Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gateway Post Acute during CMS and state inspections, most recent first.
Failure to Treat a Resident with Dignity and Respect: A cognitively intact resident reported that an AA verbally and mentally abused another resident during group activities, including making demeaning comments, isolating her from peers, and speaking disrespectfully about her pain and diabetes. The resident said the other resident appeared visibly sad, and the DON, SSD, and Administrator confirmed the allegation was investigated and found to be abuse.
The facility failed to follow its abuse policy after a resident reported that an Activities Assistant was verbally and mentally abusive to another resident during an activity group. The DON, SSD, and Administrator stated the allegation was reported, but the accused staff member continued working and had resident contact until later suspension, even though the policy required immediate leave with no resident contact until the investigation was complete. The investigation later found the abuse allegation was founded and the staff member was terminated.
CDM lacked the required six hours of in-service training on California dietary service requirements under HSC 1265.4(b) pathway #4 before assuming full-time DSS duties. The RD worked part-time at the facility, and the CDM acknowledged she did not have the Title 22 training required for the role that supervises dietary operations, meal service, sanitation, and regulatory compliance.
Lack of Competency Verification for Wound Vac and Colostomy Care: Staff performed wound vac and colostomy care for two residents without documented competency validation. The DON stated there were no competencies in her file or an LPN's file before wound vac dressing changes for a resident with an abdominal wound, and an LPN stated she had not received training or a skill check-off for colostomy care before changing another resident's colostomy bag. The DON also stated the facility did not have competencies for staff on colostomy care.
Meal Preferences Not Honored: A resident at risk for malnutrition was served lunch with chicken covered in alfredo sauce even though his meal ticket noted he disliked gravy and sauces. During observation, the resident said he was not going to eat the meat, and the CDM confirmed the sauce should not have been on his plate.
Food deliveries and boxed food items were stored directly on the floor in the dry storage area, and clean pans were placed on shelving with rust, chipped paint, and corrosion. In the kitchen, staff used a cleaner-sanitizer on a food prep counter without first removing soil, despite the product instructions stating that cleaning is still required before sanitizing and that the process requires two steps with one product.
Food items stored for residents were not consistently labeled, dated, or monitored, and a resident refrigerator was found above the required safe temperature with extensive debris inside. Staff observed unopened supplements labeled with a room number instead of a resident name, opened jelly jars without a proper open date, and expired applesauce and Glucerna that should have been discarded. The RD confirmed the jelly was stored at 50.5 degrees F, above the facility’s 41-degree standard, and the AD stated the refrigerator was not maintained in a clean manner.
Hand hygiene was not provided before meals for multiple residents, including residents who needed assistance with personal hygiene, and a CNA stated she did not offer hand hygiene before delivering lunch trays. Two LVNs also failed to clean and disinfect reusable glucometers after blood glucose checks, instead only wrapping the devices in disinfectant wipes before storing them. The facility policy and the glucometer manufacturer’s instructions required cleaning and disinfection between resident uses.
Insufficient bedroom square footage was identified in four of 27 rooms after surveyors measured multiple-occupancy rooms and found they did not meet the required 80 sq. ft. per resident. The Administrator acknowledged the deficiency, and a resident stated that having fewer residents in the room would make it easier to get in and out. A prior room waiver was requested but could not be provided.
A resident's preference for closed privacy curtains was not honored when a CNA opened the curtains and stated she liked them open. The resident asked for the curtains to be shut and said he felt taken advantage of because he could not close them himself. The CNA later acknowledged she did not ask the resident his preference and should have honored his wishes.
A resident’s physician order for weekly colostomy bag changes and PRN changes for leakage or soilage was not followed. The TAR showed no bag changes during one month and only one change in the prior month, and an LVN stated the bag should be changed weekly per the order and the site should be monitored.
Incomplete Care Plan for Soft Helmet Use: A resident with seizure and traumatic brain injury was observed wearing a soft helmet while seated in a wheelchair, but staff stated there was no care plan documenting why the helmet was used, how long it should be worn, or whether skin or head checks were needed. The LVN and DON both confirmed the soft helmet was not recorded in the medical record or addressed in the resident’s care plan, despite the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables.
The facility failed to follow its Elopements P&P when a resident with a BIMS score of 3 exited through an exit door unsupervised. The resident, whose wheelchair alarm sounded, pushed open the door and self-propelled outside without staff present; CNA later stated the resident should not be outside without staff, and the DON stated residents who want to go outside should be monitored.
A resident's tray card listed a 2-handle cup with lid, but staff observed a one-handled slow sip covered mug at the meal. OT, the CDM, and the RD reviewed the EHR and tray card and found no physician order for a 2-handle cup, while the current diet order was for a slow sip covered mug. The facility's FNS communication process relied on paper slips, and no slip was found for either device, resulting in inconsistent directions between departments.
Failure to follow standardized texture-modified recipes occurred when a cook prepared pureed bread and pasta for residents on pureed and blenderized diets using unmeasured amounts of milk and thickener. The cook stated she was judging consistency by sight rather than measuring ingredients, and the RD stated standardized recipes should have been followed for all texture-modified foods and diet orders.
Inaccurate wound vac documentation was found for a resident with intact cognition. The OSR directed staff to cleanse the abdominal wound, apply black foam, and use the wound vac at -125 mm/hg every shift every 3 days, but the TAR showed the wound vac was signed off with two staff signatures for each shift on days it was changed. The DON stated staff were only changing it once a day and it should be signed off once a day, while the physician and the resident stated the wound vac was actually changed once every 3 days.
A resident who experienced a fall and reported increased pain had a STAT x-ray ordered for the left hip and shoulder, but the x-ray was not performed until approximately 19 hours after the order was placed. Both facility staff and the contracted x-ray provider indicated that STAT orders should be completed within 4-8 hours. The delay was confirmed through interviews and record reviews, and the x-ray ultimately revealed a left clavicle fracture.
A resident with a history of osteomyelitis and diabetic neuropathy experienced severe pain during a wound dressing change, as the Infection Preventionist failed to assess or manage the pain despite visible signs of distress. The resident, who had been prescribed Morphine, did not receive pain medication prior to the procedure, contrary to the facility's pain management policy.
A facility failed to implement proper infection control practices when an IP did not use appropriate PPE or perform hand hygiene during a procedure on a resident with an open wound. Additionally, the facility lacked effective infection control surveillance, as the IP did not conduct necessary observations or data analysis, and no documentation was provided.
The facility failed to implement an effective Antibiotic Stewardship program, lacking participation from key personnel and oversight. A resident was treated for a UTI without a positive urine culture, and another was treated indefinitely for Valley Fever without lab confirmation. The facility's policies on antibiotic use were not followed, leading to potential unnecessary medication use.
A facility failed to assess a resident's competency to self-administer eye drops, as required by policy. The resident had been self-administering the medication for over two months without a physician's order or IDT assessment. This oversight posed a potential risk for medication errors and health risks.
A facility failed to notify a physician about the discontinuation of restorative therapy for a resident with spinal cord injury and muscle weakness, and about another resident's toe wounds. The first resident's therapy was stopped due to refusal to participate, but no physician notification was documented. The second resident's toe was red, swollen, and had wounds, yet there was no nursing assessment or physician notification documented, despite facility policy requiring weekly skin assessments.
The facility failed to maintain a homelike environment for two residents, resulting in unkempt living conditions. A resident's toilet had a dark brown ring, and the Maintenance Supervisor and Housekeeping staff confirmed it was stained and needed replacement. Another resident's restroom had broken and missing tiles with a sticky black substance, which the Administrator and Maintenance Supervisor agreed required repair.
A facility failed to ensure the accuracy of a resident's assessment, specifically regarding dental status. The resident complained of tooth pain, but the MDS inaccurately indicated the resident had no natural teeth, while records showed some natural teeth were present. The facility's policy requires certification of assessment accuracy, which was not followed.
A facility failed to conduct a PASRR Level 2 evaluation and psychiatric assessment for a resident with serious mental disorders, despite a positive PASRR Level 1 screening. The resident, diagnosed with schizophrenia, anxiety disorder, and major depressive disorder, did not receive the necessary follow-up evaluations, as confirmed by the MDSC. This failure to comply with DHCS guidelines potentially affected the resident's placement and access to mental health treatment.
The facility failed to provide summaries of the baseline care plans to two newly admitted residents within 48 hours of admission. One resident, admitted with osteomyelitis and diabetes, underwent a transmetatarsal amputation, while another, admitted for aftercare following surgical amputation, had toes amputated. Both residents' baseline care plans were incomplete, and summaries were not provided, contrary to the facility's policy.
A facility failed to develop a hospice care plan for a resident admitted under hospice care, as required by their policy. The resident's records indicated hospice care, but no End of Life or Hospice care plan was created. The facility's policy mandates comprehensive care plans with measurable objectives and regular updates, especially after significant changes in a resident's condition.
A resident with hypertension was given AmLODPine Besylate despite having a systolic blood pressure below the prescribed threshold, contrary to physician orders. Additionally, HYDROcodone-Acetaminophen was administered for severe pain even when the resident's pain level was recorded as 0 or 2, below the severe pain threshold. LVNs showed discrepancies in following physician orders, contrary to the facility's medication administration policy.
A resident with major depressive disorder and Alzheimer's Disease was not provided with activities of her choice, despite expressing a desire to engage in group activities and enjoy fresh air. The facility failed to develop an activities care plan for her, and there was a lack of documentation regarding her participation or refusal of activities, contrary to facility policy.
A resident with hemiplegia and hemiparesis following a stroke did not receive a comprehensive pain management care plan, leading to unrelieved pain and isolation. The facility's incomplete pain assessment failed to trigger necessary physician notifications, and the resident's daily use of Oxycodone indicated insufficient pain management.
A facility failed to follow its repositioning policy for a resident with Alzheimer's, who was at risk for pressure ulcers. The resident's care plan required repositioning every two hours, but records showed multiple instances in August where this was not done. The RNC confirmed that documentation was inconsistent, and if not documented, repositioning was considered not done, contrary to the facility's policy.
A resident with dysphagia and missing teeth was served a regular textured meal despite recommendations for a mechanical soft diet. The resident, who pockets food, was at risk due to the facility's failure to adjust her diet according to the Speech Language Pathologist's evaluation. The Registered Dietician had not received updated recommendations, and the facility's policy on dysphagia management was not followed.
A facility failed to complete pre-dialysis and post-dialysis communication assessments for a resident with ESRD, missing several scheduled assessments. The DSD confirmed that these assessments were crucial for communication between the facility and the dialysis center regarding the resident's condition, as outlined in the facility's policy.
A facility failed to follow its bed safety and bed rail policy for a resident with encephalopathy, muscle weakness, and dysphasia. The Bed Rail and Entrapment Risk Observation/Assessment was incomplete, lacking documentation of the family's request for bed rails, and the Interdisciplinary Team was not involved in the review. Additionally, there was no physician's order or care plan for the use of bilateral bed rails, contrary to the facility's policy requiring interdisciplinary evaluation and informed consent.
The facility failed to employ a full-time DON for a 62-bed facility, leading to a lack of oversight in nursing services and quality of care. The DSD managed nursing staffing hours without review, and the IP lacked guidance in infection control, relying on external consultations.
An expired Advair Diskus Inhaler was found on a medication cart during an observation and interview with an LVN. The inhaler, which should have been discarded by its labeled discard date, was not removed, contrary to the facility's policy on medication storage. The LVN confirmed that it is the nurse's responsibility to check and dispose of expired medications.
A facility failed to maintain a medication error rate of 5% or less, resulting in an 8% error rate. An LVN administered an incorrect insulin dosage to a resident without a physician's order, and another LVN gave Tylenol two hours earlier than prescribed. The facility's policy requires medications to be administered as prescribed.
A resident received an incorrect insulin dosage due to a Licensed Vocational Nurse (LVN) administering an additional six units of Humalog insulin without a Physician's Order (PO). The LVN acted on the resident's request but failed to document the extra dosage, violating the facility's medication administration policy.
The facility did not ensure that two kitchen staff members followed the dress code policy, which required all facial hair to be covered by a beard restraint. Observations revealed that their mustaches were exposed, contrary to the policy. The Dietary Service Supervisor incorrectly believed that trimmed mustaches could be left uncovered, leading to a potential risk of food contamination.
A facility failed to monitor the intake and output of a resident on a fluid restriction, as required by their policy. The resident had a fluid restriction order of 1.8 liters per 24 hours, but monitoring ceased after the first 30 days post-admission. This lapse was confirmed by the Director of Staff Development, who could not provide documentation of ongoing monitoring, despite the facility's policy requiring it.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a cognitively intact resident reported witnessing an Activities Assistant verbally and mentally abuse another resident during group activities. The resident, whose BIMS score was 14, told the DON, SSD, and Administrator that the AA made demeaning comments to the other resident during bingo, including refusing to give her two bingo cards, calling her stubborn, saying her foot was too heavy to lift, and stating she would not help because it would cause her pain. The resident also reported that during a later nail-painting activity, the AA placed the other resident by herself at a table and said she would not assist her in removing nail polish because she took too long. The resident further stated she and other residents moved to comfort the other resident because she appeared visibly sad from the AA's comments and isolation from peers. The resident also reported that later, when ice cream was handed out, the AA gave ice cream to the other resident despite her diabetes and told her that if her sugar went up, staff could just give her more insulin. The Administrator stated the facility investigated the allegation, found abuse by the AA toward the other resident, and terminated the AA. The facility policy stated residents are to be treated with dignity and respect at all times.
Failure to Remove Accused Staff Member After Abuse Allegation
Penalty
Summary
The facility failed to implement its policy and procedure for an allegation of verbal and mental abuse involving one resident and another resident during an activity group. On 5/20/26, Resident 1 reported to the Social Services Director that an Activities Assistant was verbally and mentally abusive to Resident 2. The Social Services Director reported the allegation to the Administrator and placed Resident 1 and Resident 2 on monitoring. The Administrator stated he was informed of the allegation on 5/20/26 and placed all residents on monitoring while the Activities Assistant continued to work. The Activities Assistant completed the remainder of her shift on 5/20/26 and worked half of her shift on 5/21/26 before being suspended. The facility investigation later concluded that abuse did occur and the Activities Assistant was terminated on 5/22/26. The facility policy stated that any employee accused of resident abuse is to be placed on leave with no resident contact until the investigation is complete, but the Administrator stated the Activities Assistant was not removed from the facility after the allegation.
CDM Lacked Required California Dietary Service Training
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) met the state education qualifications required to supervise Food and Nutrition Service operations. During interview and record review, the Registered Dietitian stated he worked part-time at the facility, usually every Tuesday or more when needed, and the CDM was identified as serving under pathway #4 of HSC 1265.4(b). During a concurrent interview and record review, the CDM stated she was a Certified Dietary Manager under pathway #4, but also stated she did not have the required six hours of in-service training on the specific California dietary service requirements in Title 22 of the California Code of Regulations before assuming full-time duties as a dietetic services supervisor. The CDM job description stated the position must supervise the Dietary Department, direct and assist meal preparation and service, order food and supplies, maintain sanitary conditions, and ensure compliance with federal, state, and local regulations.
Lack of Competency Verification for Wound Vac and Colostomy Care
Penalty
Summary
Nurses and nurse aides were not ensured to have the appropriate competencies to care for residents requiring wound vac and colostomy care. For Resident 57, whose BIMS score was 13, the order summary directed cleansing an abdominal wound with Dakins quarter strength gauze, then applying black foam for wound vac therapy at -125 mmHg every shift every 3 days. The treatment administration record showed the wound vac was changed on 5/6/26 and 5/9/26, and the DON stated LVN 4 changed the wound vac on 5/6/26 and the DON changed it on 5/9/26. The DON stated there were no competencies in her file or LVN 4's file prior to performing the wound vac dressing change. For Resident 9, the order summary directed colostomy bag changes every week and as needed for leakage or soilage. The treatment administration record showed the colostomy bag was changed on 4/11/26 by LVN 2, and LVN 2 stated she had not had any training or skill check-off for colostomy care. During interview, the DON stated she did not have competencies for staff on colostomy care. The facility policy stated staff must demonstrate the skills and techniques necessary to care for residents' needs, and that skin and wound care competency requirements and trainings for nursing staff are established and monitored.
Meal Preferences Not Honored
Penalty
Summary
The facility failed to honor Resident 20’s meal preferences when lunch was served with chicken covered in a creamy white sauce, even though the resident’s meal ticket indicated he disliked gravy and sauces. During observation in the dining room, Resident 20 was eating lunch and stated he was not going to eat the meat. The Certified Dietary Manager confirmed that the white sauce on the chicken was alfredo sauce and stated that Resident 20 did not like sauces and that the alfredo sauce should not have been on his plate. Resident 20’s care plan identified him as at risk for malnutrition and included an intervention to cater to food preferences.
Food Storage, Equipment, and Sanitizing Practices Not Followed
Penalty
Summary
Food deliveries and boxed food items were stored directly on the floor in the dry food storage area during an observation with the Certified Dietary Manager. An opened shipping box containing thickened dairy drink containers, a Frito Lay shipping box, and a box of individual bottled waters were all placed on the floor instead of being stored at least 6 inches above it. The Registered Dietitian stated that food deliveries cannot be stored directly on the floor, and the facility policy titled Storage of Food and Supplies required all food and food containers to be stored 6 inches off the floor on clean surfaces protected from contamination. In the kitchen, stainless steel pans were stored face down on a bottom shelf of a metal work table where chipped and missing paint, rust, and corrosion were present. During a later observation, pots and pans were again seen turned over on a table by the exterior door, with the food-contact surface resting on an extensively rusted frame. The Registered Dietitian stated the shelving needed to be replaced because it was a source of cross-contamination. The FDA Food Code cited in the report stated that nonfood-contact surfaces requiring frequent cleaning must be constructed of corrosion-resistant, nonabsorbent, and smooth material. The foodservice operation also used a cleaner-sanitizer on food contact surfaces in a way that did not follow the manufacturer's instructions. A Dietary Aide wiped a food preparation counter with a cloth from a red bucket containing SmartPower Sink and Service Cleaner Sanitizer, then checked the solution concentration with a test strip after use. The Registered Dietitian and Certified Dietary Manager stated the product was used in one step and that staff did not pre-clean surfaces before sanitizing. However, the manufacturer's FAQ stated that soils still need to be removed before sanitizing and that this requires two steps with one product, using one side of a towel or wipe to clean and the other side to sanitize.
Food Storage, Labeling, Temperature, and Cleanliness Deficiencies
Penalty
Summary
The facility failed to implement its policies and procedures for food brought in from outside sources and for refrigerated storage of resident food items. During observation and interview, a refrigerator used to store food brought in from outside the facility contained six unopened Ensure bottles labeled only with a room number rather than a resident name, and the Certified Nursing Assistant stated the bottles were supposed to be labeled with the resident’s name. In the resident refrigerator storage room, two opened jelly jars were labeled only with a resident name and a date written as "Rec 9/30," and the Active Director stated staff were supposed to place an open date but did not know how long the jars could be stored after opening. The same refrigerator also contained two unopened packages of applesauce marked by the manufacturer with a best-by date that the Active Director said was expired and should have been thrown out, as well as six unopened bottles of Glucerna dated by the manufacturer as 1 May 2026, which the Active Director identified as an expiration date and said should have been discarded. The resident refrigerator storage room also had a refrigerator thermometer showing 50 degrees Fahrenheit, and the Registered Dietitian inserted a digital thermometer into the opened jelly jars and found the internal temperature was 50.5 degrees Fahrenheit, stating the food was not stored safely. The facility’s procedure required refrigerator temperatures of 41 degrees Fahrenheit or lower. In addition, the refrigerator was observed to have extensive debris on the third shelf space, and the Active Director stated the refrigerator was not maintained in a clean manner. Posted signage on the refrigerator stated that items should be labeled with the resident’s name and today’s date and that outdated items or items without names and dates would be thrown out, and another sign stated the refrigerator would be cleaned daily.
Hand Hygiene Not Provided Before Meals and Glucometers Not Cleaned After Use
Penalty
Summary
Hand hygiene was not provided before meals for six sampled residents. Resident 68 stated staff did not offer or provide hand hygiene prior to meals. Resident 68’s BIMS dated 5/4/26 showed a score of 14, and the MDS dated 5/4/26 indicated the resident needed assistance with personal hygiene, including washing and drying face and hands. During observations on 5/12/26, CNA 2 delivered lunch trays to Resident 23, Resident 13, Resident 59, and Resident 1, and did not offer or provide hand hygiene before the residents began eating. CNA 2 stated she did not offer or provide hand hygiene to those residents prior to delivering their lunch meal trays and stated she should have offered and provided hand hygiene. Resident 59 stated staff had only offered hand hygiene prior to meals once and said he had his wife bring him hand sanitizer from home so he could clean his hands before meals. Resident 59’s BIMS dated 4/20/26 showed a score of 13, and the MDS dated 4/20/26 indicated partial/moderate assistance was needed with personal hygiene. Resident 71 stated staff do not offer or provide hand hygiene prior to meals being served. Resident 71’s BIMS dated 4/22/26 showed a score of 15, and the MDS dated 4/22/26 indicated partial/moderate assistance was needed with personal hygiene. Two LVNs did not clean and disinfect glucometers after use. During observations, LVN 1 and LVN 2 checked residents’ blood glucose levels and then placed the used glucometers on the medication cart, wrapped them in disinfectant wipes, and stored them without first wiping the devices down. LVN 2 also used a new glucometer after an error code occurred and again wrapped the used glucometer in a disinfectant wipe without physically cleaning it. Both LVNs stated they did not wipe the glucometers with a wiping motion and only wrapped them in disinfectant wipes. The facility policy required reusable equipment to be cleaned and disinfected between resident uses, and the manufacturer’s guidelines for the EVENCARE G3 meter stated the meter should be cleaned and disinfected between each patient.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the minimum square footage required by regulation in four of 27 bedrooms. During a concurrent observation and interview with the Administrator, the multiple-occupancy rooms were measured and found to be 315 square feet with 4 resident beds, 286 square feet with 2 resident beds, 286 square feet with 4 resident beds, and 390 square feet with 4 resident beds. The Administrator stated these rooms did not meet the required minimum of 80 square feet per bed for multi-occupancy rooms and acknowledged that this was a deficiency. During an interview, Resident 43 stated that if there were 3 residents in the room it would be easier to get in and out. A copy of a previous room waiver was requested but could not be provided.
Resident Privacy Curtains Preference Not Honored
Penalty
Summary
The facility failed to uphold Resident 14's right to a dignified existence, self-determination, communication, and to exercise his rights when his preference for closed privacy curtains was not honored. During an interview, Resident 14 stated that CNA 3 entered the room and opened the privacy curtains, and when Resident 14 asked for them to be shut, CNA 3 replied that she likes the curtains open. Resident 14 stated he felt taken advantage of because he could not close the curtains himself. In a later interview, CNA 3 stated she likes the curtains open, did not ask Resident 14 whether he wanted the curtains closed or opened, and acknowledged that she should have asked Resident 14 and honored his wishes. The facility's Resident Rights policy stated that residents are entitled to exercise their rights and privileges to the fullest.
Failure to Follow Weekly Colostomy Bag Change Order
Penalty
Summary
The facility failed to implement a physician order for Resident 9’s colostomy bag change every week and as needed for leakage or soilage. Review of the Order Summary Report showed the weekly colostomy bag change order, but review of the Treatment Administration Record showed the colostomy bag was not changed during May and was changed only once in April, on 4/11/26. During interview, LVN 2 stated the colostomy bag should be changed every week per physician’s orders and that staff should be monitoring the site. The facility policy on colostomy care required documentation of the date and time care was provided, who provided it, how the resident tolerated the procedure, and the signature and title of the person recording the data.
Incomplete Care Plan for Soft Helmet Use
Penalty
Summary
The facility failed to ensure Resident 5 had a comprehensive care plan that included measurable objectives and timetables to meet the resident’s physical needs. Resident 5’s admission record dated 2/3/26 identified seizure and traumatic brain injury. During observation and record review on 5/12/26, Resident 5 was seen sitting in the hallway in a wheelchair wearing a soft helmet on his head. An LVN stated the helmet was worn to protect the resident and that Resident 5 was to wear it out of bed, but also stated there was no care plan to indicate why the helmet was being used, how long it should be worn, or whether the resident’s skin or head should be assessed for breakdown. The LVN further stated there was nothing in the medical record indicating the soft helmet. During interview and record review, the DON reviewed Resident 5’s undated care plan and stated there was no care plan for the soft helmet and that the soft helmet was not recorded anywhere in the resident’s medical record. The DON stated the care plan would inform staff why Resident 5 had a soft helmet and what interventions needed to be followed. The facility’s policy titled Care Plans, Comprehensive Person-Centered, dated 3/2022, stated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical and functional needs is developed and implemented for each resident.
Unsupervised Exit by Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to follow its policy and procedure titled Elopements when Resident 38 exited the building unsupervised. During observation, Resident 38, who had an alarm on the back of the wheelchair, pushed open an exit door and self-propelled the wheelchair out of the exit door without staff present. During a concurrent observation, CNA 1 was seen pushing Resident 38’s wheelchair from outside back into the resident hallway with an audible alarm sounding, and stated that Resident 38 should not be outside without staff. Resident 38 had a BIMS score of 3 on 2/27/26, indicating severe cognitive impairment. In interview, the DON stated there should be monitoring in place for residents who want to go outside. The facility’s Elopements policy dated 2/2007 stated staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or DON.
Mismatch Between Tray Card and Ordered Adaptive Drinking Equipment
Penalty
Summary
The facility failed to ensure accurate and consistent communication between departments regarding adaptive equipment for Resident 51. During a dining room observation, Resident 51 had a clear cup with one blue handle and a blue lid containing a red liquid, while the tray card indicated a 2-Handle Cup with Lid. An OT observed that the cup in use did not match the tray card and stated the one-handled cup was not consistent with the tray card direction. A concurrent record review showed Resident 51 had a physician's dietary order for a slow sip covered mug dated 4/9/26. The OT stated there was no physician's order for a two-handled cup and that the observed cup was a slow sip covered mug intended to control fluid flow and limit the volume per sip to prevent aspiration and/or choking. The OT also stated Resident 51 had been assessed for a slow sip mug, not a two-handled cup. The CDM and RD reviewed the tray card and EHR and stated the tray card should match current medical orders because it is the sole reference used by kitchen staff to prepare meal trays. The CDM stated kitchen staff should follow the individualized directions on the tray card, but also stated Resident 51 did not have a two-handled cup during the meal and that the blue handles on the cup were removable. The facility's communication process required nursing staff to complete a paper communication slip for FNS, despite the ability to enter adaptive equipment orders directly into Nutrition Management, and no communication slip was found for either a two-handled cup or a slow sip covered mug.
Failure to Follow Standardized Texture-Modified Recipes
Penalty
Summary
The facility failed to ensure a [NAME] followed standardized texture modified recipes for seven residents on pureed or blenderized diets. During a concurrent observation and interview in the kitchen, the cook stated she placed seven pieces of bread in a food processor, then added an unmeasured amount of milk and an unmeasured amount of thickener, and said she was unable to state how much of either ingredient she used because she did not measure them. She stated she was looking for a pudding-like texture when preparing the pureed bread. During another observation, the cook measured six servings of pasta at 4 ounces per serving and placed it into a food processor, then poured an unmeasured amount of milk from a stainless-steel pan into the processor and added thickener from an unlabeled pitcher after visually checking the texture. She transferred the pureed pasta to a separate container for lunch service and stated she was not sure how much milk or thickener she added because she did not measure the ingredients. In a later observation, she added more unmeasured milk to the remaining pureed pasta and blended it further, stating she was processing the pureed bread further for blenderized diet orders and was just looking for the right consistency. The facility's recipe for pureed starches specified measured amounts of warm milk and stabilizer, and the RD stated standardized recipes should have been followed for all texture-modified foods and diet orders.
Inaccurate wound vac documentation
Penalty
Summary
The facility failed to ensure accurate wound records for one sampled resident, Resident 57, because the physician's order for the abdominal wound vac was unclear. The resident's BIMS score dated 4/16/26 was 13, indicating intact cognition. The Order Summary Report dated 5/5/26 directed staff to cleanse the abdominal wound with Dakin's quarter strength gauze, leave it in place for 2 minutes, then remove the gauze and apply black foam for the wound vac at -125 mm/hg pressure every shift every 3 days for the abdominal wound. During a concurrent interview and record review on 5/12/26, the DON reviewed the TAR for May 2026 and found that Resident 57's wound vac had been changed on 5/6/26 and 5/9/26 with an initial sign-off for each shift. The DON stated staff were only changing it once a day and it should be signed off once a day, and that the TAR should not have two staff signatures for each shift. On 5/13/26, the physician stated the wound vac was to be changed once every three days, and the resident also stated staff only changed the wound vac once every three days. The facility policy on documentation accuracy stated clinical records should accurately reflect the care given by each member of the health care team.
Delay in STAT X-ray Completion Following Resident Fall
Penalty
Summary
A deficiency occurred when a STAT x-ray ordered for a resident following a fall was not completed in a timely manner. The resident, who had fallen from her bed and was experiencing increased pain, had a physician's order placed for a STAT x-ray of the left hip and left shoulder. Despite the order being labeled as STAT, the x-ray was not performed until approximately 19 hours after the order was obtained. Both the LVN and DON confirmed that the facility's practice is for STAT orders to be completed within 4-6 hours, and the x-ray company's agreement indicated STAT orders should be completed within 6-8 hours. The delay was confirmed through interviews and record reviews. The resident was observed lying in bed with her left arm immobilized and reported that her arm was broken. The x-ray results later confirmed a left clavicle fracture. The facility's policy and procedures also stated that urgent radiological requests labeled as STAT should be carried out in a timely manner according to the contracted agency's policy. The failure to obtain the STAT x-ray within the expected timeframe constituted a deficiency in meeting the resident's needs for timely diagnostic services.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for Resident 51 during a wound dressing change, as observed by a surveyor. Resident 51, who was admitted with acute osteomyelitis, Type 2 diabetes mellitus with diabetic neuropathy, and other skin ulcers, exhibited signs of severe pain during the procedure. The Infection Preventionist (IP) conducted the dressing change on the resident's amputated left big toe and a vascular wound on the left ankle without assessing or addressing the resident's pain, despite visible signs of distress such as facial grimacing and a reported pain level of nine out of ten. During the procedure, the IP continued to flush and clean the wounds with Daikin and betadine solutions, ignoring the resident's verbal and non-verbal expressions of pain. The IP informed the resident that pain medication would be administered after the treatment, but did not pause the procedure to manage the pain. The resident had been prescribed Morphine, a narcotic pain medication, but it was not administered prior to the dressing change, resulting in unnecessary suffering. The facility's policy on pain assessment and management requires assessing pain before, during, and after treatment, and intervening as needed. However, this protocol was not followed, as evidenced by the lack of pain assessment and management during the dressing change. The resident's care plan also indicated the need for pain management, but the IP failed to adhere to these guidelines, leading to the deficiency noted in the report.
Inadequate Infection Control Practices and Surveillance
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during an incident involving the Infection Preventionist (IP) and a resident with an open wound. The IP did not adhere to the facility's policies on personal protective equipment (PPE) and hand hygiene. Specifically, the IP did not wear a face shield or goggles during a procedure with potential for splash, did not change gloves, and failed to perform hand hygiene after dressing changes. The IP also handled clean dressings and medication cart keys without removing gloves or washing hands, and exited the resident's room carrying a trash bag without performing hand hygiene. Additionally, the facility did not conduct effective infection control surveillance activities. The IP admitted to not performing surveillance on cleaning blood glucose meters and only observing day shift staff due to not working nights. The IP lacked knowledge on conducting infection control surveillance, had no previous data collected, and did not analyze or track hand hygiene surveillance results. The facility's infection control policies required ongoing surveillance for healthcare-associated infections, but no documentation of such activities was provided by the IP.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship program, as evidenced by the lack of participation from key personnel such as the pharmacist, medical director, and director of nursing in the program. The Infection Preventionist (IP) was responsible for the program but admitted that there were no antibiotic stewardship meetings and could not provide documentation that antibiotic stewardship was part of the infection control committee agenda. This lack of oversight led to instances where antibiotics were prescribed without proper justification or documentation, such as in the case of a resident who was treated for a urinary tract infection without a positive urine culture, contrary to the McGreer Criteria guidelines. Additionally, another resident was treated indefinitely with fluconazole for a diagnosis of Valley Fever without laboratory confirmation or physician documentation. The resident's history and physical did not mention Valley Fever, and there was no evidence of reevaluation or referral to an infectious disease specialist. The facility's policies and procedures on antibiotic stewardship, which require review and surveillance of antibiotic use, were not followed, leading to potential unnecessary medication use and lack of proper medical oversight.
Failure to Assess Resident's Competency for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed and determined to be competent to self-administer medication, specifically eye drops. During an observation and interview, it was noted that a bottle of eye drops was left on the bedside table of the resident, who stated that the nurse leaves them there for self-administration. The resident mentioned having the eye drops in the room for over two months, indicating a prolonged period without proper assessment or authorization for self-administration. Further investigation revealed that there was no documentation of a physician's order or interdisciplinary team (IDT) assessment regarding the resident's ability to self-administer the medication. The facility's policy requires an IDT evaluation to determine if self-administration is clinically appropriate and safe, but this process was not followed. The lack of documentation and assessment posed a potential risk for medication administration errors and serious health risks to the resident.
Failure to Notify Physician of Therapy Discontinuation and Wound Condition
Penalty
Summary
The facility failed to notify the physician regarding the discontinuation of restorative therapy for a resident diagnosed with post-laminectomy syndrome, cord compression, and muscle weakness. The resident, who required staff assistance due to spinal cord injury and muscle weakness, was initially placed on a restorative nursing assistant (RNA) program. However, due to the resident's refusal to participate, the therapy was discontinued without notifying the physician. The Director of Rehabilitation Services and the Director of Staff Development were unable to provide documentation of physician notification or any subsequent therapy or range of motion exercises for the resident. Additionally, the facility did not notify the physician about a resident's left big toe, which was observed to be red, swollen, purplish, and with wounds. A Certified Nursing Assistant reported the skin abnormalities to a nurse, but there was no documentation of a nursing assessment or physician notification regarding the wounds. The facility's policy required weekly skin assessments, but the assessments did not indicate any evaluation of the wounds. The facility was unable to provide a policy on physician notification.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for two residents, resulting in them living in an unkempt environment. For Resident 162, a dark brown ring was observed on the inside of the toilet bowl during an observation and interview. The resident was unaware of the last time the toilet had been cleaned. The Maintenance Supervisor and Housekeeping staff confirmed the presence of the stain and stated that the toilet was stained and should be replaced. The Administrator also confirmed the toilet's condition and agreed it should be replaced. In the case of Resident 46, during an observation and interview, broken and missing tiles with a sticky black substance were found in the corner entrance of the restroom. The Administrator acknowledged that the area looked unfinished and should have been fixed, while the Maintenance Supervisor agreed that the restroom should not have broken and missing tiles and needed repair. The facility's policy and procedure on maintaining a homelike environment emphasized providing a clean, sanitary, and orderly environment, which was not upheld in these instances.
Inaccurate Resident Assessment Regarding Dental Status
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the accuracy of resident assessments, specifically for one resident. During an observation and interview, the resident pointed to his upper tooth and complained of pain. A subsequent review of the resident's Minimum Data Set (MDS) revealed inaccuracies in Section K, which indicated the resident had broken or loosely fitting dentures and no natural teeth, contrary to the resident's actual condition of having some natural teeth with some missing. The facility's policy requires that any person completing a portion of the MDS must sign and certify the accuracy of that portion, which was not done correctly in this case.
Failure to Conduct PASRR Level 2 Evaluation and Psychiatric Assessment
Penalty
Summary
The facility failed to ensure that a resident received a psychiatric evaluation and a Preadmission Screening and Resident Review (PASRR) Level 2 evaluation after a PASRR Level 1 screening indicated the need for further evaluation of the resident's mental disorder. The resident's PASRR Level 1 screening, dated January 15, 2024, was positive for serious mental disorders, including schizophrenia, anxiety disorder, and major depressive disorder. Despite this, the resident did not receive a psychiatric evaluation or a PASRR Level 2 follow-up, as confirmed by the Minimum Data Set Coordinator (MDSC) during interviews and record reviews. The MDSC was unable to find documentation of a physician's referral to a psychiatrist or any physician progress notes regarding a psychiatric evaluation for the resident. The Department of Health Care Services (DHCS) guidelines state that a positive Level 1 screening should be followed by a PASRR Level 2 evaluation to determine the most appropriate placement and whether specialized services are needed. The lack of a PASRR Level 2 evaluation and psychiatric assessment for the resident indicates a failure to comply with these guidelines, potentially affecting the resident's placement and access to necessary mental health treatment.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a summary of the baseline care plan (BCP) to two newly admitted residents, Resident 51 and Resident 109, within 48 hours of their admission. Resident 51 was admitted with acute osteomyelitis, Type 2 diabetes mellitus with diabetic neuropathy, and other skin ulcers. Following a transmetatarsal amputation of the left first toe due to gangrene, the BCP for Resident 51 was incomplete, and neither the resident nor their representative received a summary of the BCP for post-operative care. This was confirmed during an interview and record review with the Minimum Data Set Coordinator (MDSC) 1. Similarly, Resident 109 was admitted with aftercare following surgical amputation, diabetes mellitus with diabetic neuropathy, and cellulitis of the left upper limb. After undergoing an amputation of the third, fourth, and fifth toes at the transmetatarsal level, the BCP for Resident 109 was also incomplete, and no summary was provided to the resident or their representative. The facility's policy and procedure, dated 2001, requires that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative. This policy was not adhered to in these cases, as confirmed by MDSC 1 during the review.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to adhere to its policy and procedure for developing comprehensive, person-centered care plans for one of the sampled residents, identified as Resident 22. Upon review of Resident 22's records, it was found that the resident was admitted under hospice care, as indicated in the Order Listing Report and the Minimum Data Set. However, during an interview and record review with the MDS Consultant, it was revealed that there was no End of Life or Hospice care plan developed for Resident 22, which should have been created following the resident's admission to hospice care. The facility's policy requires that care plans include measurable objectives and timetables to address the resident's needs and be reviewed and updated when there is a significant change in the resident's condition or at least quarterly. This oversight had the potential to not meet Resident 22's physical, psychosocial, and functional needs.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to administer medications to a resident according to physician orders, which could potentially lead to adverse medication outcomes. The resident, who had a history of hypertension, was given AmLODPine Besylate despite having a systolic blood pressure of 103, which was below the prescribed threshold of 110 for withholding the medication. This action was contrary to the physician's order, which specified holding the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Additionally, the resident was administered HYDROcodone-Acetaminophen for severe pain, even when the pain level was recorded as 0 or 2, which is below the severe pain threshold of 7-10 as per the care plan. Interviews with LVNs revealed discrepancies in understanding and following the physician's orders, with one LVN stating she would administer severe pain medication for a pain level less than seven if it was scheduled and requested by the patient, while another LVN acknowledged that administering the medication for a pain level less than seven would not be in accordance with the physician's order. The facility's policy on medication administration emphasized that medications should be administered as prescribed, highlighting a failure in adherence to this policy.
Failure to Provide Resident with Person-Centered Activities
Penalty
Summary
The facility failed to provide a resident with activities of her choice, resulting in her not participating in person-centered activities. The resident, who was admitted with diagnoses including major depressive disorder and Alzheimer's Disease, expressed a desire to engage in group activities, enjoy fresh air, and participate in her favorite pastimes such as knitting and needlepoint. Despite these preferences being documented in her assessments, the resident reported that she only left her room for therapy or showers and wished staff would take her outside or to the activities room. The facility's Director of Activities acknowledged that there was no activities care plan for the resident, which should have been developed to reflect her preferences and refusals. The facility's policy required a comprehensive, person-centered care plan to be developed within a specific timeframe, but this was not done for the resident. Additionally, there was a lack of documentation regarding the resident's participation or refusal of activities, which was contrary to the facility's policy on maintaining appropriate departmental documentation.
Failure to Develop Pain Management Care Plan
Penalty
Summary
The facility failed to provide quality care to Patient 15, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke. Despite the patient's capacity to understand and make decisions, a care plan for pain management was not developed. This oversight was identified during a review of the patient's care plan, where it was noted that the interdisciplinary team had not created a comprehensive, person-centered care plan for pain management within the required timeframe. Additionally, the admission Nursing - Pain Observation and Assessment (NPOA) for Patient 15 was incomplete. The assessment lacked critical details such as the type, duration, frequency, and pattern of the pain, as well as its impact on activities of daily living. The incomplete assessment failed to trigger necessary notifications to the physician for potential new orders to address the patient's pain more effectively. Patient 15 experienced unrelieved pain, which was documented as moderate but was severe enough to prevent the patient from engaging in desired activities, such as going outside. The patient's Medication Administration Record indicated daily use of Oxycodone for pain rated between seven and nine on the pain scale, suggesting that the current pain management strategies were insufficient. The facility's policies on pain assessment and management were not adequately followed, contributing to the patient's ongoing pain and isolation.
Failure to Reposition Resident as Per Policy
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding repositioning for a resident, identified as Resident 22, who was at risk for developing pressure ulcers due to Alzheimer's disease. The care plan for Resident 22, dated October 7, 2020, indicated the need for monitoring, reminding, and assistance to turn and reposition at least every two hours. However, a review of the resident's turning and repositioning records revealed multiple instances where the resident was not repositioned during both day and night shifts in August 2024. Specifically, the records showed that on several dates, the resident was not turned or repositioned as required by the facility's policy. During an interview and record review with the Registered Nurse Coordinator (RNC 2), it was confirmed that the documentation of turning and repositioning was inconsistent with the facility's repositioning policy. The RNC 2 acknowledged that if the repositioning is not documented, it is considered not done. The facility's policy, revised in May 2013, emphasized the importance of repositioning as a critical intervention for preventing skin breakdown and promoting circulation, especially for residents who are immobile or dependent on staff for repositioning. The failure to consistently document and perform the required repositioning placed Resident 22 at risk for developing pressure ulcers.
Failure to Provide Appropriate Diet Texture for Resident with Dysphagia
Penalty
Summary
The facility failed to provide an appropriate diet texture for a resident diagnosed with dysphagia and feeding difficulties. The resident, who was missing most of her top teeth and did not wear dentures due to the risk of swallowing them, was observed being served a regular textured meatball sandwich. Despite the resident's tendency to pocket food and hold onto large pieces, her diet was not adjusted to accommodate her swallowing difficulties. The resident's care plan indicated a risk for weight loss, dehydration, skin breakdown, and altered nutritional status related to her medical condition. The Speech Language Pathologist (SLP) evaluated the resident and recommended a mechanical soft diet due to moderate oropharyngeal dysphagia and a mild aspiration risk. However, the resident continued to receive a regular textured diet. The Registered Dietician (RD) stated that she follows the speech therapist's recommendations but had not received any new recommendations to change the resident's diet. The facility's policy on dysphagia management included obtaining a physician's order for modified consistency diets, but this was not implemented for the resident.
Incomplete Dialysis Communication Assessments for Resident with ESRD
Penalty
Summary
The facility failed to ensure complete pre-dialysis and post-dialysis communication assessments for a resident with end-stage renal disease (ESRD) who was dependent on renal dialysis. The resident was admitted with a diagnosis of ESRD and had scheduled dialysis treatments on Mondays, Wednesdays, and Fridays. However, the facility did not complete the required pre-dialysis assessments on several occasions, including 10/2, 10/4, 10/9, 10/11, 10/14, and 10/16. Additionally, the post-dialysis assessments from the dialysis center were not completed and returned to the facility on multiple dates, including 10/2, 10/4, 10/7, 10/9, 10/11, 10/14, and 10/16. The Director of Staff Development (DSD) confirmed that the facility's protocol required pre-dialysis assessments to be completed and sent with the resident to the dialysis center, and post-dialysis assessments to be obtained from the dialysis center and placed in the resident's medical record. These assessments were crucial for ensuring communication between the facility and the dialysis center regarding the resident's condition, including level of consciousness, skin issues, medications, and vital signs. The facility's policy and procedure for caring for residents with ESRD emphasized the importance of agreements with the dialysis center to manage the resident's care and exchange information effectively.
Failure to Follow Bed Rail Policy and Procedure
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding bed safety and bed rails for a resident, resulting in several deficiencies. The resident, who was admitted with diagnoses including encephalopathy, muscle weakness, and dysphasia, was observed with bilateral bed rails up and foam wedges between the resident and the bed rails. However, the Bed Rail and Entrapment Risk Observation/Assessment (BEAR) was found to be inaccurate and incomplete, lacking documentation of the reason for the family's request for bed rails. Additionally, the Interdisciplinary Team (IDT) was not involved in the review of the use of bed rails, as evidenced by the absence of documentation of IDT members and physician consultation in the BEAR. Furthermore, there was no physician's order for the continuous use of bilateral bed rails, nor was there a care plan for their use. The facility's policy requires that the use of bed rails be based on an interdisciplinary evaluation, resident assessment, and informed consent, with alternatives attempted first. The lack of a physician's order and care plan indicates a failure to meet these criteria, potentially putting the resident's safety and health at risk.
Absence of Director of Nursing Leads to Oversight Deficiencies
Penalty
Summary
The facility failed to employ a full-time Director of Nursing (DON) for a 62-bed facility, resulting in a lack of oversight on nursing services and quality of care. During an entrance conference, the Administrator confirmed the absence of a DON. The Director of Staff Development (DSD) revealed that there had been no DON for over a year, and she was responsible for calculating and submitting nursing staffing hours to the Payroll Based Journal (PBJ) without oversight or review from the Administrator or Registered Nurse Consultant (RNC). Additionally, the Infection Preventionist (IP) reported a lack of guidance and direction in managing the infection control program, particularly in antibiotic stewardship, due to the absence of a DON. The IP had to seek consultation from external sources like the County Health Department Nurse and the Infection Control Consultant (ICC).
Expired Medication Found on Medication Cart
Penalty
Summary
The facility failed to ensure that one of three medication carts did not contain expired medication, specifically an Advair Diskus Inhaler, which was labeled with a discard date of 10/8/24. During an observation and interview with an LVN at Medication Cart 3, it was confirmed that the inhaler should have been discarded by the specified date. The LVN stated that it is the responsibility of the nurse assigned to the medication cart to check expiration dates and dispose of any expired medications or supplies. A review of the facility's policy and procedure on medication storage indicated that outdated, contaminated, or deteriorated medications should be immediately removed from stock and disposed of according to the facility's procedures for medication disposal.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in an observed error rate of 8%. This was due to two specific incidents. In the first incident, a Licensed Vocational Nurse (LVN) administered an incorrect dosage of insulin to a resident. The resident's blood sugar level was 236 mg/dl, and according to the sliding scale, they were to receive four units of Humalog insulin. However, the LVN administered an additional six units of insulin based on the resident's request, despite there being no physician's order for this additional dosage. The LVN did not document the administration of the extra six units, and the Director of Staff Development (DSD) confirmed that it was not acceptable to administer medication without a physician's order. In the second incident, another LVN administered Tylenol to a resident two hours earlier than prescribed. The resident's order entry indicated that Tylenol should be given every six hours for pain, but the medication was administered only four hours after the previous dose. The facility's policy on administering medication requires that medications be given in a safe and timely manner, as prescribed. The DSD confirmed that the early administration of Tylenol was not in accordance with the prescribed orders.
Medication Error Due to Unauthorized Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. A Licensed Vocational Nurse (LVN) administered an incorrect dosage of insulin to a resident, identified as Resident 109. The LVN prepared and administered 10 units of Humalog insulin based on a sliding scale order for the resident's blood sugar level of 236 mg/dl. However, the LVN included an additional six units of insulin that were not prescribed in the resident's Physician's Orders (PO). This additional dosage was given at the resident's request, but without a valid PO, and was not documented by the LVN. Further review of Resident 109's POs confirmed the absence of an order for the additional six units of Humalog insulin before meals. The Director of Staff Development (DSD) confirmed that it was against standard practice to administer medication without a PO, emphasizing that excessive insulin could lead to hypoglycemia. The facility's policy on administering medication, dated April 2019, mandates that medications be administered safely, timely, and as prescribed, which was not adhered to in this instance.
Non-compliance with Dress Code Policy in Kitchen
Penalty
Summary
The facility failed to ensure that two kitchen staff members, the Dietary Service Supervisor (DSS) and a kitchen cook (KC), adhered to the facility's policy and procedures regarding dress code in the Food & Nutrition Department. During an observation, both DSS and KC were noted to have facial hair, specifically beards and mustaches, with their mustaches left uncovered by the beard restraint they were wearing. This was contrary to the facility's policy, which required all facial hair, including mustaches, to be covered by a beard restraint. During an interview, the DSS incorrectly stated that exposed mustaches were permissible if trimmed, which was not in alignment with the written policy from 2018. This oversight had the potential to lead to food contamination.
Failure to Monitor Fluid Intake and Output for Resident on Fluid Restriction
Penalty
Summary
The facility failed to monitor the intake and output of a resident who was on a fluid restriction, as required. The resident had a fluid restriction order of 1.8 liters per 24 hours, which was documented in their Order Summary Report. Despite this, the facility did not continue to monitor the resident's fluid intake and output beyond the first 30 days after admission. This oversight was confirmed during an interview with the Director of Staff Development, who acknowledged the lack of ongoing monitoring documentation. The facility's policy on restricting fluids, which mandates recording the amount of fluid consumed, was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Porterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Medical Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Sierra Valley Rehab Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Sequoia Transitional Care | 1.5 mi | ★★★★★ | 15 | 0 |
| River Walk Care Center | 1.6 mi | ★★★★★ | 17 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 11.9 mi | ★★★★★ | 23 | 0 |
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