Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gordon Lane Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including uncovered clean linen being transported and left unattended, failure to notify public health and implement contact isolation for a resident with unresolved scabies, a CNA using the same gown and gloves between two residents (one on EBP), and instances where a urinary catheter drainage bag and negative pressure wound therapy tubing were found touching the floor. Staff interviews and policy reviews confirmed these lapses.
The facility did not have a program in place to monitor antibiotic use, resulting in a lack of systematic tracking or evaluation of antibiotic prescribing and administration for residents.
A resident who was cognitively intact and needed set-up or clean assistance with personal hygiene bought razors and blades online for personal use, but the SSD told him he could not keep sharp objects at the bedside. The resident said he felt frustrated because the SSD controlled access to his razor blades, and he reported no staff supervised his shaving or retrieved the razor afterward. The SSD confirmed the facility kept the backup blades, but there was no documented evidence the resident was given an explanation about the risks of keeping the razor and blade at the bedside or his right to access the razors he purchased.
Call light not within resident's reach. A resident's call light button was observed tangled and hanging near the floor while the resident was asleep in bed, leaving it out of reach. CNA verified the call light was not within reach and said the resident was newly admitted and the call light did not have a clip. The resident stated he used the call light to ask staff for help, and the DSD said the call light should be clipped to the side of the bed and monitored by staff.
Advance Directive Not Readily Accessible in Medical Record: A resident with memory problems and severe impaired cognitive skills had an advance directive noted on the POLST, but the copy was not found in the resident’s chart or EHR. An LVN could not locate it during record review, and the DON stated it was kept in the medical records department instead of being readily accessible to staff.
A facility failed to properly monitor psychotropic medication use for two residents. One resident received Seroquel for psychosis with mood disturbance, but the record did not show monitoring of the specific behavior, orthostatic BP checks, or identified non-pharmacological interventions. Another resident received escalating quetiapine doses, but the monthly behavior summary was left blank and did not document the number of behavioral episodes or side effects; an RN, LVN, and DON verified the missing documentation.
Failure to Provide Discharge Notice and Ombudsman Notification: The facility did not document providing discharge notice or notifying the LTC Ombudsman for two residents in closed records. One resident left AMA after a physician order to discharge the resident, and the record showed the resident had decision-making capacity; the other resident had no capacity to make decisions and died in the facility, with a physician order to release the remains to the mortuary. The records did not show the required discharge notice or Ombudsman notification.
PASARR screening was not accurately completed for a resident with a history of developmental delay and later documented psychotropic medication use. The Level 1 screen did not reflect the resident’s antipsychotic therapy or fully address suspected mental illness, and the DON confirmed the facility relied on the acute care hospital PASARR without updating it to match the resident’s current status.
The facility failed to develop and implement person-centered care plans for two residents. One resident had scabies with contact isolation orders and severe cognitive impairment, but the record showed no care plan for the diagnosis or isolation precautions. Another resident had a surgical wound related to a left metatarsal amputation, but the plan of care did not include a problem for the wound. Staff and the DON verified the missing care plan entries.
The facility failed to carry out ordered monitoring and documentation for multiple residents. One resident with edema and a 3-pound weight gain did not have VS monitored every shift as outlined in the care plan. Another resident with a left foot wound had staples removed, but the record did not show documentation of the removal, post-removal monitoring, or a care plan problem for the staple removal. A third resident with severe cognitive impairment had a wound physician’s ivermectin recommendation for scabies, but the primary MD was not documented as notified and there was no further wound or dermatology follow-up after the recommendation.
A resident with sacral MASD was not monitored every shift for 72 hours after the change of condition, and the record did not show a care plan for the resident’s noncompliance with repositioning. The sacral area later became an unstageable pressure injury. In a separate finding, another resident’s alternating pressure mattress was repeatedly observed in static mode while the resident was in bed, despite staff confirming it should be in alternating pressure mode for wound management.
Head-of-bed elevation was not maintained during enteral feedings for two residents with GTs. One resident receiving continuous Novasource Renal was observed at 20 degrees despite a care plan calling for 30 to 45 degrees during and after feeding, and an LVN confirmed the improper positioning. Another resident with dysphagia and a GT was observed receiving DiabetiSource AC with the HOB at 24 degrees, and the LVN confirmed the angle should have been 30 to 45 degrees; staff reported they used visual checks to judge positioning.
IV access care and documentation deficiencies were identified for multiple residents. A resident with a midline catheter did not have required admission documentation for dressing care, catheter measurements, or device changes; a resident with a Port-A-Cath did not have ordered every-shift site monitoring documented; a resident with a PIV did not receive the ordered ultrasound-guided insertion; and another resident’s PIV site was observed without the required label. The DON and MDS Coordinator verified the missing documentation and unmet orders.
A facility failed to provide safe respiratory care for two residents needing suctioning. One resident had suction equipment left on the nightstand, undated and unlabeled, with the Yankauer not stored in a set-up bag and the canister containing whitish fluid; staff could not verify when the equipment was last changed. For another resident, suctioning was performed without a physician order in the chart, and the Yankauer, tubing, and canister were also left undated, unlabeled, and not stored in a bag when not in use.
Pain meds were administered outside physician-ordered parameters for several residents, including PRN oxycodone, hydrocodone-acetaminophen, tramadol, and acetaminophen given when documented pain scores did not match the orders. For one resident with a pain care plan, PRN oxycodone was also given without documented use of the ordered non-pharmacological interventions before administration. Staff interviews and MAR review confirmed the discrepancies.
Incomplete Dialysis Communication Documentation: A resident receiving HD had repeated gaps in the dialysis communication forms between the facility and the dialysis center. Required pre-dialysis, dialysis center, and post-dialysis information was missing on multiple treatment days, including meds given before HD, access site status, vital signs, weights, fluid removed, intake, and post-treatment assessment details. Staff confirmed the forms were expected to be completed and that residents returning from HD were to be monitored and have VS checked.
A resident ordered vancomycin IV q12h for bacteremia did not receive the 0900 dose on time, despite the facility’s medication schedule and policy requiring timely administration. In addition, controlled substance shift count logs for two med carts had multiple missing incoming and outgoing nurse signatures across several shifts, and the DON verified the omissions.
The facility failed to monitor a resident on Eliquis for signs of bleeding, despite a care plan that required observation and documentation of anticoagulant adverse effects. The facility also failed to follow insulin orders for another resident with diabetes, including not administering sliding-scale insulin when indicated, not documenting a blood glucose check for one dose, and not fully documenting insulin glargine administration and related blood sugar follow-up. The DON and LPNs verified the findings during record review.
Improper medication labeling and storage were observed when an open PPD vial in the refrigerator and a used vial of Humulin N in a med cart had no open-date labels. An expired bottle of Arthritis Pain tablets was also found in a med cart, and the LVN and DON verified the findings.
A resident with capacity and who was cognitively intact had multiple unlabeled, undated outside food items kept on a bedside table, including fried chicken and chicken wings delivered by mobile app. The resident stated the facility had no refrigerator for outside food, did not store food brought in by family or visitors, and did not educate her on safe food handling guidelines; staff gave inconsistent accounts about food storage practices, and the record lacked documentation of resident education.
Facility Assessment was missing required input from direct care staff, resident/family representatives, and other involved parties, and it did not include a plan to maximize recruitment and retention of direct care staff. The DON/Administrator review confirmed there was no documentation showing active involvement of these required individuals, and the Administrator stated she was not aware of the current CMS guidance.
Incomplete and Inaccurate Medical Record Documentation: A resident with a left arm AV fistula had multiple BP readings documented on the access arm despite the facility policy prohibiting it. Another resident’s H&P contained conflicting capacity documentation and an unapproved correction without initials or date. A deceased resident’s chart also included a progress note entered after death, even though the record showed the resident had already expired.
A resident receiving hospice services had hospice physician orders for CHHA, LVN, and RN visit frequencies that were not transcribed into the EHR. The hospice calendars were incomplete and inaccurate, and documentation showed missing CHHA and skilled nursing visits during some weeks. RN and the DON confirmed the orders were not entered and that the facility did not follow up with the hospice provider regarding the missed visits.
A resident with bilateral 1/2 side rails for turning and repositioning had no documented zone entrapment assessment or recorded measurements when the rails were installed. The resident was observed using the rails, and staff stated the licensed nurse completed the rail assessment while maintenance was responsible for the entrapment check, but facility records did not show that the required assessment was completed upon installation.
Uncovered urinary catheter drainage bag: A cognitively intact resident with an indwelling urinary catheter was observed in bed with the drainage bag visible and not placed in a privacy bag. CNAs and an LVN verified the bag was uncovered, and the DON acknowledged it needed to be fully covered.
Staff failed to follow infection control protocols for a resident on contact precautions for scabies, including not donning an isolation gown before care and improperly discarding used PPE in a regular trash bin. Additionally, clean linens were placed on a dirty hamper, leading to contamination. These actions were confirmed by facility leadership and staff.
A CNA exposed her breasts to a resident who was unable to make decisions, and the facility failed to report the incident to authorities, notify the resident's responsible party, initiate an abuse investigation, or monitor the resident's status as required by policy. Staff interviews revealed a lack of awareness and no in-service training was provided following the event.
A resident did not receive multiple prescribed medications upon readmission because pharmacy orders were electronically misfiled and not processed, resulting in a delay of several days before medications were delivered. Nursing staff identified the issue, contacted the pharmacy, and notified facility leadership, but the medications remained unavailable until the error was discovered and corrected.
The facility failed to securely store medications, with a resident's multivitamin left on a bedside table without a self-administration assessment, and Hibiclens cleanser left unattended in a shower room. These actions posed a risk of unauthorized access.
A facility failed to update a resident's care plan to include the use of a wound vac for a pressure ulcer on the sacrococcyx area, as ordered by the physician. The care plan did not reflect the prescribed treatment of cleaning the wound, applying a granulating foam, sealing with a transparent dressing, and connecting to a wound vac at 150 mmHg every Monday, Wednesday, and Friday. This oversight was confirmed during a medical record review and acknowledged by the DON.
A facility failed to follow infection control practices during high-contact care for a resident with a medical device and pressure injury. The Treatment Nurse did not wear a gown or perform hand hygiene as required, posing a risk of disease transmission. The DON confirmed the expectation for staff to use PPE and perform hand hygiene during such activities.
A facility failed to report an allegation of staff-to-resident abuse to the CDPH, L&C Program in a timely manner. A resident with intact cognition called 911, alleging rough handling by a CNA during care. Despite the police visiting the facility, the incident was not reported to the appropriate authorities, as confirmed by interviews with the Administrator, DON, and SSD.
A facility failed to follow its abuse policy by not removing an accused CNA from resident care areas during an investigation of alleged physical abuse. The CNA continued working as the police deemed the allegation unsubstantiated. Additionally, the facility did not report the investigation results to the CDPH L&C Program, posing a risk to the involved resident and others.
A facility failed to ensure a resident was free from unnecessary psychotropic medications by not obtaining informed consent for quetiapine use, inadequately monitoring behavior and side effects of medications, and not providing non-pharmacologic interventions. Staff confirmed the lack of documentation and monitoring, and the administrator acknowledged these deficiencies.
A resident, who was severely cognitively impaired, was subjected to verbal abuse by a CNA who used foul language in Spanish when the resident asked for help. A student nurse witnessed the incident and reported it, leading to the facility substantiating the abuse. The facility's policy emphasizes resident protection, yet this incident occurred, and the CNA was suspended.
A facility failed to follow infection control practices by placing a COVID-19 positive resident in the same room as a COVID-19 negative resident, contrary to CDC guidelines. This occurred due to a miscommunication during admissions, leading to a high risk of infection transmission. The error was identified and corrected the following day.
The facility failed to ensure the proper recording of personal belongings for two residents, leading to incomplete inventory forms and unlisted items. One resident's form lacked a date and signature, while another's form was missing a signature and had unlisted belongings. Staff confirmed these discrepancies during interviews and observations.
A resident with mild cognitive impairment and frailty syndrome missed a scheduled telemedicine neurology consultation because no staff member was present to assist during the appointment. The Case Manager was unavailable and did not delegate the task, leading to the resident not attending the consultation.
A facility failed to create a comprehensive care plan for a resident with mild cognitive impairment likely due to vascular dementia. Despite the resident's medical records indicating a need for a neurology consult and highlighting their vulnerability to cognitive decline, the care plan did not address these issues. This was confirmed by the DON during a review, posing a risk for inadequate care.
A facility failed to maintain accurate medical records for a resident by not documenting the administration of a prescribed treatment. The resident's Treatment Administration Record (TAR) lacked the nurse's initials for two scheduled applications of a warm compress, as required by the facility's policy. The LVN responsible for the resident's care confirmed the omission, and the DON reiterated the policy for documenting treatments.
The facility failed to ensure proper storage and labeling of medications, with issues found in Medication Room A, the Central Supply Room, and treatment and medication carts. Unsealed packages, expired medications, and unsanitary conditions were observed, and a zinc oxide ointment was left unattended.
The facility failed to ensure proper food preparation, storage, and sanitary requirements in the kitchen, leading to potential foodborne illnesses. Observations included improperly labeled and dated foods, a heavily marred chopping board, a discolored can opener, and utensils with water residue. These deficiencies were confirmed by the Dietary Services Supervisor.
The facility failed to ensure proper infection control practices, including the use of expired disinfectant wipes, improper handling of medical equipment, and inadequate hand hygiene. Staff did not follow Enhanced Barrier Precautions, and community supplies were not sanitized between uses, increasing the risk of infection spread.
The facility failed to ensure the call light system was fully functional, resulting in inaudible call lights at nursing stations and delayed responses to residents' needs. Observations confirmed that the call lights in several rooms were not working properly, and specific residents reported unaddressed call light activations.
A resident was administered Seroquel and paroxetine without documented informed consent. The informed consent forms were not signed by the physician, and the facility's verification form was incomplete. Interviews with staff confirmed the oversight, and the facility's policies on informed consent were not followed.
The facility failed to ensure call light accessibility for two residents and did not respond promptly to another resident's call light. The DON and Administrator acknowledged these deficiencies.
A facility failed to develop and implement a comprehensive care plan for a resident receiving Vancomycin IV therapy for a UTI/sepsis. The care plan was not updated promptly, leading to a delay in individualized care and monitoring.
The facility failed to update a resident's comprehensive care plan to include necessary treatments for both lower extremities to maintain skin integrity from cellulitis related to venous insufficiency. Despite physician's orders for specific treatments, the care plan did not reflect these interventions, as confirmed by staff interviews and medical record reviews.
A facility failed to follow a physician's orders for wound care on a resident's right lower leg. An LVN used Derma Klenz instead of soap and water and did not use a protective drape, contrary to the prescribed treatment. The DON acknowledged the deficiency.
The facility failed to follow physician's orders for wound care on a resident's pressure injuries, leading to improper treatment. The LVN did not apply Santyl ointment as ordered and used Derma Klenz instead of normal saline. Additionally, protective pads were not used, and the resident's diaper was not properly managed, potentially worsening the pressure ulcers.
Multiple Infection Control Deficiencies Identified
Penalty
Summary
The facility failed to maintain proper infection control practices in several areas, as evidenced by direct observations, interviews, and review of facility policies and procedures. One incident involved a laundry rolling rack with clean residents' clothing being transported uncovered through hallways and left unattended, contrary to facility policy requiring clean linen to be covered during transport and storage. Staff verified that the linen should not have been left uncovered or unattended, acknowledging the lapse in infection control protocol. Another deficiency was identified in the management of a resident with unresolved scabies. Despite ongoing symptoms and treatment with Elimite cream and Ivermectin, the resident was not placed on contact isolation after the initial treatment failed, and there was no follow-up skin testing or consultation with a dermatologist. The facility also failed to notify the local public health department about the unresolved case, as required by both facility policy and public health guidelines. Interviews confirmed that the resident continued to have generalized, crusty rashes and increased itchiness, and that the public health nurse was not informed of the situation. Additional infection control breaches included a CNA using the same gown and gloves to provide care to two different residents, one of whom was on enhanced barrier precautions (EBP), which is against CDC standards and facility policy. Observations also revealed that a resident's indwelling urinary catheter drainage bag and another resident's negative pressure wound therapy tubing were both found touching the floor, which staff acknowledged should not occur to prevent contamination and infection. These findings were confirmed through interviews with staff and review of relevant medical records and facility policies.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program indicates that antibiotic prescribing and administration were not being systematically monitored or assessed by the facility staff.
Failure to Document Resident’s Rights and Use of Personal Razors
Penalty
Summary
The facility failed to show documented evidence that one sampled resident was provided an explanation of his rights regarding personal property, specifically related to keeping and using razors and blades. The resident was cognitively intact and required set-up or clean assistance with personal hygiene. During an initial tour, he stated he had bought a set of razors and blades online for personal use, but when the SSD brought the package to his room, the SSD told him he was not supposed to have sharp objects in the room. The resident said the SSD left him a razor and a blade from the set and that he felt frustrated because the SSD wanted to control the use of his razor blades. On follow-up interview, the resident stated the SSD told him he could not keep a razor at the bedside because of the sharp blades and would give him backup blades upon request. He said the SSD gave him his razor and a blade, while keeping the backup blades. He also stated no staff supervised him while shaving and no staff came to retrieve the razor after he was done, and he kept the used razor at the bedside. The SSD confirmed she explained that he could not keep the razor and blades at the bedside and that social services would keep them because of facility policy, but she could not provide documented evidence that the resident was given an explanation addressing the risks of having a razor and blade at the bedside or his right to access the razors he bought online.
Call light not within resident's reach
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs of one resident when Resident 105's call light button was not within reach. The facility's policy on call lights stated staff should ensure the call light is within reach and accessible to residents in bed or other sleeping accommodations. During observation on 8/1/25 at 0547 and 0603 hours, Resident 105 was asleep in bed while the call light cord was routed through the right bed rail and tangled with the button, leaving it hanging near the floor and out of reach. CNA 7 was observed untangling the cord and placing the button on the resident's stomach area. During a concurrent interview, CNA 7 verified the call light cord and button were tangled and hanging near the floor and confirmed the button was not within Resident 105's reach. CNA 7 later stated the resident was newly admitted and the call light did not have a clip. Resident 105's medical record showed the resident was admitted on [DATE] and had the capacity to understand and make decisions. In a later interview, Resident 105 stated he used his call light to ask staff for help. The DSD stated the call light should be placed within the resident's reach by clipping it on the side of the bed and that CNAs, licensed nurses, and managers should monitor call lights and report missing clips to maintenance.
Advance Directive Not Readily Accessible in Medical Record
Penalty
Summary
The facility failed to maintain a copy of a resident’s advance directive in the medical record that was readily accessible to facility staff. Review of the facility policy stated that upon admission, if a resident has an advance directive, copies are to be made and placed on the chart and communicated to staff. For one sampled resident, the medical record showed a POLST dated 4/10/25 indicating the resident had an advance directive dated 4/17/21, but the section for a health care agent did not contain any entry, and the copy of the advance directive was not found in the resident’s medical record or EHR. The resident was admitted and later readmitted to the facility, and the MDS showed the resident had a memory problem and severe impaired cognitive skills for daily decision making. During interview and concurrent record review, an LVN confirmed the advance directive should be available in the medical record and was unable to locate it. The DON stated the advance directive was available in the medical records department rather than in the resident’s chart or EHR, and acknowledged it should have been placed in the resident’s medical record to be easily accessible to staff. The Medical Records Director stated the department was open Monday through Friday and that staff would not be able to access records when the department was closed.
Unnecessary Psychotropic Medication Monitoring Not Completed
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use. For one resident, who had no capacity to understand and make decisions, the physician ordered Seroquel 12.5 mg in the evening for psychosis manifested by mood disturbance, and the medication was administered in June and July 2025. The resident’s record did not show monitoring of the specific behavior related to the Seroquel order, did not show a physician’s order or monitoring for orthostatic blood pressure related to the medication, and did not identify or implement non-pharmacological interventions for the psychosis behavior. During interview and concurrent record review, an RN verified that when residents are prescribed antipsychotic medications, the related behavior should be monitored and documented, orthostatic blood pressure should be monitored, and non-pharmacological interventions should be implemented and documented. The RN verified that the resident’s episodes of mood disturbance related to Seroquel were not monitored, orthostatic blood pressure was not monitored, and non-pharmacological interventions were not identified or implemented. The DON later verified these findings. For a second resident, quetiapine was ordered repeatedly at increasing doses during June and July 2025, and the medication was administered as ordered. The resident’s Monthly Behavior Summary form for quetiapine use for June 2025 was blank, with no monthly evaluation of the number of behavioral episodes or side effects noted. An LVN verified the form was not completed and could not say who completed it, and the DON verified the form was blank and stated the QA nurse should have completed the behavior summary form monthly for psychotropic medication use at the beginning of the following month.
Failure to Provide Discharge Notice and Ombudsman Notification
Penalty
Summary
The facility failed to provide the notice of discharge and failed to notify the Ombudsman for two sampled residents reviewed in closed records. Facility policy required transfer/discharge notices to include the reason and basis for discharge, the effective date, the destination, appeal rights, state appeal contact information, assistance information, and Ombudsman contact information, and stated that the Ombudsman must be notified and evidence maintained when notice is sent. The policy also stated that, in certain exceptions to the 30-day notice requirement, the notice must be provided to the resident, resident's representative if appropriate, and the LTC Ombudsman as soon as practicable before the transfer or discharge. For Resident 9, the record showed the resident was admitted and later readmitted, had capacity to make decisions, and had a physician order to discharge the resident against medical advice. A progress note documented that the resident left the facility against medical advice and the physician was notified, but the record did not show that a discharge notice was provided or that the Ombudsman was notified. For Resident 99, the record showed the resident was admitted, had no capacity to understand and make decisions, and died in the facility; a physician order released the remains to the mortuary. The record did not show that the Ombudsman was notified of the resident's death or that a discharge notice was provided.
PASARR Screening Not Accurately Completed
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for one of two sampled residents. The facility’s policy stated that all applicants are to be screened for serious mental disorders, intellectual disabilities, or related conditions, and that a negative Level 1 screen ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. For Resident 5, the acute care hospital orthopedic H&P dated 11/5/24 documented a past medical history of developmental delay, but the facility’s PASARR Level 1 screening dated 11/13/24 indicated the resident was not on psychotropic medications and left the suspected mental illness section incomplete. The resident’s order summary showed a physician order dated 11/14/24 for risperidone 1 mg by mouth at bedtime for schizophrenia with frequent mood swings, and the MAR showed the medication was administered from 11/14/24 through 1/19/25. The resident’s H&P dated 7/24/25 also showed no capacity to make medical decisions. During interview and record review, the DON verified the resident had received risperidone and stated the facility used the acute care hospital PASARR but did not update it to reflect the psychotropic medication use and history of developmental delay. The Administrator, DON, and Nurse Consultant were later informed and acknowledged the findings.
Failure to Develop Care Plans for Scabies, Isolation, and a Surgical Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 63's scabies and contact isolation. Resident 63 was admitted and later readmitted to the facility, had a Quarterly MDS showing a BIMS score of 3 indicating severe cognitive impairment, and had physician orders for contact isolation for scabies and for Ivermectin treatment. Review of the medical record showed no documented evidence that care plans were developed for the scabies diagnosis or the contact isolation precautions. During interview and record review, an LVN verified the resident had contact isolation orders for scabies and acknowledged the care plan did not show a completed plan for the resident's isolation and diagnosis. The DON also verified there was no documented evidence that the facility created a care plan for the resident's positive diagnosis for scabies and contact isolation. The facility also failed to develop a care plan problem for Resident 2's surgical wound related to a left metatarsal amputation. Review of the resident's skin check noted the resident was admitted with a recent left metatarsal amputation, but the plan of care did not include a problem to address the surgical wound. During interview and concurrent record review, LVN 5 stated the resident had a surgical wound on the left foot and verified a care plan problem had not been developed. LVNs 5 and 6 further confirmed that no care plan problem had been developed for the surgical wound, and LVN 6 stated any licensed nurse could initiate a care plan.
Failure to Follow Care Plans, Monitor Changes in Condition, and Document Wound-Related Orders
Penalty
Summary
The facility failed to provide necessary care and services to ensure Resident 4 was monitored according to the plan of care after a change in condition involving a 3-pound weight gain related to edema. The resident was observed awake and lying in bed with edema in both legs, and the medical record showed the resident had been readmitted to the facility and was able to make decisions. The eINTERACT change in condition evaluation documented the weight gain and edema, and the revised plan of care included monitoring the signs and symptoms of bilateral lower extremity edema, monitoring vital signs every shift, and notifying the physician for significant changes. Despite the care plan, the medical record did not show documented evidence that Resident 4’s vital signs were monitored every shift. During interview and record review, an LVN verified that the resident’s vital signs were not monitored every shift and stated that such monitoring was important to identify potential health issues, determine whether the resident was doing well, and ensure safety. The DON also acknowledged that the interventions in the resident’s plan of care should be implemented because failure to do so might prevent the facility from meeting the intended goals for the resident’s specific problem. The facility also failed to ensure Resident 2 was monitored after staples were removed from a left foot wound following a left metatarsal amputation. The record showed the wound had been closed with staples, but there was no documentation of staple removal, no documentation of monitoring after removal, and no care plan problem developed to address the staple removal. During interview, staff stated the staples were removed at a follow-up appointment, but they could not produce documentation showing the number of staples removed or any monitoring after removal. Staff also verified that the resident’s progress notes did not document when the appointment occurred or when the resident returned. For Resident 63, the facility failed to document that the primary physician was notified of the wound physician’s medication recommendation for scabies, and there was no further wound physician or dermatology follow-up after 6/17/25. The wound assessment included a medication management recommendation for ivermectin for crusted or resistant scabies, and the wound physician later stated those were his ordered medication recommendations and that staff were expected to contact the resident’s primary physician if they wanted to continue them. The DON verified that the recommendation should have been followed up with the primary physician and documented, and the record did not show that this occurred.
Failure to Monitor Sacral Skin Breakdown and Maintain Pressure Mattress Settings
Penalty
Summary
The facility failed to monitor a resident after a new moisture-associated skin damage (MASD) was identified in the sacral area, and the resident’s record did not show documented licensed nurse monitoring every shift for 72 hours after the change of condition. The resident was readmitted with partial/moderate mobility assistance needs and had a sacral wound treatment order that later changed from MASD care to treatment for an unstageable pressure injury. The skin check record first identified the sacral MASD, then later documented worsening discoloration and texture changes, and eight days after the initial MASD identification the wound care specialist classified the area as an unstageable pressure injury in the left sacrum. The resident was also documented as being noncompliant with repositioning. The care plan addressed the sacral pressure injury and included treatment, RD follow-up, a low air loss mattress, turning and repositioning every two hours or as needed, wound follow-up, and physician notification if treatment was not effective. However, the medical record did not show a plan of care initiated specifically for the resident’s noncompliance with repositioning. During interviews, staff stated the resident often refused turning, preferred to remain in bed or in a wheelchair for long periods, and at times wanted the mattress in static mode because the resident did not like the mattress moving. The facility also failed to ensure another resident’s alternating pressure mattress was not left in static mode while the resident was in bed. The resident was observed asleep in bed on multiple occasions with the mattress machine showing static mode. The manufacturer’s manual stated static mode provides a firm surface for transfer or repositioning and prevents bottoming out when sitting, while staff confirmed the mattress should be in alternating pressure mode when the resident is in bed and that static mode was used for transfers, repositioning, or comfort. The resident had an order for a low air loss mattress for wound management and a skin maintenance order for the coccyx area.
Head-of-Bed Elevation Not Maintained During Tube Feedings
Penalty
Summary
The facility failed to provide appropriate care and services for the use of gastrostomy tubes for two sampled residents who were receiving enteral feedings. For one resident, the physician ordered continuous Novasource Renal via GT, and the care plan directed staff to keep the head of the bed elevated at least 30 to 45 degrees during and 30 minutes after tube feedings. During observation, the resident was lying in bed receiving the feeding with the head of the bed at less than 30 degrees, measured at 20 degrees. A concurrent interview with an LVN confirmed the resident was receiving the feeding at that angle and that the head of the bed should have been elevated to 30 to 45 degrees. For another resident with dysphagia and a GT, the care plan also directed staff to elevate the head of the bed at least 30 to 45 degrees during and 30 minutes after tube feedings. During observation, the resident was receiving enteral feeding with the head of the bed below 30 degrees, and the angle was measured at 24 degrees. The LVN confirmed the measurement and stated the head of the bed should have been elevated to at least 30 to 45 degrees while the feeding was infusing. The report also notes that staff determined head-of-bed elevation by visual check, and the Maintenance Director stated the facility did not have a device to check the angle of the head of the bed.
IV Access Care and Documentation Deficiencies
Penalty
Summary
The facility failed to provide necessary IV care and services for multiple residents receiving IV therapy. The report identified deficiencies involving a midline catheter, a peripheral IV, a Port-A-Cath, and labeling of a peripheral IV site. The residents involved included a resident receiving IV antibiotics through a midline catheter, a resident receiving vancomycin through a peripheral IV, a resident receiving TPN through a Port-A-Cath, and a resident with a peripheral IV in the left wrist. For the resident with the midline catheter, the physician ordered a transparent dressing change upon admission and every Sunday, measurement of the external catheter length and arm circumference upon admission and every Sunday, and changes to the injection cap and securement device upon admission and as needed. The resident stated the dressing had not been changed as expected and that staff should change it weekly. The record showed dressing changes on several dates, but documentation was missing for the admission dressing change and for the required measurement of the external catheter length and arm circumference on admission. The record also did not show documented evidence that the injection cap and securement device were changed upon admission as ordered. For the resident with the Port-A-Cath, the physician ordered the site to be monitored every shift for signs and symptoms of infection and bleeding while TPN was administered through the device. The record showed that monitoring was not documented on multiple night shifts across June and July, and the medical record did not show evidence that the site was monitored every shift as ordered. For the resident with the peripheral IV, the physician ordered an ultrasound-guided IV through an outside vascular access provider. The outside provider’s note showed only one attempt with a 22-gauge catheter, after which the resident refused further sticks and insisted on ultrasound only, but the documentation did not show that ultrasound was used. For the resident with the peripheral IV in the left wrist, the site was observed without a label, even though facility policy required the dressing to be labeled with the date, time, and nurse’s initials.
Respiratory suction equipment left unlabeled and improperly stored; suctioning performed without an order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required suctioning. For one resident, the record showed orders for suctioning as needed for increased secretions and every four hours four times a day for increased secretions, but on observation the Yankauer suction tip, tubing, and suction canister were left on the nightstand, not stored in a set-up bag, and none of the items were labeled with the date showing when they were last changed. The suction canister contained whitish liquid, and staff could not verify when the equipment had last been changed. A nurse confirmed the items were not labeled and not stored in a set-up bag, and stated they should have been stored and labeled that way. For the second resident, the medical record did not show a physician's order for suctioning, although a nurse stated she had suctioned the resident before and believed there was an order as needed. On observation, the Yankauer suction tip and suction canister were left on top of the nightstand, the tip was not inside a set-up bag when not in use, and the equipment was undated and unlabeled. The nurse verified there was no suction order in the electronic record and confirmed the canister and Yankauer were not labeled or dated. The DON later stated there should be a physician's order before suctioning, the Yankauer should be inside a bag when not in use, and the suction canister should be changed after use and about one-third full.
Pain medications given outside ordered parameters and without documented non-pharmacological intervention
Penalty
Summary
The facility failed to provide safe, appropriate pain management for four sampled residents by not following ordered pain parameters and, for one resident, by not documenting a required non-pharmacological intervention before giving PRN oxycodone. The facility’s pain management policy stated that pain should be assessed and treated based on professional standards and the resident’s cognitive status, and the medication administration policy stated medications should be given as ordered by the physician. For one cognitively intact resident with a diagnosis of acute osteomyelitis and a left foot amputation wound, the physician ordered acetaminophen for mild pain, ibuprofen for moderate pain, and oxycodone for severe pain, with pain to be monitored every shift using a 0 to 10 scale. The MAR showed oxycodone was administered multiple times when the documented pain level was zero. During interview, CNA 6 stated the resident complained of left foot pain and had pain all the time, and the DON verified the medication was given when the pain level was zero. For another cognitively intact resident, the physician ordered hydrocodone-acetaminophen PRN for moderate pain only after pain assessment on a 0 to 10 scale. The MAR showed the medication was administered on multiple occasions when the documented pain level was zero, and on other occasions when the pain level was 3. Staff interviews confirmed the medication should not have been administered when the resident had no pain and that the documented pain level did not match the prescribed parameters. For a third resident with moderate cognitive impairment but documented capacity to make decisions, the physician ordered acetaminophen for mild pain and tramadol for moderate to severe pain. The MAR showed acetaminophen was given for a pain level of 5 and tramadol was given for pain levels of 3 and 0 on several occasions. Staff confirmed the PRN pain medications should not have been administered because the resident’s pain level was not within the ordered parameters. For a fourth cognitively intact resident with a care plan addressing pain and non-pharmacological interventions, the physician ordered oxycodone PRN for severe pain. The MAR showed oxycodone was administered for pain levels of 7, 8, and 9, but the record did not show that a non-pharmacological intervention was provided before the medication was given. An LVN confirmed there was no documented evidence that the intervention occurred before administration.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure dialysis communication forms were completed for a resident receiving hemodialysis. Resident 5 had no capacity to make medical decisions, had physician orders for AVF LUA access site monitoring every shift, and was scheduled for hemodialysis on Monday, Wednesday, and Friday. Review of the resident’s dialysis communication forms showed missing pre-dialysis documentation on multiple treatment days, including medications administered prior to hemodialysis and, on several dates, shunt/catheter location and status. The forms also lacked required dialysis center and post-dialysis information on multiple dates. Missing entries included vital signs, pre- and post-weight, shunt/catheter location/status, fluid removed, meal/snack intake, new physician orders or recommendations, nurse’s signature, catheter dressing status, presence of bruit or thrill, bleeding, and the resident’s general condition. Staff interviews confirmed the forms were expected to be completed by the charge nurse and dialysis center, and that residents returning from dialysis were to be monitored and have vital signs checked, but the documented information was incomplete.
Delayed IV Antibiotic Administration and Missing Controlled Substance Count Signatures
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration when Resident 102’s vancomycin was not given on time. Resident 102 was admitted with the capacity to make decisions and had a physician’s order for vancomycin 750 mg IV every 12 hours for bacteremia for 5 days. The facility’s medication administration policy required medications to be administered within 60 minutes before or after the scheduled time unless otherwise ordered, and the facility’s medication schedule listed the IV antibiotic for 0900 and 2100 hours. During an initial tour, Resident 102 was observed lying in bed with a PIV line to the left wrist and receiving IV antibiotic therapy. On concurrent review of the medical record with RN 1, the nurse verified the resident was ordered the IV antibiotic every 12 hours for 0900 and 2100 administration times, but stated she had not administered the 0900 dose as scheduled. The DON was later informed of the finding and acknowledged that the IV antibiotic should have been administered timely. The facility also failed to ensure controlled substance shift count logs were signed for Medication Carts A and B. The facility policy required controlled substances to be accounted for and for two licensed nurses to account for all controlled substances and access keys at the end of each shift. Review of March 2025 logs showed multiple missing incoming and/or outgoing nurse signatures on several shifts for both carts. LVNs verified the missing signatures and stated the logs should have been signed by the nurses working those shifts to account for the narcotic medications. The DON also verified the missing signatures and stated she did not know why the nurses missed signing the logs.
Failure to Monitor Anticoagulant Therapy and Follow Insulin Orders
Penalty
Summary
The facility failed to ensure a resident receiving Eliquis was monitored for signs and symptoms of bleeding. The resident was readmitted to the facility, had the capacity to make decisions, and had a physician’s order for Eliquis 2.5 mg by mouth twice daily for DVT prophylaxis. The care plan included monitoring and documenting adverse reactions of anticoagulant therapy, including blood in urine or stool and other signs of bleeding, but the medical record did not show documented evidence that the resident was observed or monitored for bleeding symptoms. The facility also failed to administer insulin lispro to another resident according to the physician’s sliding-scale order. The resident had diabetes and an order for insulin lispro before meals based on blood glucose levels. The MAR showed one instance where the resident’s blood glucose was 158 mg/dL, but no insulin was administered and the code documented indicated no insulin was required. Another entry showed no blood glucose level documented and no insulin administration. The licensed staff confirmed that blood glucose should be checked before administration and that the insulin should be given according to the ordered parameters. In a separate insulin-related issue, the facility failed to document and follow the ordered process for insulin glargine administration. The resident had an order for 15 units of insulin glargine at bedtime, and the MAR showed it was administered. However, the progress notes did not document the administration or whether the resident’s blood sugar was rechecked afterward. The record also showed the resident ate only 26-50% of dinner, and there was no documentation about additional nourishment or snacks after the meal.
Improper Medication Labeling and Expired Medication Left in Carts
Penalty
Summary
The facility failed to provide proper pharmacy services to ensure medications and biologicals were stored, labeled, and disposed of according to policy and accepted principles. Review of the facility policy on labeling medications and biologicals stated that medication labels must be legible, multi-use vials must include the date they were initially opened or accessed, and opened or accessed vials should be discarded within 28 days unless the manufacturer specifies otherwise. During observation and interview, an open PPD vial was found in Medication Room A refrigerator with no date label showing when it was opened, and LVN 3 verified the finding. A used vial of Humulin N was also observed in Medication Cart B with no date label indicating when it was opened, and LVN 4 verified the finding. In addition, Medication Cart A contained a bottle of Arthritis Pain tablets with an open date label but an expiration date that had already passed; LVN 1 and the DON verified that the expired medication should have been removed from the cart.
Outside Food Not Safely Stored or Educated
Penalty
Summary
The facility failed to ensure food brought in from outside was safely stored for Resident 96 and failed to ensure the resident was educated on safe food handling guidelines. The facility’s policy stated that prepared food brought in by family or visitors had to be approved by nursing, eaten within two hours, and any remaining food discarded, while manufactured food not requiring refrigeration could be kept in the resident room in a sealed container and consumed before expiration. Resident 96 was admitted and later readmitted to the facility, and her H&P noted she had the capacity to understand and make decisions; her MDS showed she was cognitively intact. During observation, Resident 96 had multiple unlabeled and undated food items on her bedside table, including containers of fried chicken, scalloped potatoes, cereal, and Hawaiian rolls. She stated the fried chicken had been delivered through a mobile food delivery service the day before and that the facility had no refrigerator to store her food. On a later observation, two undated containers of fried chicken and chicken wings were again found on her bedside table, and she stated the facility did not store the food and had no refrigerator for food brought in by family or visitors. She also stated she kept outside food requiring refrigeration at her bedside until it spoiled and that the facility did not educate her on safe food handling guidelines. Review of the medical record did not show documentation that such education had been provided, and staff interviews reflected inconsistent understanding about whether the facility stored outside food.
Facility Assessment Missing Required Input and Recruitment Plan
Penalty
Summary
The facility failed to ensure its Facility Assessment addressed the active involvement of required individuals in developing the assessment and included a plan to maximize recruitment and retention of direct care staff. Based on interview and facility document review, the Facility Assessment dated [DATE] did not show that direct care staff members, direct care representatives, residents, residents' representatives, or residents' family members were actively involved in developing the assessment or in planning to maximize recruitment and retention of direct care staff. On 8/4/25 at 1445 hours, the Administrator was interviewed and the Facility Assessment was reviewed concurrently. The Administrator verified that there were no direct care staff, direct care representatives, residents' representatives, or family members actively involved in developing the Facility Assessment, and also verified there was no documentation of a plan to maximize recruitment in the Facility Assessment. The Administrator stated she was not aware of the current guidance and acknowledged the Facility Assessment had not been updated based on the latest CMS guidance.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident with end stage renal disease and a left upper arm AV fistula, the facility’s hemodialysis policy stated blood pressures and laboratory sticks were not to be taken on the arm with the dialysis access device. However, the resident’s blood pressure summary showed multiple readings documented as obtained on the left arm, and the resident stated he never allowed nurses to take his blood pressure on that arm. The LVN and DON both verified the findings, and the DON stated the blood pressure should not have been taken on the left upper arm where the AV fistula was located. For another resident, the H&P documentation was inaccurate and inconsistently corrected. One H&P showed both the capacity and no capacity options checked for the resident’s ability to understand and make decisions. A second H&P contained the same information except the no-capacity option was crossed out with scribbled lines and the word error written next to it, but there were no initials or date showing who made the correction or when. The Medical Records Director stated only the physician who completed the original entry could correct the H&P, while the primary physician stated he had not written the word error and would have needed to make an addendum or progress note entry to correct the record. The facility also documented in the medical record of a deceased resident after death had occurred. The resident’s record showed the date and time of death, and a physician order was written to release the remains to the mortuary. Despite this, a progress note later documented monitoring temperature and oxygen saturation every four hours. The Medical Records Director, LVN, DON, and Nurse Consultant were informed of the finding, and the Medical Records Director and LVN stated there should not have been any progress note entry after the resident had expired.
Hospice Visit Orders Not Transcribed and Visits Not Documented
Penalty
Summary
The facility failed to provide the necessary care and services for a resident receiving hospice services by not ensuring the hospice physician’s orders for the frequency of hospice staff visits were transcribed into the resident’s electronic health record. The resident had orders dated 12/18/24 to admit to hospice services under Hospice Provider A and to notify hospice for any change in condition or symptoms, with no 911 calls or hospitalization without notifying hospice. However, the resident’s Order Summary Report did not include the hospice visit frequencies, even though the hospice binder contained orders for CHHA visits three times per week for ADL assistance, skilled nurse visits once per week with three PRN visits, and RN visits every 14 days. Facility records also showed that the projected hospice staff visit calendars were incomplete and inaccurate. The January and February 2025 calendars contained a handwritten note indicating CHHA visits were two times per week, while the March 2025 calendar incorrectly listed 3/1/25 as a Friday and did not show the frequency of LVN and CHHA visits. The April through July 2025 calendars also failed to show the frequency of LVN and CHHA visits. The sign-in/sign-out sheet documented some CHHA visits during several weeks, but it also showed only one CHHA visit for the week of 7/20 to 7/26/25 and no CHHA visits for the week of 7/27 to 8/2/25. The hospice notes did not document LVN or RN visits for the week of 1/5 to 1/11/25 or for the week of 7/27 to 8/2/25, and the medical record did not contain documented evidence of those CHHA and skilled nursing visits during those weeks. During interview and record review, RN 2 verified that the hospice visit frequency orders were not transcribed to the electronic health record, the projected calendars were inaccurate and incomplete, and there were missing CHHA and skilled nursing visits. RN 2 also stated the facility did not follow up with Hospice Provider A regarding the missing visits. The DON stated she was the hospice coordinator and confirmed the hospice visit frequency orders were not written on the paper Telephone Order sheets, so they were not transcribed to the electronic health record, and that the sign-in/sign-out sheets and hospice notes were the documentation used to show hospice staff visits.
Missing Zone Entrapment Assessment for Bed Rails
Penalty
Summary
The facility failed to ensure that Resident 4’s zone entrapment assessment was completed and that measurements were recorded when the side rails were installed during the resident’s admission. Resident 4 was readmitted to the facility, was able to make decisions, and required partial/moderate assistance with mobility. The physician ordered bilateral 1/2 side rails for turning and repositioning, and the care plan addressed the use of the rails for turning/repositioning and the risk for entrapment. The resident was observed in bed with bilateral 1/2 side rails elevated and stated she had used the side rails since admission and during prior admissions. Resident 4 stated she held onto the side rails when turning or transferring from bed to wheelchair and needed staff assistance to clean her. CNA 8 stated the resident had the side rails since admission, could turn by herself, and used the rails when being cleaned or transferred. LVN 1 stated that before installing side rails, the licensed nurse completed a side/bed rail assessment and that maintenance would complete the zone entrapment assessment. The Maintenance Director stated he was responsible for completing the zone entrapment assessment or measuring the side rails upon installation and during routine bed inspection. Facility document review did not show that the zone entrapment assessment for Resident 4 was completed when the side rails were installed during the current admission. The Maintenance Director verified that the assessment or measurement should have been completed upon installation for the resident’s safety. The DON was informed that the bed rails should not be applied if the zone entrapment assessment was not completed.
Uncovered urinary catheter drainage bag
Penalty
Summary
The facility failed to ensure care was provided in a manner that promoted dignity and respect for one resident with an indwelling urinary catheter. Resident 36 was admitted to the facility and had a history of obstructive uropathy. The resident's H&P dated 4/1/25 showed the resident had the capacity to understand and make decisions, and the quarterly MDS showed a BIMS score of 13, indicating the resident was cognitively intact and had an indwelling urinary catheter. During an initial tour of the resident's room, the resident was observed lying in bed with an indwelling urinary catheter attached to a drainage bag. The drainage bag contained blood-tinged urine and was not placed in a privacy bag, making it visible when entering the room. CNA 1, LVN 4, and CNA 9 each verified that the drainage bag was not covered, and CNA 1 stated it should be placed in a privacy bag for the resident's dignity. The DON later acknowledged that the indwelling urinary catheter drainage bag needed to be fully covered.
Infection Control Deficiencies: PPE Use and Linen Handling
Penalty
Summary
Staff failed to adhere to infection prevention and control practices for a resident placed on contact precautions due to scabies. During an observation, a CNA was seen inside the resident's room feeding the resident without wearing an isolation gown, despite a contact precautions sign posted outside the room instructing staff to don PPE before entry. The CNA stated that there was no isolation gown available at the designated supply area and acknowledged that a gown should have been worn. After donning a gown and completing care, the CNA discarded the used gown in a regular trash bin, which was overflowing with used gowns, instead of the designated biohazard bin. The CNA explained that the appropriate bin was not available in the room at the time. Further interviews with the Infection Preventionist (IP) and Director of Nursing (DON) confirmed that the CNA did not follow proper gowning and disposal procedures. The IP stated that gowns must be donned before entering isolation rooms and disposed of in the correct bin. The Environmental Services Director also acknowledged the lack of a designated trash bin for used PPE in the room and stated that designated bins had been provided and checked the previous day. Additionally, improper handling of clean linens was observed. A CNA was seen placing clean linen on top of a dirty hamper outside the resident's room. Both the CNA and the Environmental Services Director confirmed that this was not in accordance with facility policy, which requires clean linens to be handled and stored in a manner that prevents contamination. The IP verified that the clean linens were now considered contaminated due to this action.
Plan Of Correction
F880 Infection Prevention & Control A. How the facility plans to correct the specific deficiencies cited: * Failure to ensure staff donned an isolation gown and properly discarded it: Immediate in-service education was provided to CNA 4 on June 17, 2025, regarding proper donning, doffing, and disposal of isolation gowns, emphasizing the importance of donning prior to entering an isolation room and proper disposal in designated biohazard bins. All nursing staff and environmental services staff will receive mandatory re-education on June 25th regarding the facility's Infection Prevention and Control policies and procedures, specifically focusing on: * Correct application and removal of all types of Personal Protective Equipment (PPE), particularly isolation gowns, when providing care to residents on transmission-based precautions. * Proper disposal of contaminated PPE into designated biohazard waste receptacles immediately after removal. * The importance of ensuring designated biohazard bins are readily available and not overflowing in isolation rooms. Environmental Services will implement a daily checklist for all isolation rooms to ensure adequate stock of PPE (including isolation gowns) at the designated supply area outside the room and the availability of empty biohazard waste bins within the room starting June 25th, 2025. This checklist will be reviewed by the Environmental Services Director or designee. * Failure to handle clean linens to prevent the spread of infection: Immediate re-education was provided to CNA 5 on June 18, 2025, regarding the proper handling and storage of clean linens, emphasizing that clean linens must never be placed on dirty hampers or other contaminated surfaces. All nursing staff and environmental services staff will receive mandatory re-education on June 25th, 2025 on the facility's policy for Handling Clean Linen, reinforcing the importance of: * Maintaining separation between clean and dirty linens at all times. * Transporting and storing clean linens in clean, designated containers or carts. * Never placing clean linens on or near contaminated surfaces, including dirty hampers. Nursing staff will be re-educated on the proper procedure for bringing clean linens into resident rooms to ensure they remain free from contamination. B. How other residents having the potential to be affected by the same deficient practice will be identified and what corrective action(s) will be taken: * All residents requiring transmission-based precautions will be identified through daily review of the facility's infection control log and resident care plans by the Infection Preventionist (IP) and Director of Nursing (DON). * An audit will be conducted for all residents currently on transmission-based precautions to ensure proper PPE is available outside their rooms and that appropriate waste receptacles are provided within their rooms. Any discrepancies will be immediately corrected. * The IP and DON will conduct focused observations during routine rounds to ensure all staff are consistently adhering to proper PPE utilization and disposal for all residents on transmission-based precautions. All nursing staff and environmental services staff will be re-educated on June 25th, 2025 on proper linen handling procedures to prevent contamination, ensuring all residents receive care with uncontaminated linens. C. What measures will be put into place or systemic changes made to ensure that the deficient practice does not recur: * Enhanced Staff Education and Competency: Comprehensive in-service training on Infection Prevention and Control, including proper PPE use, disposal, and clean linen handling, will be conducted for all nursing staff (RNs, LVNs, CNAs) and environmental services staff by July 15, 2025. This training will include practical demonstrations and return demonstrations to ensure competency. New employee orientation will include a dedicated and enhanced module on infection prevention and control practices. Annual competency evaluations will include observation of proper PPE use and linen handling for all staff involved in resident care. * Increased Environmental Monitoring during Angel Rounds: The existing Angel Rounds checklist will be revised to include specific checks for all resident rooms, especially those with residents on isolation precautions: * Verification of PPE availability: During Angel Rounds, nursing supervisors/designees will visually confirm that appropriate PPE (e.g., isolation gowns, gloves) is stocked and readily accessible at the designated supply area outside isolation rooms. * Trash Bin Monitoring: During Angel Rounds, nursing supervisors/designees will visually inspect all trash bins within resident rooms and bathrooms to ensure they are not overflowing with used PPE or other waste and that designated biohazard bins are present and utilized for waste disposal. The QAPI Committee will review all infection control incidents, audit results, and staff competency records on a monthly basis for a period of six months, and quarterly thereafter. Specific data points to be monitored will include: * Number of observed instances of non-compliance with PPE use and disposal. * Number of observed instances of improper clean linen handling. * Completion rates of staff education and competency evaluations related to infection control. * Findings from Angel Rounds related to PPE and trash bin monitoring. The QAPI Committee will track trends related to infection control practices and identify areas requiring further intervention, such as additional staff training, revised procedures, or environmental modifications. Corrective actions will be implemented as needed based on QAPI findings, and their effectiveness will be continuously evaluated by the QAPI Committee. The Administrator, DON, and IP will be responsible for overseeing the implementation of this Plan of Correction and ensuring ongoing compliance.
Failure to Report and Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policies after an incident involving a certified nursing assistant (CNA) exposing her breasts in a resident's room. The incident was witnessed by another CNA, who reported that the CNA in question lifted her scrub top and exposed her breasts to the resident, who was awake at the time. The CNA later admitted to the exposure and stated it was a joke, referencing the resident's birthday. The resident involved was unable to make decisions and was rarely or never understood, as documented in their medical record and Minimum Data Set (MDS). Despite the incident, the facility did not report the alleged abuse to the appropriate authorities, including the state agency, ombudsman, law enforcement, or the resident's responsible party, within the required timeframes. The facility's policy required immediate reporting of abuse allegations, but there was no documented evidence of such reporting. Additionally, the facility did not initiate an abuse investigation, nor did it monitor the resident for clinical or psychosocial status following the incident. There was also no care plan developed in response to the alleged incident. Interviews with facility staff, including the Administrator and Director of Staff Development (DSD), revealed a lack of awareness and action regarding the incident. The Administrator considered the event a code of conduct issue rather than abuse, and the DSD described it as a rumor rather than a reportable event. No in-service training was provided to staff regarding the code of conduct or sexual abuse prevention after the incident was reported. These failures resulted in the facility not protecting the resident from potential abuse and not following required procedures for investigating and reporting such allegations.
Plan Of Correction
F 610 Corrective Action To Correct Deficiency: • On 5/24/25, upon being made aware of the allegation, CNA 10 was immediately suspended pending the outcome of an investigation and has since been terminated. • On 5/30/25, Resident 4 was assessed by the licensed nurse for any adverse clinical or psychosocial effects related to the incident, with none noted. • On 5/30/25, the facility initiated a formal investigation into the allegation of abuse. • On 5/30/25, Resident 4's physician and responsible party were notified of the incident and the investigation. • On 5/30/25, the incident was reported to the California Department of Public Health (CDPH), the long-term care ombudsman, and local law enforcement. • On 5/30/25, a care plan was initiated for Resident 4 to include interventions for psychosocial monitoring by licensed nurses and social services. Corrective Action To Correct Deficiency: • On 5/14/25, all of Resident 2's medications were received from the pharmacy and administered per physician orders. • On 5/14/25, Resident 2 was assessed by a licensed nurse for any adverse signs or symptoms related to the delayed medication administration. The resident's physician was notified, and no adverse effects were identified. Identify Any Other Residents Who May Have Been Affected By the Deficient Practice: • On 6/13/25, the DON initiated a full audit of all new admissions and readmissions from 5/12/25 to 6/13/25 to verify that all admission medication orders were received from the pharmacy and administered in a timely manner. No other residents were identified as being affected by a similar issue. Systemic Change To Prevent Recurrence: • On 6/11/25, licensed nursing staff were re-educated by the DON on the facility's Medication Reconciliation P&P for new admissions and readmissions. The training emphasized the process for verifying receipt of medications from the pharmacy within 24 hours of admission. • Effective 6/12/25, a new verification process was implemented. The nursing unit manager or designee on each shift is now required to use a "New Admission/Readmission Pharmacy Checklist" to verify that all new medication orders have been faxed to the
Failure to Administer Prescribed Medications Upon Readmission Due to Pharmacy Processing Error
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for one of five sampled residents following readmission. Upon review of the medical records, it was found that the resident had multiple physician orders for medications including omeprazole, venlafaxine, lamotrigine, lisinopril, metformin, metoprolol, vitamin C, acetaminophen, magnesium hydroxide, gabapentin, vitamin B-12, clonidine, and dextromethorphan-guaifenesin. Despite these orders, the resident did not receive the majority of these medications upon readmission, with only gabapentin being available initially. Interviews with nursing staff revealed that the medications were not delivered as expected, prompting the LVN to contact the pharmacy, refax the orders, and notify both the nursing supervisor and the physician. The medications remained unavailable for several days, and further attempts were made to communicate with the pharmacy and notify the DON. The delay in medication delivery persisted from the day after readmission until at least two days later, during which time the resident did not receive the prescribed treatments. A review with the Pharmacy Manager identified that the resident's readmission orders were electronically misfiled, resulting in the medications not being processed or delivered in a timely manner. The pharmacy's tracking log confirmed delays in receiving and processing the orders, with some medications not being sent until days after the initial request. Facility leadership, including the DON and Administrator, verified these findings during interviews.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to ensure medications were stored securely, as evidenced by two separate incidents. In the first incident, a resident had a bottle of One a Day Multivitamin/Multimineral on the bedside table, which was accessible to another resident who was observed self-propelling in a wheelchair into the room. The facility's policy requires an assessment for self-administration of medications, which was not completed for this resident. RN 1 confirmed the presence of the multivitamin and removed it, acknowledging that the assessment had not been conducted. In the second incident, a bottle of Hibiclens antiseptic skin cleanser was found unattended on the grab bars in a shower room. CNA 1 confirmed that the cleanser should not have been left there, and the DON later acknowledged that it was not supposed to be unattended. These lapses in medication storage posed a risk of unauthorized access by non-licensed staff and visitors.
Failure to Update Care Plan for Wound Vac Treatment
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was revised to reflect the current wound care treatment and interventions as ordered. Specifically, the care plan did not include the use of a wound vac for the treatment of a pressure ulcer on the sacrococcyx area, as prescribed by the physician. The physician's order, dated from June 8, 2022, to September 15, 2022, required cleaning the wound with normal saline, applying a granulating foam, sealing with a transparent dressing, and connecting to a wound vac at 150 mmHg every Monday, Wednesday, and Friday during the day shift for 30 days. However, the care plan dated July 8, 2022, did not incorporate these specific wound vac instructions. During a review of the closed medical record for the resident, it was confirmed that the care plan lacked the necessary updates to include the wound vac treatment. An interview with RN 1 revealed that the care plan should have been individualized and updated to reflect the current treatment and interventions for the resident's pressure ulcer. The Director of Nursing (DON) acknowledged these findings, indicating a lapse in ensuring the care plan was comprehensive and up-to-date, which posed a risk of not providing individualized and person-centered care for the resident.
Infection Control Deficiency During High-Contact Care
Penalty
Summary
The facility failed to implement effective infection control practices, specifically during high-contact care activities for a resident with an indwelling medical device and a pressure injury. The Centers for Disease Control and Prevention (CDC) guidelines recommend the use of personal protective equipment (PPE), including gowns and gloves, during such activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, during a wound care observation, the Treatment Nurse did not wear a gown while treating the resident's pressure injury and failed to perform hand hygiene before resuming the resident's tube feeding. The deficiency was confirmed by the Director of Nursing (DON), who acknowledged that staff are expected to don gloves and gowns and perform hand hygiene during high-contact care activities, including wound treatment. The failure to adhere to these infection control practices posed a risk for the transmission of diseases and infections within the facility.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when the facility did not report an allegation of staff-to-resident abuse in a timely manner to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The incident involved a resident who had an intact cognition, as indicated by a BIMS score of 14, and who called 911 to report that a Certified Nursing Assistant (CNA) was rough during a brief change. Despite the police visiting the facility in response to the resident's call, the facility did not report the incident to the appropriate authorities. Interviews conducted with the facility's Administrator, Director of Nursing (DON), and Social Services Director (SSD) confirmed that they were aware of the resident's 911 call and the subsequent police visit. However, they acknowledged that no report was sent to the CDPH, L&C Program regarding the incident. The CNA involved in the allegation stated that he reported the incident to the charge nurse, yet the facility's policy of immediate reporting to the Administrator and other appropriate agencies was not followed, leading to the deficiency.
Failure to Implement Abuse Policy and Report Investigation Results
Penalty
Summary
The facility failed to adhere to its abuse policy and procedures regarding the investigation of an alleged physical abuse incident involving a resident. The policy required the removal of the accused employee from resident care areas during the investigation, but the facility did not suspend the accused CNA. Instead, the CNA continued to work on the day of the alleged incident. The facility's internal investigation was conducted while the police were present, but the accused CNA was not removed from duty because the police deemed the allegation unsubstantiated. The facility only reassigned the CNA to a different resident. Additionally, the facility did not report the results of the abuse investigation to the California Department of Public Health Licensing and Certification Program (CDPH L&C Program) as required. The investigation summary was completed and signed by the Administrator on the same day as the incident, but there was no documented evidence that the summary was sent to the CDPH L&C Program. These failures posed a risk to the resident involved and other vulnerable residents in the facility.
Failure to Monitor and Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by several deficiencies in their care. The facility did not obtain informed consent from the resident or their surrogate for the use of quetiapine, a medication used to treat bipolar disorder. Additionally, the facility did not adequately monitor the resident's behavior or the side effects and adverse effects of the psychotropic medications, including citalopram, quetiapine, divalproex sodium, and lorazepam. The facility's policy and procedure on the use of psychotropic medication required that residents be monitored for their response to medications, including progress towards goals and the presence or absence of adverse consequences. However, the resident's medical record lacked documentation of behavior monitoring and interventions for a period of time, and there was no evidence of monitoring for side effects or adverse effects of the medications. Furthermore, the facility did not provide non-pharmacologic interventions to facilitate the reduction or discontinuation of the psychotropic drugs, as required by their policy. Interviews with facility staff, including LVNs and an RN, confirmed the lack of informed consent, monitoring, and documentation for the psychotropic medications. The staff acknowledged that there were no physician's orders for monitoring the side effects of the medications, and the monitoring records were absent from the medication administration record (MAR). The facility administrator was made aware of these findings and acknowledged the deficiencies.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident's rights to be free from verbal abuse by a staff member. A student nurse witnessed a Certified Nursing Assistant (CNA) using foul language in Spanish towards a resident who was asking for help. The incident was reported, and the facility's investigation substantiated the occurrence of verbal abuse. The resident involved was severely cognitively impaired and unable to recall the incident during an interview. The facility's policy on abuse, neglect, and exploitation, revised in December 2022, emphasizes the protection of residents' health, welfare, and rights. Despite this policy, the incident occurred, and the facility documented the event in their SOC 341 form. The administrator confirmed that other residents assigned to the CNA did not report verbal abuse, and the CNA was immediately suspended following the incident.
Improper Cohorting of COVID-19 Positive and Negative Residents
Penalty
Summary
The facility failed to adhere to infection control practices by improperly cohorting a COVID-19 positive resident with a COVID-19 negative resident. Resident 8, who tested positive for COVID-19, was placed in the same room as Resident 9, who tested negative. This action was contrary to CDC guidelines, which recommend that patients with confirmed SARS-CoV-2 infection be placed in a single-person room or cohorted only with others who have the same respiratory pathogen. The facility's infection preventionist (IP) confirmed that it was not the facility's policy to cohort COVID-19 positive residents with those who tested negative. The incident occurred due to a miscommunication during the admissions process, where the admissions team was unaware of Resident 8's COVID-19 positive status. Resident 8 was initially admitted to Room A, where Resident 9 was later admitted, despite Resident 8's need for isolation precautions. The IP discovered the error the following day and moved Resident 8 to a different room. The IP acknowledged that Resident 9 was at high risk for developing a respiratory infection due to this oversight.
Failure to Properly Record Resident Belongings
Penalty
Summary
The facility failed to properly record the personal belongings of two residents, which could lead to the loss or theft of their items. For Resident 2, the Clothing and Possessions form was incomplete, lacking a date and signature from the resident or responsible party. Although personal belongings were listed, there was no documented evidence that the form was completed upon the resident's readmission. LVN 1 confirmed the form's incompleteness during an interview and document review. For Resident 6, the inventory process was similarly flawed. The resident was unsure if her belongings were inventoried upon admission, and the form lacked a signature from the resident or responsible party. An inventory check revealed personal belongings not listed on the form, and the resident's clothing was unlabeled. LVN 2 verified these discrepancies during an observation and interview. The DON later acknowledged these findings.
Missed Neurology Consultation Due to Lack of Staff Assistance
Penalty
Summary
The facility failed to ensure that Resident 1 attended a scheduled neurology consultation appointment. Resident 1, who had mild cognitive impairment likely due to vascular dementia and frailty syndrome, was scheduled for a telemedicine neurology consultation. The appointment was to be conducted using Resident 1's telephone at the facility. However, at the time of the appointment, no staff member was present to assist Resident 1, resulting in the resident missing the scheduled consultation. The Case Manager acknowledged that she reminded Resident 1 of the appointment but was unavailable to assist at the scheduled time due to attending to other residents. The Case Manager did not delegate the task to another staff member, which led to Resident 1 not attending the neurology consultation. The Director of Nursing confirmed the expectation that a staff member should have been present to assist Resident 1 during the appointment. This oversight had the potential to delay Resident 1's plan of care.
Failure to Develop Individualized Care Plan for Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident with mild cognitive impairment likely due to vascular dementia. This deficiency was identified during a review of the facility's policies and procedures, which require the development of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. The medical record review revealed that the resident, who was admitted to the facility with primary issues of mild cognitive impairment and secondary issues of frailty syndrome, did not have a care plan addressing their cognitive impairment and vulnerability to cognitive decline. The deficiency was confirmed during an interview and concurrent medical record review with the Director of Nursing (DON), who verified that the resident's plan of care lacked a comprehensive and individualized approach specific to their cognitive condition. The resident's physician's progress note and order summary report indicated the need for a neurology consult for dementia, highlighting the resident's risk for cognitive decline, yet this was not reflected in the care plan. This oversight posed a risk for not providing appropriate and individualized care to the resident.
Failure to Document Treatment Administration
Penalty
Summary
The facility failed to maintain an accurate medical record for one of the sampled residents, specifically regarding the documentation of a treatment administered. The deficiency was identified through interviews, medical record reviews, and a review of the facility's policies and procedures (P&P). The facility's P&P required licensed staff to document all services provided in the resident's medical record in accordance with state law and facility policy. However, the Treatment Administration Record (TAR) for a resident did not include the initials of the licensed nurse, indicating that the treatment was provided as ordered by the physician. The specific incident involved a resident who had an order for a warm compress to be applied to the right groin area four times a day. On a particular day, the TAR lacked documentation of the nurse's initials for two scheduled applications of the warm compress. During an interview, the Licensed Vocational Nurse (LVN) confirmed that she was responsible for the resident's care during the shift in question and acknowledged the missing documentation. The Director of Nursing (DON) also confirmed that the facility's policy required the nurse to document the treatment on the TAR to show it was administered as per the physician's order.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in multiple areas. In Medication Room A, an unsealed package of IV Statlock PICC Plus was found among other IV supplies. The Central Supply Room had various over-the-counter medications stored alongside oral medications, which was acknowledged by the CNA responsible for stocking the room. Additionally, the treatment cart contained expired dressings, unreadable labels on topical creams, and was not maintained in a sanitary condition, with items like a wet wound dressing box and stained drawers observed during the inspection. Two medication carts were found with sticky residue on medication bottles, and one cart contained an expired medication. Specifically, a bottle of ProStat liquid with an expiration date was found in Medication Cart A, and bottles of Milk of Magnesia and Geri Tussin with dried residue were found in Medication Cart C. These findings were verified by the respective LVNs during the inspections. Furthermore, a zinc oxide ointment was left unattended on top of a treatment cart in the hallway near Station 2, which was acknowledged by both an RN and an LVN. The facility's P&P on medication storage was reviewed, and it was noted that medications should be stored securely and only accessible to authorized personnel. The DON confirmed that the zinc oxide ointment should not have been left unattended and should have been stored properly in the treatment cart.
Food Preparation and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food preparation, storage, and sanitary requirements in the kitchen, which had the potential to cause foodborne illnesses to the residents. During an initial kitchen tour, several deficiencies were observed, including improperly disposed, labeled, and dated foods. Specifically, opened hamburger buns, carrots not in their original plastic bag, and grape jelly without received and used by dates were found. Additionally, pieces of ham were incorrectly labeled. These findings were verified by the Dietary Services Supervisor (DSS). The facility's policies and procedures (P&P) for food storage were not adhered to, as expired or outdated food products were not discarded as required. The USDA Food Code 2022 guidelines for cutting surfaces and can openers were also not followed. A heavily marred and scratched brown chopping board and a discolored countertop can opener were observed, both of which were confirmed by the DSS to be potential sources of pathogenic microorganisms transmissible through food. Furthermore, the facility failed to ensure that stainless steel mixing bowls, knives, and water pitchers were properly rinsed prior to use, as hard water marks were observed on these items. A knife and a blender were found with remaining water residue, and a clean spatula was placed on an unsanitized preparation area during pureed food preparation. These observations were verified by the DSS, who acknowledged that water remnants could contain bacteria and that utensils should be completely dry before use. Additionally, an inspection of Medication Cart C revealed containers of chocolate pudding and apple sauce with mismatched preparation dates on the lids and containers. The DSS and DSS in Training confirmed that dietary staff were responsible for checking these containers for proper preparation dates and that both dates should match.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices, leading to multiple deficiencies. LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date and placed spoons and a piston syringe directly on the bedside table without a barrier during medication administration for residents. LVN 4 did not follow Enhanced Barrier Precautions by failing to wear a gown during G-tube medication administration and did not perform hand hygiene or change gloves between tasks, using the same pair of gloves throughout the medication pass. Additionally, LVN 4 placed used spoons and a piston syringe plunger directly on the bedside table without a barrier. The facility also failed to sanitize Derma Klenz spray after use with residents, as observed with LVN 2 during wound care for two residents. The Derma Klenz spray was used as a community supply and was not cleaned before being returned to the treatment cart. This practice was confirmed by the Infection Preventionist (IP), who stated that the spray should have been cleaned to prevent the spread of infection. CNA 8 did not perform hand hygiene before handling clean towels, entering a resident's room, or donning new gloves, and failed to label a basin found on top of a toilet tank in a shared restroom. Additionally, CNAs 1 and 2 did not wear gowns while assisting a resident under Enhanced Barrier Precautions, despite the signage indicating the need for gowns and gloves during high-contact care activities. These failures were acknowledged by the Director of Nursing (DON) and other staff members during interviews.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure the residents' call light system was fully functional. Observations revealed that the call light system for two of the nursing stations was not audible, and specific residents' call lights were not answered promptly. For instance, Resident 61's call light was observed to be on but not audible on multiple occasions. The Maintenance Director confirmed that the call lights for certain rooms were not audible and mentioned that the facility had received recommendations to replace the entire call light system. Additionally, the survey team found that the call lights in several rooms were not working properly, as they did not produce audible sounds at the nursing stations. Furthermore, Resident 67 reported that a CNA did not return after initially attending to the resident, and the call light was not responded to when activated. The DON and Administrator acknowledged that the staff should have attended to Resident 67's needs. The facility's P&P required staff to respond to activated call lights, but this was not adhered to, leading to delays in addressing residents' needs. The Administrator stated that the call light system had stopped working the previous week, and manual bells were provided to residents only after the survey team meeting with the facility's management team.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed consent was obtained prior to administering psychotropic medications to one of the six sampled residents. Specifically, Resident 26 was administered Seroquel XR 300 mg for schizophrenia and paroxetine 40 mg for depression without documented informed consent. The medical records showed that the informed consent forms for both medications were not signed by the physician, and the facility's verification form was incomplete, lacking verification of informed consent from the facility staff. Interviews with the LVN and the DON confirmed that Resident 26 had been receiving these medications since mid-February 2024. Both staff members acknowledged that the informed consent forms should have been signed by the physician and that the facility's verification form should have been fully completed. The facility's policies on informed consent and the use of psychotropic medications were not adhered to, resulting in the resident not being fully informed about their treatment.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure the accommodations of needs were met for one of 19 final sampled residents and two non-sampled residents. Specifically, the call lights were not within reach for two residents, and the call light was not answered promptly for another resident. These failures had the potential for the residents not getting their needs met timely. Resident 83 was observed with the call light behind the headboard of the bed, and Resident 84 had the call light clipped to the call light panel on the wall, making it inaccessible. Both residents were capable of using the call light and making their needs known. Additionally, Resident 67 reported that a CNA promised to check periodically but did not return, and the call light was not answered when pressed. The DON and Administrator acknowledged these findings and confirmed that call lights should be within reach and attended to promptly.
Failure to Implement Comprehensive Care Plan for IV Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident receiving Vancomycin IV therapy. The resident was readmitted to the facility and had an order for Vancomycin IV solution to treat a UTI/sepsis. Despite the order being placed and the therapy starting, the care plan addressing the Vancomycin IV therapy was not initiated until several days later. This delay in care planning was confirmed through interviews with multiple registered nurses and the Director of Nursing, who acknowledged that the care plan should have been initiated as soon as the physician's orders were received. The medical record review showed that the resident's comprehensive care plan initially addressed IV therapy for a different antibiotic, Rocephin, but did not include a focused problem for Vancomycin IV therapy until much later. The failure to promptly update the care plan to include the new IV therapy meant that the resident's care was not appropriately individualized and monitored according to the facility's policies and procedures. This oversight had the potential to impact the resident's treatment and overall care quality.
Failure to Update Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to ensure the comprehensive care plan for Resident 84 was revised to reflect the treatment for both lower extremities for maintenance of skin integrity from cellulitis related to venous insufficiency. This deficiency was identified during a review of the facility's policies and procedures, medical records, and interviews with staff. The facility's policy mandates the development and implementation of a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. However, the care plan for Resident 84 did not include the necessary interventions for the treatment of the left and right lower legs, despite physician's orders for specific treatments to address swelling and maintain skin integrity. During the review, it was found that Resident 84 had physician's orders to clean the left and right lower legs with soap and water, apply vitamin A and D ointment daily, and wrap with Kerlix and a cohesive bandage every day for 14 days. However, these interventions were not reflected in the resident's care plan. Interviews with an LVN and the DON confirmed that the care plan had not been updated to include these treatments. This oversight placed Resident 84 at risk for not having their specific care needs addressed appropriately.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide the necessary care and services to prevent the development of a wound for a resident observed for wound care. Specifically, the facility did not follow the physician's orders for treating the resident's right lower leg swelling. The physician's orders specified that the area should be cleaned with soap and water, vitamin A and D ointment should be applied, and the leg should be wrapped with Kerlix and a cohesive bandage. However, during an observation, an LVN used Derma Klenz wound cleanser instead of soap and water and did not place a cloth barrier or protective drape under the resident's foot during the wound care procedure. The LVN verified that he did not follow the physician's orders and acknowledged the mistake during an interview and medical record review. The Director of Nursing (DON) was informed of these findings and acknowledged the deficiency. This failure to adhere to the prescribed wound care protocol had the potential to contribute to the development or worsening of skin breakdown for the resident.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide the necessary care and services to prevent the worsening of a pressure ulcer for Resident 26. Specifically, the facility did not follow the physician's orders for wound treatment on Resident 26's right hip and right lateral malleolus pressure injuries. During a wound care observation, the LVN did not apply Santyl ointment to the right lateral malleolus pressure injury as ordered and used Derma Klenz instead of normal saline to cleanse the right hip pressure injury. Additionally, the LVN did not place protective pads under the pressure injury sites to protect the body sites and failed to prevent the resident's diaper from flipping back to the wound bed, which could lead to contamination and further complications. The LVN admitted to not obtaining the correct wound care supplies from the central supply and using what was available in the treatment cart. This deviation from the physician's orders and facility policies resulted in improper wound care for Resident 26, potentially exacerbating the resident's existing pressure ulcers. The facility's policy on clean dressing changes, which emphasizes the importance of following physician's orders and using appropriate protective measures, was not adhered to in this instance, leading to the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,269 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fullerton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Catherine Healthcare | 1.2 mi | ★★★★★ | 22 | 0 |
| Park Vista At Morningside | 1.7 mi | ★★★★★ | 21 | 0 |
| Terrace View Care Center | 2.3 mi | ★★★★★ | 28 | 0 |
| Greenfield Care Center Of Fullerton, Llc | 2.3 mi | ★★★★★ | 15 | 0 |
| The Pavilion At Sunny Hills | 2.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.