirmed that allegations of abuse are required to be reported within two hours, while the facility policy stated physical abuse reports must be made to the Department within two hours.
Incomplete care planning for falls, medication refusals, and fluctuating psychosocial/behavioral needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered nursing care plans for two residents. Resident 26 was admitted with dementia, a history of falls, and difficulty walking, and had a high fall risk score of 21. After being found on the floor next to the bathroom door and unable to explain how the fall occurred, an interdisciplinary care conference identified likely causes as confusion and unassisted ambulation. The meeting documented interventions such as reminding the resident to use the call light, keeping the call light within reach, ensuring non-skid footwear, providing staff supervision, and activating the tab alarm, but the updated care plan contained only general interventions and did not clearly reflect those specific measures. Resident 26 also repeatedly refused prescribed Seroquel. The MAR showed refusals 11 times in the morning and 16 times in the evening between 3/01/25 and 3/25/25, meaning the medication was received less than half the time it was ordered. The nursing care plans did not include a plan to address the repeated refusals, and there were no documented interventions to encourage acceptance, use alternative approaches, notify the physician of refusals, or evaluate whether the medication was effective. During interview, nursing staff confirmed the MAR reflected the refusals, and the ADON stated that although interdisciplinary notes showed the facility had begun addressing the refusals, those interventions were not clearly reflected in the care plan and the physician notification could not be found in the record. Resident 43 was admitted with dementia, major depression, and diabetes mellitus, and had a BIMS score of 8, indicating moderately impaired cognition. The MDS coordinator stated the resident cycled between staying in bed for extended periods and being up, wandering into rooms, and requiring a wander guard for exit-seeking behavior, but the care plan did not clearly reflect individualized interventions for this pattern. Observations over several days showed the resident was transferred out of bed only twice in four days. The active care plan included an intervention for staff to take the resident outside on beautiful sunny days, but on a sunny day observation the resident was not outside, and staff interviews confirmed she was often in bed, did not want to get up even with encouragement, and was mostly in bed despite occasional activity participation.
Failure to Provide Adequate Fall Supervision, Post-Fall Assessment, and Care Plan Updates
Penalty
Summary
The facility failed to ensure three sampled residents remained free of accidents when they did not receive adequate supervision to prevent falls, did not have resident-centered nursing care plans developed or updated after falls, did not receive complete post-fall assessments or neurological checks, and did not have interdisciplinary team meetings to identify the root cause of the falls. The report states these failures involved Resident 26, Resident 54, and Resident 81. Resident 26 was admitted with dementia, a history of falls, and difficulty walking, and had a fall risk score of 21 indicating high fall risk. After being found on the floor next to the bathroom door, the resident was unable to explain how the fall occurred and had a small bump to the right side of the head. Neurological checks were started and the physician and administrator were notified, but the record did not show a comprehensive post-fall assessment that included range of motion, mobility or transfer assessment, evaluation for possible musculoskeletal injury, or detailed pain-focused interventions. Tylenol was given after the fall, but the MAR did not document a pain score, description, location, or reassessment of pain effectiveness. An OT note stated the resident remained at prior level of function, but did not include functional reassessment after the fall. Several days later, the resident was transferred to the hospital for back pain and was diagnosed with a T12 compression fracture. Resident 54 was admitted with encephalopathy, dementia, and repeated falls with unsteadiness on feet, and was unable to complete the BIMS. Her care plan identified fall risk but contained only minimal, generalized interventions such as anticipating needs, keeping the call light in reach, and maintaining a safe environment. Progress notes documented new behaviors and confusion, but the falls care plan was not updated. After an unwitnessed fall while ambulating in the room, she sustained a superficial cut above the right eye, and hospital records showed a right femoral neck fracture. The care plan was updated the day of the fall with no new interventions, and after she returned to the facility disoriented and requiring cues, the falls care plan still was not updated. Later notes documented a black eye and that she continued trying to get out of bed and required one-to-one supervision, but the care plan was not revised to reflect that need. The record also did not show that an IDT meeting was held to discuss the root cause of the fall. Resident 81 was admitted with myopathies, unsteadiness on feet, osteoarthritis, osteoporosis with multiple fractures, and moderate cognitive impairment. She was found on the floor in her room, stated she had fallen, hit her head and left arm, and reported pain of 10/10. She returned from the hospital with a diagnosis of a left closed fracture of the left humerus, and the ED report later stated she fell while trying to make her bed, tripped over her shoes, and fell on her left side. The fall IDT reports showed meetings on other dates, but there was no indication in the progress notes that an IDT meeting was held after this fall. One fall intervention was added to assess for pain, and later a falls risk evaluation identified medication-related fall risks, but the care plan was not updated following that assessment until during the survey.
Delayed Initial Nutrition Assessments for Four Residents
Penalty
Summary
The facility failed to ensure that residents' nutritional needs were recognized and evaluated upon admission for four sampled residents. Resident 20 was admitted with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Orthopedic Aftercare Following Surgical Amputation, Resident 31 was admitted with cellulitis of the left lower limb, Resident 78 was admitted with diagnoses including Nonrheumatic Aortic Valve Stenosis and Unspecified Protein-Calorie Malnutrition, and Resident 79 was admitted with diagnoses including Osteomyelitis and Morbid (Severe) Obesity due to excess calories. For each of these residents, the clinical record lacked evidence of a nutritional assessment completed at or shortly after admission to identify weight history, diet orders, allergies, swallowing risks, and nutrition-related diagnoses. The initial nutritional assessments for these residents were completed after admission rather than at or shortly after admission, with the assessments documented on 9/1/25 for Resident 20, 2/7/26 for Resident 31, 1/31/2026 for Resident 78, and 2/2/26 for Resident 79. During interviews, the CDM stated that the RD completes nutrition assessments on admission, quarterly, and more frequently when there are significant weight changes, and explained that timely assessments identify weight fluctuations, dietary needs, and texture requirements. The DON stated that the RD completes an initial nutrition assessment on admission or within the first week and that delayed assessments place residents at risk for not eating adequately, experiencing weight loss, and associated health decline if nutritional needs are not promptly identified and addressed.
Inadequate Pain Assessment and Management for Two Residents
Penalty
Summary
The facility failed to ensure pain was adequately assessed, monitored, and managed for two residents who had significant pain-related conditions. One resident was admitted with dementia, a history of falls, and difficulty walking, and after a fall was found on the floor next to the bathroom door with a bump to the head and unable to explain how the fall occurred. Tylenol was given after the fall, but the MAR pain monitoring section documented a pain score of 0 and did not include a place to record pain location, description, characteristics, or reassessment after medication administration. Nursing notes documented that the resident denied pain at one point, but other notes did not show a documented pain assessment, and later the resident repeatedly refused scheduled Tylenol without documentation of pain level, pain location, follow-up assessment, or non-pharmacological interventions. For the same resident, the record showed physician orders for Tramadol and scheduled Tylenol for pain, yet pain was only assessed twice after the fall, and both times the pain score was 6. A physician note stated the resident seemed to express pain as anger and frustration, indicating pain may have been shown through behavior rather than verbal complaint. The resident was later transferred to the hospital for back pain and diagnosed with a T12 compression fracture, returning with a TLSO brace. The resident’s care plan addressed pain related to a femur fracture, but it did not identify individualized non-pharmacological interventions, and the physician progress note did not document a pain assessment or a plan related to the fall. The second resident was admitted with diagnoses including injuries from a motor vehicle accident, multiple fractures, pain in unspecified joints, pain in both shoulders, and dysphagia. Hospital discharge information showed weakness and debility after polytrauma, including fractures of the left tibia, left humerus, right femur, right clavicle, multiple ribs, and C5-C7 cervical fractures, and acute pain treated with morphine in the hospital. In the facility, the resident’s pain regimen remained unchanged and included a lidocaine patch, gabapentin, scheduled Tylenol, and Tramadol for breakthrough pain. The resident requested Tramadol daily, and the documented pain level remained 7 despite the scheduled medications. Physician progress notes did not mention response to pain management modalities or a chronic pain plan, and the resident stated his pain was constant and that Tramadol did not help. Staff also reported that he had a lot of pain and was waiting at the medication cart whenever he could request medication, and the DON stated uncontrolled pain could lead to more pain and overall decline.
Incomplete Physician Response to Pharmacist GDR Reviews
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review was fully documented and acted upon for five residents, including Resident #86, Resident #4, Resident #78, Resident #5, and Resident #81. Survey review found a lack of documented engagement and response between Pharmacy, Nursing, and the Medical Director for the Monthly Medication Review, including irregularity reporting and GDR recommendations recorded in the facility’s GDR Request Binder. During record review and interviews, the DON stated that multiple pharmacist recommendations were not documented as either agreed to or disagreed with by the Medical Director. For Resident #4, GDR requests in 5/25, 6/25, and 2/26 were not documented with a response, and the DON stated no labs were ordered as recommended by the pharmacist. For Resident #86, GDR requests in 5/25, 6/25, 7/25, and 9/25 included discontinuation of medications, but there was no documented response from the Medical Director. For Resident #78, a 4/25 GDR request recommended discontinuation of medication related to a rash and an AIMS test, but there was no documented agree/disagree response. The DON also stated that for Resident #86, repeated pharmacist recommendations in August and September 2025 for GDRs, medication discontinuation, and monitoring of lab values were not responded to as acknowledged and accepted or refused. The consultant pharmacist stated she reviewed medications, labs, and pain medication use and collaborated with the Administrator, Medical Director, and DON on antipsychotic monitoring, but did not always hear back from the physician. The Medical Director stated he reviewed GDR recommendations monthly and signed paper documentation when in the facility, but could not explain why some GDRs had not been signed or why the response and rationale were not documented. Resident #5 had diagnoses including alcohol induced persisting dementia, bipolar disorder, and major depressive disorder, and a GDR for Seroquel was declined without rationale from the primary physician. Resident #81 had diagnoses including anxiety, PTSD, and bipolar 2 disorder, and GDR requests for Depakote Sprinkles and Aripiprazole were declined without physician rationale.
Missed Hand Hygiene and Glove Change During Medication Administration
Penalty
Summary
Infection prevention and control practices were not consistently followed during medication administration observations for multiple residents. During one medication pass, a licensed nurse did not perform hand hygiene before entering a resident’s room and later picked up two medication cups with fingers inside the cups, contaminating them. During another medication pass, a licensed nurse did not perform hand hygiene before collecting medications or before entering the rooms of two residents. During a separate observation, the Infection Preventionist also missed hand hygiene opportunities when entering and exiting a resident’s room during medication administration. During a tube-feeding medication administration observation in one resident’s room, a licensed nurse prepared medications, entered the room, cleaned the resident, removed a soiled towel, and placed it into a plastic bag, then continued administering medications without changing gloves or performing hand hygiene. When interviewed, the nurse stated she should have changed her gloves because they could have been contaminated with body fluids or bacteria. The facility policy titled, General Dose Preparation and Medication Administration, stated that hand hygiene should be performed before and after direct resident contact and that medications should not come into contact with any surface except the medication cup.
Failure to Timely Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving staff and one resident. A Social Services Progress Note dated 2/03/26 at 9:08 a.m. documented that the facility was informed by Life Partner 1 that the resident reported two staff members were arguing, got into her face, and spit in her face. The resident was admitted to the facility on [DATE] and later died on 3/13/26. The resident’s EMR did not show that the allegation was timely reported to CDPH or that immediate follow-up actions were started when the allegation was first made. During interviews, Life Partner 1 stated the resident told him staff had gotten into her face and spit on her, and that he reported the concern to facility staff and administration. The Administrator stated she did not believe the incident occurred, thought the resident may have been experiencing confabulations or delusions, and did not report the allegation to CDPH when it was initially made. She later stated she submitted the SOC 341 during the survey and was gathering staff information related to the event. The facility policy titled Abuse, Neglect and Exploitation required an immediate investigation when abuse was suspected or reported and required alleged violations to be reported immediately, not later than two hours if abuse or serious bodily injury occurred, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury.
Incomplete Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure the transfer and discharge of Resident #94 was documented in the medical record and that appropriate information was communicated to the receiving health care institution and the Ombudsman. During record review and interviews, Medical Records stated the resident was admitted and discharged on 12/29/15, and the Social Services note indicated he was transferred to the hospital. However, there was no physician order to transfer, no nursing progress note, no documentation of notification to the Ombudsman, and no record showing where the resident's personal belongings went. The DON stated that for a resident transfer or discharge to the hospital, the record should have included a nursing progress note explaining why the resident was transferred, documentation of notification to the physician, responsible party, and Ombudsman, a change of condition in the MDS, final disposition of personal items on the inventory sheet, a Social Services plan for house or home health, and education. Social Services also stated there was no inventory disposition sheet for the resident's personal items and no notification documentation to the Ombudsman. The only documentation found was a Social Services note indicating the resident was transferred to the hospital.
Enteral Feeding Not Administered Per Order and Feeding Bottle Unlabeled
Penalty
Summary
Resident #12, who was admitted with a diagnosis of chronic kidney disease, had enteral feeding running by pump when observed on 3/23/26 at 8:43 a.m. The Glucerna bottle label showed a start time beginning with 8, but the complete time was unreadable due to smudging, and the bottle label indicated a rate of 85 mL/hr while the pump was running at 90 mL/hr. A record review on 3/23/26 showed the physician's order for continuous enteral feeding at 90 mL/hr x 20 hrs. On 3/26/26 at 7:32 a.m., the resident's enteral feeding pump was again observed running, and the Glucerna bottle was not labeled for the resident, time, date, or rate. The DON stated that without the bottle being labeled, staff would not know if the feeding was good and that it could create gastric issues, an infection, or other issues. LN F stated that night shift hung the enteral feeding and that the bottle should show when it was hung, then stated the unlabeled bottle was not good because staff had no idea when it was hung and it could be old and building bacteria. The facility policy stated feeding tubes will be utilized according to physician orders, and the medication storage policy stated infusion labels must include the medication name, volume, infusion rate, date and time of administration, and initials of the person administering.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to ensure behavioral and mental health services were provided for one resident with diagnoses of Major Depressive Disorder and Delusional Disorder. The resident’s admission record showed these diagnoses, and the MDS dated 3/4/26 indicated a BIMS score of 15 with no cognitive impairment. The resident’s Trauma Informed Care Screener dated 2/20/26 indicated he had experienced a traumatic event, and the current care plan dated 1/5/26 identified disturbed thought processes related to delusional ideas, psychosis, depression, and an actual or suspected history of personal trauma. The care plan also noted the resident was at risk for behaviors if triggered by past traumas and included an intervention to refer him to Psychiatry or a mental health provider. Despite these findings, the Order Summary dated 3/27/26 showed no orders or referrals for psychiatric or mental health services, and the clinical record showed no psychiatric or mental health consult had occurred. The resident was prescribed Wellbutrin for verbalization of sadness. During interview, the resident stated he experienced a home invasion just before Christmas the prior year and felt he had some PTSD, and he reported that a psychiatrist in the hospital did not believe his trauma was real, which made it difficult for him to talk about what had happened. The DON stated psychiatric services should be provided if indicated on the care plan and that trauma informed care was very important for the facility’s population.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure medications were stored securely when a Licensed Nurse left a packet requiring disposal on top of a medication cart and then left the cart unattended while entering a resident's room to administer medications. During medication cart reviews, surveyors found loose pills at the bottom of multiple carts, including 6 in the South cart, 2 in the East cart, and 4 in the [NAME] cart. An open date on a medication in the South cart was illegible, and one nurse stated she could not tell what the date was. Another Licensed Nurse stated she did not know where to dispose of the loose pills. Surveyors also observed a medication cart in the hallway, facing outward, unlocked and unattended while a Licensed Nurse was inside a resident room giving medications; the nurse later locked the cart after noticing the surveyor watching it and acknowledged that anybody could have accessed the medications. In addition, an emergency medication kit containing intravenous medications was observed unlocked and accessible, with no log or documentation showing who opened it or when it was accessed. The Director of Nursing confirmed they were unaware of why, when, or by whom it was opened, and inventory review showed two 500 mL normal saline bags were missing. The facility policy stated medications should not be left unattended, carts should be locked when out of sight or unattended, and emergency kits should be sealed and stored in a secure area.
Missed Medical Appointment Due to Lack of Transportation
Penalty
Summary
The facility failed to ensure Resident 64 could attend a needed medical appointment when transportation was not arranged, causing the appointment to be cancelled and not rescheduled. Resident 64 was admitted with diagnoses including injuries from a motor vehicle accident, multiple rib fractures, pain in unspecified joint, pain in both shoulders, muscle spasm, and dysphagia. His MDS dated 2/4/26 showed a BIMS score of 13 with no cognitive impairment. Resident 64 stated during interview that he had constant pain after his accident and had missed a pain management appointment because of facility transportation issues that had been ongoing for about a year. Record review showed no Social Services progress notes about the missed appointment. A list of missed medical appointments showed that Resident 64 missed a nerve conduction study scheduled at a hospital on 3/18/26 and it had not yet been rescheduled. The SSD stated the appointment was cancelled because the facility van was not operable and the facility was waiting for new registration tags, and she had not documented progress notes about the missed appointments. The SSD stated it was not okay for residents to miss medical appointments due to lack of transportation. The DON stated her expectation was that Social Services arrange alternate transportation if the van was not available, and that missed pain management appointments did not meet her expectation because chronic pain needed to be treated effectively.
Failure to Protect Resident Privacy During Physician Examinations
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical information when the facility physician conducted medical examinations in a group setting in the dining area. Resident 2, who had diagnoses including morbid obesity, depression, and epilepsy and was assessed as having little to no cognitive impairment, reported being examined by the physician in the dining room in front of other residents. During an interview, Resident 2 stated that this examination in the dining room bothered her and made her feel embarrassed, and that the physician barely spent any time with facility residents. Resident council minutes reflected that all participating residents wanted to know if they could see a new physician. In a phone interview, the facility physician acknowledged conducting a few medical examinations among a group of residents in the dining area, explaining that he only came to the facility once a month, had many residents to see, and had to “chase down” residents wherever they were in the building. Electronic correspondence from a resident advocate to the agency included multiple anonymous complaints alleging that the physician conducted group examinations in the dining area where resident privacy and confidentiality were not honored. Facility policies titled “Physician Visits and Physician Delegation” and “Resident Rights” required the physician to review the resident’s total program of care at each visit and affirmed residents’ rights to personal privacy and confidentiality, including privacy during medical treatment, but these requirements were not followed during the group examinations.
Failure to Develop Suicide-Specific Safety Care Plan After Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan focused on safety and monitoring for a resident who expressed suicidal ideation. The resident was admitted with diagnoses including malnutrition, difficulty walking, muscle weakness, and repeated falls, and had little to no cognitive impairment per the MDS dated 2/09/26. On 2/12/26, a mobile crisis team evaluated the resident after he made depressive and suicidal statements, reporting dissatisfaction with facility food, feelings of weakness, hearing problems, and a desire for hospice care. The county mental health note documented that the resident had made suicidal statements and that staff worked with him on meeting some of his needs. On 2/16/26, the resident was found on the floor after a fall and was sent to a general acute care hospital (GACH). The GACH history and physical documented that the resident was passively suicidal and had stated he did not like living at the facility and would kill himself if he returned. The GACH discharge summary later indicated there was no suicidal ideation at discharge and that shared decision making supported his return. The resident was readmitted to the facility on 2/18/26. On 2/19/26, he was found unresponsive and without vital signs on the bathroom commode, with copious amounts of blood on and around him and a toenail cutting tool nearby; his official time of death was documented as 7:20 a.m. Interviews and record review showed that no care plan addressing suicidal ideation or self-harm safety was initiated for the resident after his suicidal statements and evaluations. The DON stated that residents with suicidal ideation were typically transferred to the hospital for psychological screening and that, if they remained in the facility, staff would implement safety measures such as removing call light cords and sharp objects and providing one-to-one supervision, and that she expected social services to initiate a suicidal ideation care plan or coordinate with nursing to do so. The administrator stated that the social service director should have started a suicidal ideation safety care plan when the resident first complained of suicidal thoughts. An occupational therapy assistant reported that the resident had said, “It’s hospice or suicide,” and that she informed social services and a nurse. Facility policies on Behavioral Health Services and Suicide Prevention required comprehensive assessment, care plan development and implementation, immediate reporting of suicidal ideation, not leaving the resident alone, and documentation of mood, behaviors, and actions taken, but these were not reflected in a suicidal ideation or self-harm safety care plan for this resident.
Failure to Prevent Resident Elopement Due to Lapses in Supervision and Device Maintenance
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, psychosis, anxiety, insomnia, bipolar disorder, and schizophrenia was admitted to the facility and had documented elopement attempts since admission. The resident was assessed as high risk for elopement and had medical orders for a Wander Guard device and a sit-stand alarm, with staff instructed to check the Wander Guard placement every shift and to escort the resident to and from meals. Despite these interventions, the resident was left alone in the dining room after dinner while staff were escorting other residents, contrary to the protocol that required the resident to be taken first. During this time, the resident exited the facility through the front doors without staff assistance. Interviews revealed that the Wander Guard device did not alert due to an expired battery, and the sit-stand alarm did not activate because the resident had removed it from his jacket. The receptionist, who usually monitored the doors, was not present on the day of the incident, and there was uncertainty about door monitoring procedures on weekends. The resident was found outside the facility by neighbors, who notified staff. The facility's policy required staff to accompany wandering residents when supervision was necessary, but this was not followed, resulting in the resident's unsupervised exit.
Staff Vaping in Resident Room in Violation of Non-Smoking Policy
Penalty
Summary
A deficiency occurred when an unlicensed staff member was found to have vaped in a resident's room, contrary to the facility's non-smoking policy. The incident was confirmed through interviews with licensed staff, the Director of Staff Development, and a review of the unlicensed staff member's written attestation, in which he admitted to vaping in the resident's room. The facility's policy clearly states that smoking, if allowed, should only occur in designated areas, and employees are required to consult their supervisor regarding designated smoking areas. The failure to adhere to this policy resulted in the deficiency.
Medication Administration Delays
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of its residents, as evidenced by the late administration of medications to two residents. Resident 1, who is prescribed Carbidopa-Levodopa for Parkinson's disease, reported receiving her medication late on multiple occasions, including on the day of the interview. The medication administration history confirmed that the doses were administered more than an hour past the scheduled times on several occasions between December 12 and December 26, 2024. The facility's administrator acknowledged that the medications were given late, which was not in accordance with the physician's orders. Similarly, Resident 2 experienced delays in receiving her scheduled 9 a.m. medications, including Metoclopramide, Vitamin D3, and Metoprolol Tartrate. On November 28, 2024, these medications were administered over two hours late. The administration records showed multiple instances of late administration between November 25 and December 9, 2024. The facility's policy requires medications to be administered within one hour of the scheduled time, which was not adhered to in these cases. The administrator confirmed the delays and recognized that the medications were not administered as scheduled.
Inadequate Supervision and Care Plan Revisions Lead to Multiple Falls
Penalty
Summary
The facility failed to ensure adequate supervision and effective care plan revisions for residents at risk of falls, leading to multiple incidents of falls with injuries. Resident 28, who had a history of falls and required assistance for transfers and walking, experienced numerous falls at the facility. Despite her high fall risk scores, her care plan was not consistently updated with new interventions or increased supervision. This lack of action resulted in several falls, including one that led to a major injury requiring surgery. Resident 15 also suffered from multiple falls, with the facility failing to update her care plan or accurately assess her fall risk. Her care plan lacked new interventions or increased supervision, even after she sustained a fracture from a fall. Similarly, Resident 233, with severe cognitive impairment, experienced falls without appropriate care plan updates or increased supervision. Her fall risk evaluations were inaccurately completed, and she suffered a major injury from a fall, which preceded her death. Additionally, Resident 227 experienced multiple falls without the implementation of a fall care plan until after the third fall. The facility's failure to follow its policies on fall management and supervision contributed to these incidents, highlighting a systemic issue in addressing fall risks and ensuring resident safety.
Inadequate Nutritional Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide adequate nutritional care and services for several residents, leading to significant weight loss and potential health risks. The Registered Dietitian (RD) was only visiting quarterly, resulting in minimal in-person assessments and a lack of tailored nutritional interventions. The Dietary Manager, who lacked a professional scope of practice, was responsible for completing dietary progress notes and initiating nutritional risk care plans, which led to incorrect coding in the Minimum Data Set (MDS) and inadequate monitoring of residents' nutritional status. Resident 29 experienced severe weight loss over several months, with a cumulative loss of 18.8% of body weight. Despite being legally blind and primarily Spanish-speaking, Resident 29 did not receive adequate assistance during meals, and their fluid intake was not properly monitored. The RD did not conduct in-person assessments or revise the care plan despite ongoing weight loss, relying instead on the Dietary Manager and other staff for information. The facility failed to address Resident 29's nutritional needs, including their preference for coffee and concerns about food safety. Resident 12 also faced issues with nutritional care, as their weight loss was not accurately documented in the MDS, and the Dietary Manager, who was not qualified to make clinical recommendations, completed their dietary progress notes. The RD did not adequately oversee the nutritional care plans, and the facility did not reassess or update interventions despite significant weight changes. These deficiencies in nutritional care and monitoring placed residents at risk for further health complications.
Administrator's Oversight Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility's Administrator failed to ensure effective oversight and necessary resources to maintain the quality of care, safety, dignity, and dietary services for all 81 residents. The Quality Assurance and Performance Improvement (QAPI) Committee, which included the Administrator, did not implement an action plan to reduce the number of falls in the facility. This oversight led to 134 falls from January 2024 through May 2024, with three resulting in major injuries. The Administrator was aware of the recurrent falls but did not ensure that interventions for fall prevention were tracked or discussed in meetings. Additionally, the Administrator did not ensure that the Registered Dietician (RD) made frequent visits to oversee kitchen operations, leading to issues such as errors in plating prescribed diets and lack of staff competencies in food handling processes. This lack of oversight compromised the nutritional status of residents and increased the risk of foodborne illness. Furthermore, the RD did not routinely visit residents with significant weight changes to assess their nutritional needs, resulting in multiple residents experiencing nutritional complications. The facility also suffered from inadequate staffing levels, which affected the ability to meet residents' individual care needs. Residents experienced long wait times for call lights to be answered and insufficient assistance with Activities of Daily Living (ADLs), leading to issues such as skin breakdown and compromised dignity. Charting for fluid and meal intake was inconsistent, increasing the risk of dehydration and nutritional concerns. Despite these staffing issues, the facility continued to accept new residents, exacerbating the problem.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to cause foodborne illness and spread infections to 80 of the 81 residents. During an inspection, multiple issues were identified, including the presence of moldy strawberries, undated and unlabeled chopped celery, and spoiled tomatoes in the walk-in refrigerator. Additionally, cooked chicken and chopped onions were improperly labeled, and expired chopped ham was found. The refrigerator floor was dirty, and the freezer was overcrowded, preventing proper air circulation. Further observations revealed unsanitary conditions in the dry storage area, where a moldy onion was found among good ones. The metal container for clean kitchen utensils contained food particles and trash, and the food preparation table and knife storage rack were stained and dusty. Large plastic containers for cereal and flour were grimy, and the exterior of the ice machine was extremely dirty. A mosquito trap with dead mosquitoes was also found in the kitchen. The facility's documentation was incomplete, with missing food thermometer calibration logs for May and June 2024. The emergency food storage room was disorganized, making it impossible to evaluate the food. The facility's policies on kitchen sanitation, labeling and dating of foods, general cleaning, and refrigerator and freezer maintenance were not followed, contributing to the unsanitary conditions observed during the inspection.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of 15 residents, as evidenced by several incidents. Resident 25 was left in a soiled sweater after breakfast, with no staff attending to her needs for a change of clothing. Similarly, Resident 12 was observed wearing a soiled shirt for several hours after lunch, and his disposable brief was not changed for at least five hours. Resident 68 was moved to a new room without timely notice or agreement, causing discomfort due to the lack of a window by his bed, which he preferred. Resident 6 experienced discomfort due to untrimmed toenails, which had not been attended to for months, causing pain while wearing shoes. Resident 55 had to wait 22 minutes to be assisted with dining, resulting in a cold meal that required reheating. Resident 29, who is legally blind and does not speak English, received no assistance during meals, leading her to eat with her fingers without guidance or a washcloth afterward. Resident 40 expressed dissatisfaction with the staff's attitude and the lack of timely assistance, highlighting an incident where a resident was left with vomit on herself by the nurses' station. Multiple residents, including Residents 35, 3, 65, 21, 46, 50, 2, and 58, reported long wait times for assistance, with some waiting in soiled conditions for hours. Resident 65 described being harassed by a staff member who spoke loudly and acted inconsiderately. During a Resident Council meeting, several residents voiced concerns about disrespectful treatment by staff, including refusal to assist with requests and ignoring residents' needs. These incidents collectively demonstrate a failure to treat residents with dignity and respect, as required by facility policy and resident rights.
Failure to Provide Residents with Contact Information for Filing Complaints
Penalty
Summary
The facility failed to provide seven residents with the necessary contact information for the California Department of Public Health, which is essential for filing complaints regarding potential abuse, neglect, exploitation, or other violations of state or federal regulations. This deficiency was identified during a Resident Council meeting where none of the seven residents present were aware of how to contact the State to file a complaint. This lack of knowledge among the residents indicates that the facility did not fulfill its obligation to inform them of their rights and the procedures for reporting grievances. A review of the facility's policy on resident rights, dated October 16, 2021, revealed that it did not include information on the residents' right to contact the Department to formally file complaints about possible violations. The regulatory Health and Safety Code S483.10(g)(4)(i)(C)(D)(ii)(vi) mandates that residents must receive notices in a format and language they understand, including a written description of their legal rights and contact information for relevant state agencies and advocacy groups. The facility's failure to provide this information deprived the residents of their right to formally file complaints about the care they were receiving.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by pervasive offensive odors throughout the building. Observations during the recertification survey revealed a strong smell of feces, urine, and body odors in the hallways and specific rooms, particularly in the North Hall. The carpet in the hallway was stained, and in one instance, a resident's bed linens were found soaked with urine and feces. Interviews with staff and residents confirmed the presence of the odor, with some staff attributing it to residents who eliminate in bed and insufficient staff to change soiled clothing and linens promptly. Residents and staff reported being accustomed to the smell, although it was initially bothersome. The Director of Nursing acknowledged the odor and mentioned using air fresheners in her office. The facility's policy on maintaining a clean and pleasant environment was not adhered to, as the offensive odors persisted despite weekly carpet cleaning. The issue was not reported to the Infection Preventionist, who stated she was unaware of the problem.
Inaccurate MDS Coding for Resident's Weight Loss Plan
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident under Section K, which pertains to Swallowing/Nutritional Status. Specifically, the MDS for a resident, who was on a physician-prescribed weight loss plan, was incorrectly coded as not being on such a regimen. This error was identified during a review of the resident's records, which showed a physician-directed weight loss recommendation and a care plan that included a weight goal. However, the MDS inaccurately reflected that the resident was not on a prescribed weight-loss regimen. The resident in question had a complex medical history, including diagnoses of paranoid schizophrenia, hallucinations, chronic pain, and borderline personality disorder. The resident's weight was within the physician-directed range, but the MDS coding error could have led to inappropriate care planning. Interviews with facility staff revealed that the Dietary Manager was responsible for completing Section K of the MDS, but there was a lack of oversight to ensure accuracy. The MDS Coordinator was involved in checking the completion of Section K but not its accuracy. Further interviews indicated that the Director of Nursing's signature on the MDS was only to verify completion, not accuracy. The facility's job descriptions did not clearly assign responsibility for the accurate completion of Section K to any specific role. This lack of clarity and oversight contributed to the coding error, which had the potential to impact the resident's medical treatment and care planning.
Failure to Develop Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized care plans for several residents, leading to potential health risks. Resident 127, who had a change in condition with shortness of breath and low oxygen saturation, did not have a care plan for oxygen administration despite physician orders. Observations showed inconsistencies in oxygen use, such as the resident being without oxygen while in a wheelchair and the oxygen concentrator running without the resident present. This lack of a care plan could lead to improper monitoring and management of the resident's oxygen needs. Resident 12, who had a choking incident, did not have a care plan for aspiration precautions despite recommendations from a speech therapist. The speech therapist had posted instructions for safe eating, but these were not incorporated into a formal care plan. Observations showed that Resident 12 was not positioned correctly while eating, and staff did not perform frequent spot checks as recommended, increasing the risk of another choking incident. Resident 33, with a diagnosis of acute and chronic respiratory failure, did not have a care plan for oxygen therapy or risk of constipation, despite medical records indicating multiple days without bowel movements. The facility's failure to implement a bowel care protocol and monitor oxygen therapy could lead to significant health issues. Additionally, Resident 227, who was at moderate risk for falls, did not have a care plan for fall prevention after multiple falls, which resulted in injuries and hospital visits. The lack of care plans for these residents indicates a systemic issue in addressing and managing residents' health needs effectively.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans for two residents were reviewed and revised after each fall, as required by their policy. Resident 28 experienced multiple falls, starting from the first documented fall on January 18, 2024, through to a significant fall on June 12, 2024, which resulted in a major injury. Despite these incidents, the care plan for falls was not consistently updated or revised to include new interventions, such as increased supervision, to prevent further falls. The care plan was only revised on April 2, 2024, after the fifth fall, and again on June 16, 2024, after the twelfth fall, but still lacked adequate interventions like increased supervision. Resident 51 also experienced a fall, and it was noted that his care plan was not updated to include necessary interventions such as a fall mat or frequent rounding. His care plan was only developed after he had already experienced falls, and there was no evidence of a fall risk assessment being conducted after his first fall to identify the cause and add preventive measures. The facility's policy required that care plans be reviewed and revised upon the onset of new problems or changes in condition, which was not adhered to in these cases. The facility's failure to follow its own Fall Management Program and Care Planning policies resulted in the residents' care plans not being updated in a timely manner to address the risks of falls. This lack of action potentially compromised the quality of care and safety of the residents, as their care plans did not reflect necessary interventions to mitigate the risk of further falls and injuries.
Failure to Follow Constipation Protocols for Two Residents
Penalty
Summary
The facility failed to monitor and follow physician orders and its own protocol for constipation management for two residents, leading to extended periods without bowel movements. Resident 29, who had multiple diagnoses including stroke sequelae, dementia, and hemiplegia, went several days without a bowel movement on multiple occasions. Despite having orders for a three-step bowel care program and medications like Milk of Magnesia and Dulcolax suppositories, these were not consistently administered, especially when the resident refused oral medications. There was no documentation of alternative bowel care measures being implemented during these periods. Similarly, Resident 33, who was severely cognitively impaired and had conditions such as stroke and morbid obesity, also experienced prolonged periods without bowel movements. The resident's medical record indicated several instances where no bowel care was initiated despite going up to 15 days without a bowel movement. The facility's protocol required bowel care to be started after three days without a bowel movement, but this was not followed. Interviews with facility staff revealed a lack of communication and adherence to the bowel care protocol. Licensed nurses and the Director of Nursing acknowledged that bowel care should have been administered per physician orders if a resident had not had a bowel movement in three days. However, there was a disconnect in communication between Certified Nursing Assistants and nurses, leading to the oversight. The facility's policy emphasized the importance of an effective bowel care program, but it was not effectively implemented for these residents.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, leading to significant deficiencies in care. Resident 232 was left in a soiled disposable brief for an extended period after returning from a hospital visit, resulting in severe skin damage and excruciating pain during his final days. Despite being completely dependent on staff for toileting and personal hygiene, Resident 232 did not receive timely incontinence care, as documented in the ADL flow sheets. Interviews with family members and staff confirmed the neglect, and the Director of Nursing acknowledged the prolonged period the brief was left unchanged. Resident 14, who was also dependent on staff for toileting hygiene, reported being left in a wet or soiled brief for more than two hours and not being repositioned frequently. This lack of care was corroborated by ADL flow sheets, which showed that Resident 14 received incontinence care only once per day on several occasions and was often not repositioned at all. The Director of Staff Development confirmed these findings and stated that incontinent residents should be checked every two hours. Additionally, Residents 67 and 4 were not provided with adequate hydration, as they were observed without access to water despite being at risk for dehydration. The facility's policy required that residents be offered drinking water throughout the day, but this was not adhered to. Furthermore, Residents 12, 20, and 29 did not receive their scheduled showers, with documentation showing refusals and a lack of follow-up to ensure personal hygiene needs were met. The facility's failure to adhere to its own policies and procedures for ADL care and documentation contributed to these deficiencies.
Inadequate Staffing Leads to Delayed Care and Resident Discomfort
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant delays in responding to call lights and providing necessary care. Several residents reported waiting for extended periods, sometimes up to several hours, for assistance with activities of daily living (ADLs) such as toileting and incontinence care. This lack of timely care led to residents experiencing discomfort, skin irritation, and feelings of neglect. For instance, one resident had to wait two hours for assistance, while another reported waiting four to six hours, resulting in lying in soiled linens. The deficiency also extended to the dining experience, where insufficient staff led to delays in feeding residents, causing their meals to become cold. Observations noted that staff were feeding multiple residents simultaneously without changing gloves, raising concerns about cross-contamination. Additionally, a legally blind resident was left to eat with her fingers due to a lack of assistance, highlighting the inadequate support provided during meal times. Staff interviews confirmed that they were often overwhelmed with the number of residents they were responsible for, which hindered their ability to respond promptly to call lights and provide necessary care. Furthermore, the facility's failure to provide prompt incontinence care resulted in severe consequences for some residents. One resident was left in a soiled brief for over 48 hours, leading to skin damage and excruciating pain. Another resident expressed concerns about the lack of incontinence care, which she believed contributed to her urinary tract infections. The facility's documentation corroborated these claims, showing that residents were often not repositioned or provided incontinence care as frequently as required. Interviews with staff and family members further highlighted the impact of staffing shortages on the quality of care provided to residents.
Dietary Errors and Inadequate Tray Checks in LTC Facility
Penalty
Summary
The facility failed to ensure that 18 out of 81 residents received their prescribed diets without errors. During a tray line observation, it was noted that residents on fortified diets did not receive the necessary butter used to fortify their meals. Additionally, residents on mechanical soft diets were served large chunks of hard melon, which did not meet the required texture for easy chewing. These errors were identified before the trays were distributed, but the dietary staff did not correct them. Furthermore, Licensed Nurses were observed checking trays only for residents eating in the social dining room, neglecting those eating in their rooms. Certified Nursing Assistants delivered meals without verifying that the trays matched the tray tickets. The Director of Nursing acknowledged that incorrect diet consistency could lead to choking. The facility's policies on fortified menu plans and modified diets emphasize the importance of delivering correct diets to ensure residents' quality of life, but these were not adhered to in this instance.
Deficiency in Food Safety Knowledge Among Kitchen Staff
Penalty
Summary
The facility failed to ensure that four kitchen staff members were knowledgeable about essential food safety processes, including the cooling process for leftover food, the thawing process for frozen food, and the 3-step process for manually washing, rinsing, and sanitizing dishware. During interviews, Dietary Aids R, S, T, and U demonstrated a lack of understanding of these processes. Dietary Aid R incorrectly described the 3-step dishwashing process, while Dietary Aids S, T, and U were unable to describe the cooling and thawing processes. This lack of knowledge was observed despite the Dietary Manager's claim of previous training, which was undocumented. The facility's policy on manual dishwashing was not followed, as evidenced by the incorrect description provided by Dietary Aid R. Additionally, the facility's claim of not saving leftovers was contradicted by the discovery of a plastic bag with cooked chicken in the refrigerator, labeled with a date that suggested it was a leftover. The facility failed to provide a policy on the thawing process for meats and food, further indicating a lack of proper food safety protocols. These deficiencies had the potential to result in foodborne illnesses and the spread of infections to all residents, except for one resident who did not eat by mouth.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to provide attractive and palatable meals to 80 out of 81 residents, excluding one resident who was on formula feedings. Observations and interviews revealed that the food served was lacking in flavor, often cold, and not presented in an appetizing manner. Residents reported dissatisfaction with the meals, noting that entrees were mismatched, and the food was frequently served at inappropriate temperatures. Specific complaints included cold food, hard breakfast eggs, and the incorrect type of coffee being served. During a taste tray observation, the Dietary Manager and surveyors confirmed that the food temperatures were below acceptable levels, with pasta and vegetables served at temperatures ranging from 93 to 117 degrees Fahrenheit. The vegetables were noted to be overcooked and lacking flavor, which was confirmed by the Dietary Manager, who stated that the residents preferred them that way. The facility's policy indicated that meals should be nutritious, attractive, and palatable, but the findings showed a failure to adhere to these standards.
Incomplete Documentation of Meal Consumption for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical documentation for two residents, leading to potential issues in tracking their care and meeting healthcare goals. Resident 25 experienced a significant weight loss of over 20% in six months, yet her meal consumption documentation for May 2024 was incomplete. Observations showed that on several days, only one meal was recorded, and on some days, no meals were documented at all. This lack of documentation was confirmed by the Dietary Manager, who acknowledged the issue and stated that it was the responsibility of the care staff to document meal consumption. Resident 29 also suffered from severe weight loss of 15.86% over six months, with inadequate monitoring of meal intake from March to June 2024. The resident's medical history included conditions such as sequelae of cerebral infarction, feeding difficulties, and dementia, which necessitated close supervision and assistance with eating. However, the facility's records showed numerous instances where meal intake was not documented, particularly for breakfast and lunch, which could have contributed to the resident's weight loss. The facility's policy on ADL documentation required CNAs to record residents' food and nourishment intake, but this was not consistently followed for Residents 25 and 29. The lack of proper documentation hindered the interdisciplinary team's ability to track the care provided and assess the residents' ability to meet their healthcare goals, potentially resulting in low quality of care and harm to the residents.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to establish, implement, and maintain an effective Quality Assurance Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) program. The Director of Nursing (DON) was responsible for the QAPI program's development, but there was a lack of documentation and involvement from the governing body and executive leadership. The facility did not maintain QAPI meeting minutes or documentation, which resulted in an inability to address and correct deficiencies related to nutrition issues and falls with injuries. The DON reported that department heads were supposed to bring reports of resident concerns or issues to be entered into the QAPI system, but this was not happening. As a result, the facility failed to track interventions for fall prevention measures, despite recording a significant number of falls, including three major injuries, over the first five months of the year. Additionally, the facility did not have a QAPI project regarding weight loss issues among residents, as the Assistant Director of Nursing had not provided any information to be entered into the QAPI plan. The DON stated that the administrator was aware of the weight loss issues, but no decisions had been made on what to measure in the QAPI plan. Staffing issues were also not being tracked in the QAPI plan. The facility's QAPI policy indicated the use of the Plan-Do-Study-Act (PDSA) cycle for performance improvement projects, but the lack of participation and data tracking by department heads hindered the program's effectiveness.
Ineffective QAPI Program Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program, which led to several deficiencies in resident care and safety. The QAPI meetings lacked the required members, including consistent attendance by the Medical Director, and were often too brief to address significant issues. The facility did not adequately monitor or address key areas such as infection prevention, activities of daily living, falls, meal and fluid intake, resident dignity, call light response times, and nutrition/hydration oversight. These deficiencies were not identified or prioritized, resulting in a lack of corrective action plans and monitoring of outcomes. The Director of Nursing (DON) reported that the Fall Committee was not operational, and interventions for fall prevention were not being tracked despite a high number of falls, including those with major injuries. The DON also noted that department heads were not providing necessary reports for the QAPI system, leading to incomplete data and unaddressed issues such as weight loss among residents. The Assistant Director of Nursing was responsible for tracking weight loss but failed to provide data, leaving the QAPI plan blank in this area. Staffing issues were also not tracked, and the DON expressed that the Administrator was aware of these problems but did not assist in resolving them. Interviews with the facility's physician revealed that while falls and weight issues were discussed, there was no comprehensive analysis or trend identification to prevent future incidents. The physician acknowledged the challenges faced by the facility, including staffing and the resident population, but felt that the residents' needs were being addressed. However, the lack of effective QAPI processes and data analysis hindered the facility's ability to implement necessary safeguards and improvements, potentially compromising resident safety and care quality.
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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.
Illustrative
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Nursing homes near Crescent City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Curry Village Health And Rehab Of Cascadia | 20.1 mi | ★★★★★ | 8 | 0 |
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