Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grace Healthcare Center during CMS and state inspections, most recent first.
A facility failed to accurately obtain and document weights for four residents with unplanned weight loss, including one resident with a gastrostomy, hemiplegia, dysphagia, and severe cognitive impairment. The DON, ADON, and RD identified a severe weight drop for one resident, but no CIC form was completed, the RP and MD were not notified, and no IDT meeting was documented. The MARs for two residents on TF also did not show when the pump was turned off as ordered and as recommended by the RD.
A facility failed to provide adequate nutrition and fluids for four residents with significant weight loss, including three residents receiving enteral feeding and one resident on a mechanical soft diet with thin liquids. Records showed severe or significant weight loss, including one resident with a 45-lb drop in one week and another with an 18.3-lb loss, while the RD documented that tube feeding orders and nutritional assessments were not aligned with the residents’ actual status. The ADON and ADM stated the weight losses were change-in-condition events and that the MD, RP, and IDT should have been notified, but the report documented inaccurate weights, incomplete documentation, and failure to complete a CIC form.
Dietary services oversight was deficient because the CDM did not complete the required Title 22 in-service training for the position and was unaware of the California requirement. The RD provided remote, unscheduled contact with the CDM rather than documented frequently scheduled consultation, and records reviewed did not show food service evaluations. Surveyors also observed a dietary aide without a hair net, wet pans stacked together, and thawing ground beef without required dating or labeling.
Excessive Residents in Shared Bedrooms: The facility failed to ensure eight sampled bedrooms had no more than four residents each. Eight rooms in Building Two each had eight beds, although the report notes the room arrangements were based on residents’ care needs and comfort, with accessible wheelchairs and toilet facilities, reasonable privacy, adequate storage space, and sufficient room for residents and staff to provide care.
Infection prevention and control failed when EBP signage and PPE supplies were placed inside resident rooms instead of outside, and staff did not wear gowns during high-contact care for residents with G-tubes and wound care. A resident’s G-tube ports had dried residue, another resident’s feeding tubing was left open to air with dried formula buildup, a suction catheter and O2 tubing were not properly dated or clean, and the same BP cuff was used on multiple residents without cleaning between uses.
Quarterly smoking assessments were not completed on time for three residents who smoked. One resident had pulmonary embolism, depression, seizures, and anxiety; another had COPD, DM, and seizures; and a third had anxiety, depression, and pain. All three had no cognitive deficit on BIMS, and staff and the MDS Nurse confirmed the assessments were supposed to be completed quarterly but were delayed, despite the facility smoking policy requiring reevaluation upon admission and quarterly thereafter.
A CNA was observed standing directly over a resident while providing feeding assistance at the bedside instead of sitting at eye level. The resident had cerebral infarction, dementia, depression, and bipolar disorder, and the CNA stated she stayed standing because the resident could be pushy and might attempt to fight. The DSD and DON stated staff are expected to sit next to residents during feeding, and facility policy says residents should be fed with attention to safety, comfort, and dignity, including not standing over them.
Failure to notify the MD of repeated elevated blood glucose levels for a resident with type 2 DM. The resident was alert, oriented, and on long-acting and short-acting insulin, but the chart lacked clear BG notification parameters. Multiple BG readings were above 350 mg/dL, and the RN stated the MD should have been notified, yet there was no documentation that this occurred. Facility policy required prompt physician notification for changes in condition and sustained changes in blood sugars.
Inaccurate MDS Coding for Surgical Wound and Dental Status: The facility failed to accurately code an MDS for one resident’s surgical wound and another resident’s oral/dental status. One resident had an abdominal surgical site with multiple wounds and daily dressing changes, but the MDS did not code the surgical wound. Another resident had broken and missing natural teeth, but the MDS did not mark the dental item for obvious or likely cavity or broken natural teeth. The DON and ADM stated that each person completing the MDS section was responsible for ensuring it reflected the resident’s condition.
Failure to Update PASARR After Significant Change: A resident with dementia, schizophrenia, and hospice services had a significant change when admitted to hospice, but the MDS Nurse did not find or complete a new level 1 PASARR screening. The resident was observed restless and unable to answer questions appropriately, and both the MDS Nurse and DON acknowledged that a new PASARR assessment should have been completed for the hospice-related change.
Missing Care Plans for Antibiotic Orders: Two residents had antibiotic orders, but no care plans were found for either medication. RN, LVN/ADON, MDSN, IP, and DON all stated that licensed nurses were responsible for initiating antibiotic care plans and that the care plans were needed to direct resident care. One resident had paraplegia, kidney disease, and a nephrostomy catheter-related infection; the other had palliative care needs, dementia, and schizophrenia.
Two residents had care plans that did not reflect current care. One resident used a Yankauer suction catheter for both mouth and nose secretions, but the CP addressed oral suctioning only, and staff gave mixed descriptions of how it was used. Another resident’s CP still listed an outdated G-tube feeding rate that did not match the active MD order, and the MDS nurse and DON acknowledged the CP was not updated to reflect the current intervention.
A resident with a G-tube was observed with feeding tubing left open to air, clogged with dried formula, and connected by an RN who acknowledged the tubing should have been capped and that she had no feeding tube training or competency validation. The DON and ADM also confirmed the RN was not competent in enteral feeding and that the required CSC was not completed upon hire.
Missing Annual CNA Performance Evaluations: The facility did not complete required performance evaluations for two CNAs, as their personnel files contained no annual evaluations since hire. The DSD acknowledged the evaluations were not completed, and the DON stated evaluations are used to determine whether staff are performing the job correctly and should occur after hire and annually thereafter.
Failure to monitor valproic acid levels and notify the MD/RP of lab refusals. A resident with bipolar disorder, dementia, and severe cognitive impairment was receiving valproic acid twice daily, but the chart had no documented valproic acid level after initiation. Staff documented repeated lab refusals, yet the record did not show that the blood draw was attempted or that the MD and RP were notified as required by the care plan and facility policy. The MRR also recommended valproic acid and ammonia levels, but the resident refused the lab draw and no notification was documented.
Medications were found unsecured and improperly labeled for one resident who kept an unlabeled MDI, OTC ointments, and OTC eye drops at the bedside, while staff stated bedside storage was not allowed and medications should be locked and inventoried. In a separate issue, a resident with severe cognitive impairment had a controlled med record that listed the resident and medication name but omitted administration instructions such as dosage, route, frequency, and reason for use, and the DON and ADM confirmed the record was incomplete.
Kitchen food safety practices were not followed when an aide worked without a hair net, wet quarter pans were stored stacked in the clean dish area, and ground beef thawing in the refrigerator had no pull/thaw date or use by date. Staff and the CDM stated hair restraints, dry dish storage, and food labeling were required to prevent contamination and bacterial growth, and the ADM stated food and kitchen items should always be labeled and kept dry.
Incomplete wound and change-of-condition documentation: A resident with paraplegia, chronic kidney disease, and a nephrostomy catheter had back wounds covered with dressings, but weekly wound measurements and change-of-condition documentation were not completed accurately or on time. The LVN/ADON entered a late wound assessment without realizing the resident had gone to the hospital and returned later that day, and RN, MDS, and DON interviews confirmed the change-of-condition note was completed days late instead of the same day.
A resident with severe cognitive impairment and declining mobility was allowed to self-propel in a facility wheelchair without proper assessment, fitting, or supervision. Staff did not evaluate the safety or appropriateness of the wheelchair, nor did they update the care plan or refer for physical therapy despite documented functional decline. This led to the resident's legs becoming entangled in the wheelchair, resulting in fractures and hospitalization.
The facility failed to ensure the Director of Nursing (DON) maintained an active RN license, resulting in the DON working with an expired license. The Assistant Director of Nursing (ADON) knew of the inactive license but did not inform leadership, and the Administrator (ADM) was unaware. The facility's policy requires active licenses for nursing staff to ensure quality care, which was not adhered to, posing a risk to resident safety and care quality.
A nurse in a LTC facility was found to have misappropriated controlled medications, including alprazolam and tramadol, from several residents without administering or documenting their disposal. This affected residents with conditions such as anxiety and chronic pain, as they did not receive their prescribed medications. The discrepancies were discovered through inventory and record reviews, revealing forged signatures and altered dates. Interviews confirmed the nurse's responsibility, highlighting a failure in the facility's processes to prevent such incidents.
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. A resident's hydrocodone-acetaminophen tablets were unaccounted for upon discharge, and the facility's system for storing and destroying controlled drugs was inadequate. Additionally, the emergency kit usage and replenishment process was not properly documented, risking medication availability in emergencies.
Three residents in an LTC facility were administered controlled pain medications without proper clinical justification or monitoring. One resident's oxycodone was changed from as needed to routine after only two days, another resident received an additional routine hydrocodone-acetaminophen order despite limited use, and a third resident's tramadol order was increased without sufficient justification. The facility failed to document pain assessments, update care plans, or monitor for side effects.
A suspended LVN, under investigation for drug diversion, was allowed to work a 12-hour shift with residents, despite explicit instructions from the OA to remain off-duty. The DON, who permitted this, was later suspended for insubordination, as the facility's policy requires employees under investigation to have no resident contact.
Two licensed nurses in the facility failed to properly disinfect glucometers after performing blood glucose tests on residents. RN 3 used a non-approved disinfecting wipe, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time. Both nurses had not received competency-based training on glucometer use, leading to potential risks of spreading bloodborne diseases.
The facility failed to provide essential competency training to three nursing staff members, including training on glucometer use and medication administration. The DON bypassed the established orientation protocol, leading to untrained staff working with residents. The facility's assessment indicated that all residents required medication management, yet the necessary training was not provided.
The facility's QAPI program was found deficient as staff, including CNAs, an LN, and a Registered Nurse Supervisor, were unaware of the program and lacked a tool for measuring performance improvement. Despite a bulletin board display on reducing pressure ulcers, the DON could not specify the performance improvement measurement tool, indicating a failure in the program's implementation.
The facility did not perform reference checks for two newly hired nurses, an LVN and an LN, as required by their policy. The LVN's file lacked any reference checks, while the LN, a recent graduate, had personal references listed but not verified. The DSD admitted to not checking personal references, contrary to the facility's policy mandating background and reference checks for all applicants.
The facility failed to provide mandatory infection control training for two nurses, as their records lacked documentation of training on hand hygiene and PPE. The DSD confirmed the absence of training, and the IP admitted to not ensuring all staff received it, despite the facility's assessment stating such training is mandatory.
A facility failed to ensure a dietary cook was competent in food service, leading to incorrect portion sizes, unfortified diets, and improper food preparation. The cook served incorrect portions, did not fortify foods as required, and failed to follow pureed food recipes. Additionally, the cook did not check food temperatures before serving, and the kitchen ran out of the main dish, resulting in unrequested meal substitutions.
The facility failed to meet the nutritional needs of residents by serving incorrect portion sizes, not following fortified diet orders, and providing alternate meals without resident requests due to insufficient main dish preparation. These actions were contrary to the dietary orders and expectations set by the Registered Dietitian and Dietary Service Supervisor.
A long-term care facility failed to maintain effective infection control, as evidenced by a resident's wheelchair with dried fecal matter, used urinals improperly placed, a laundry room with pooled dirty water, and a nephrostomy catheter bag on the floor. Staff interviews confirmed these practices violated facility policies and posed infection risks.
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Additionally, a water leak from a washing machine in the laundry room led to pooled water, posing safety hazards. Despite staff awareness, these issues persisted due to inadequate maintenance follow-up and documentation.
Two residents in the facility lacked comprehensive care plans, leading to deficiencies in their care. One resident, with multiple health issues, did not have a care plan for the anticoagulant apixaban, while another resident on Enhanced Barrier Precaution due to skin issues lacked a care plan to guide staff. The absence of these care plans was confirmed by facility staff, highlighting a failure to adhere to policy requirements for developing individualized care plans.
The facility failed to adhere to professional standards for two residents. A resident's medication was left unattended, contrary to policy, risking improper administration. Another resident, with a condition requiring padded side rails, was observed without them, despite physician orders. Staff interviews confirmed awareness of policies, yet practices did not align, leading to these deficiencies.
The facility failed to properly label medications for 11 residents, as inhalers lacked expiration dates, potentially leading to the use of expired medications. Additionally, a medication cart was left unattended with keys on top, risking unauthorized access. These issues were confirmed by staff and violated the facility's policies on medication storage and labeling.
The facility failed to maintain sanitary food preparation practices for 54 residents due to the absence of an air gap in the kitchen's two-compartment prep sink. The Dietary Service Supervisor and Maintenance Supervisor were aware of the issue, which was noted in a previous survey. The Registered Dietitian highlighted the necessity of an air gap to prevent contamination, as required by facility policy and the FDA Food Code.
A resident with moderate cognitive deficit was not provided privacy during personal hygiene care, as a CNA left the door open and the privacy curtain was not fully drawn, exposing the resident to the hallway. The facility's policy on resident rights was not upheld, as confirmed by interviews with staff.
A resident with quadriplegia and no cognitive impairment was neglected when staff failed to provide supplies for his suprapubic catheter care, resulting in him being soiled with urine. Despite his independence and ability to manage his own care, the resident's requests for supplies were ignored by multiple staff members, leading to his distress and embarrassment.
A facility failed to notify the LTC-Ombudsman of a resident's emergency hospital transfer for a urinary tract infection. The resident had severe cognitive impairment and multiple medical conditions. Staff interviews revealed a lack of awareness about the notification requirement, which was confirmed by the DON. CMS guidelines mandate that such notices be sent to the Ombudsman.
A facility failed to meet required timelines for MDS assessments for a resident discharged to home. The MDSN did not complete or transmit the discharge MDS assessment, with the last assessment being a quarterly one. The DON and ADM acknowledged the MDSN's responsibility for timely completion and transmission of assessments, as per facility policy.
A facility failed to re-evaluate and document a resident's Level I PASARR, despite the resident having diagnoses of dementia, psychosis, depression, and anxiety. Staff interviews revealed confusion and lack of responsibility for PASARR assessments, with no designated person to complete them. The facility's policy required mental disorder screening upon admission, but this was not followed, resulting in the deficiency.
A resident with moderate cognitive impairment was using a bed rail without proper assessment, documentation, or informed consent. The facility failed to obtain a physician's order, create a care plan, conduct a safety evaluation, or secure informed consent for the use of the side rail, contrary to their policy. Staff interviews confirmed these omissions, which could potentially place the resident at risk.
A resident missed a dose of acetylsalicylic acid 325 mg due to the facility running out of the medication. The responsibility for re-ordering medications was with the nurses, and the facility's policy required reordering at least three days before the last dose. The Director of Nursing confirmed that the Associate Director of Nursing was sent to obtain the medication from a local pharmacy.
A resident's low air loss (LAL) mattress cover was found torn, potentially compromising its function and cleanliness. Staff interviews confirmed the importance of the LAL mattress for the resident's skin health, as the resident had a history of skin issues. The facility's policy required repair or replacement of worn components, which was not followed.
The facility was found non-compliant with regulations limiting resident room capacity to four. Eight rooms housed eight residents each, despite ensuring accessibility and privacy. Staff and residents reported no issues with care or space, but privacy curtains were noted as not always closing completely.
A facility failed to report an allegation of physical abuse within the required 24-hour timeframe. An LVN reported the allegation to the ADM, and the SSD was also aware, but the report to the CDPH was delayed. The resident involved had moderate cognitive impairment and reiterated the abuse claim during an interview.
Inaccurate weights, missing CIC notifications, and incomplete TF documentation
Penalty
Summary
The facility failed to meet professional standards of practice related to weight assessment, change in condition communication, care planning, and enteral nutrition documentation for four residents who had documented unplanned weight loss. Residents 1, 6, 7, and 8 were on weekly weight monitoring because of significant weight loss, but the facility could not determine that their weights were obtained accurately. The Director of Nursing stated the Restorative Nursing Assistants were not consistently using the same device, were not weighing residents at the same time each time, and were not ensuring the residents wore the same clothes. The facility had both a Hoyer lift scale and a standing scale, and the DON stated the Hoyer lift was calibrated on 4/30/26. Resident 1 had the most significant documented change. The weekly weight record showed a weight of 141 lbs on 4/27/26 and 96 lbs on 5/4/26, and later a weight of 91.8 lbs was obtained during observation with the RD stating it was consistent with the resident’s appearance. Resident 1 was nonverbal, had hemiplegia, dysphagia, a gastrostomy, and severe cognitive impairment with a BIMS score of 0. The DON, ADON, and RD stated the 45 lb loss was severe and a change in condition, but no CIC form was completed, the RP and MD were not notified, and no IDT meeting was conducted to review the cause of the weight loss or update the care plan. The MD later stated he had been informed of the weight loss one to two weeks earlier and that 91 lbs was more accurate than 141 lbs, but the documentation in the record did not reflect timely notification or the required change-in-condition process. Residents 6, 7, and 8 also had documented weight fluctuations during the same period, with Resident 6 dropping from 122.1 lbs to 103.8 lbs, Resident 7 decreasing from 101 lbs to 97 lbs, and Resident 8 varying between 209 lbs and 223 lbs. Resident 6 and Resident 7 had diagnoses including hemiplegia, dysphagia, gastrostomy, and severe cognitive impairment, while Resident 8 had intracerebral hemorrhage, hemiplegia, and required supervision for transfers and personal care. The facility did not complete CIC forms or document notification of the RP and MD for these residents, and no IDT meetings were documented to address the weight loss. In addition, the 4/2026 and 5/2026 MARs for Residents 1 and 7 did not document when tube feeding was turned off as ordered and as recommended by the RD, even though staff stated the pumps were turned off daily for medication administration and stomach rest.
Failure to Provide Adequate Nutrition and Monitor Significant Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition and fluids for four sampled residents who were identified as having significant weight loss and required either enteral feeding or a modified oral diet. Resident 1, Resident 6, and Resident 7 were dependent residents with dysphagia and gastrostomy tubes, and Resident 8 was on a regular mechanical soft diet with thin liquids. The record review and interviews showed that staff did not administer nutrition in accordance with policies, procedures, and professional standards of practice, and the residents experienced documented unplanned weight loss during the survey period. Resident 1 had diagnoses including hemiplegia, convulsions, dysphagia, gastrostomy, and a C4 injury, with a BIMS score of 0 and dependence for transfers and personal hygiene. The weekly weight record showed a drop from 141 lbs to 96 lbs in one week, and the RD stated this 45-lb loss was severe. During observation, Resident 1 appeared thin with visible rib cages and knee caps, and the scale showed 91.8 lbs. The RD stated the resident was underweight and was not getting enough nutrients from the tube feeding, while prior nutrition notes had described the resident as overweight and had reduced the tube feeding rate based on that assessment. Resident 6 had diagnoses including hemiplegia, psychosis, dysphagia, and gastrostomy, with a BIMS score of 0 and dependence for transfers and personal hygiene. The weekly weight record showed a decline from 122.1 lbs to 103.8 lbs, and the RD described this as an 18.3-lb severe weight loss. Resident 6 was receiving bolus tube feeding with free water flushes, and the nutrition notes documented prior concerns about significant weight loss and changes to the tube feeding regimen. Resident 7 had diagnoses including convulsions, gastrostomy, extrapyramidal and movement disorder, and rhabdomyolysis, with a BIMS score of 0 and dependence for transfers and personal hygiene. The weekly weight record showed a loss from 101.2 lbs to 97 lbs, and the RD documented a 15-lb loss over 3 months and 26 lbs over 6 months, with tube feeding providing 65 ml/hr for 20 hours. Resident 8 had diagnoses including nontraumatic intracerebral hemorrhage and hemiplegia/hemiparesis, with a BIMS score of 11 and supervision needed for transfers and personal hygiene. The weekly weight record showed a drop from 221.4 lbs to 209.2 lbs, and the report identified a 12-lb loss in one week. The nutrition note stated the resident was on a regular diet with mechanical soft texture and thin liquids, with intake reported at 75-100% at meals, and also noted the resident reported losing weight in his legs. The ADON and Administrator stated that these weight losses were change-in-condition events, that the MD and RP should have been notified, that an IDT meeting should have been held, and that inaccurate weights, incomplete documentation, and failure to complete a CIC form were unacceptable.
Dietary Manager Qualification and RD Consultation Deficiencies
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) met California requirements for the position. A review of California Health and Safety Code 1265.4 showed that a CDM serving as the full-time person responsible for the day-to-day operation of dietetic services must complete at least six hours of in-service training on the specific California dietary service requirements in Title 22 before assuming full-time duties. The CDM’s personnel file showed he was credentialed as a certified dietary manager through 8/31/26, but during interview he stated he had been employed as the CDM since October 2025 and was not aware of the additional six-hour requirement for skilled nursing facilities. He stated he had worked in a hospital previously and had not been told of any additional requirements. The facility also failed to ensure the CDM received frequently scheduled consultation from the Registered Dietitian (RD). The RD stated she worked remotely, reviewed records once or twice a week, and communicated with the CDM by telephone conferences, phone calls, and email. She stated the consultations were not scheduled weekly at a set date and time, and she did not keep documentation or a log of the consultations. The facility’s business correspondence from the RD showed recommendations related to clinical nutrition, but did not show evaluation of food services. The facility’s policy stated that if a dietitian is not employed full time, the director of food and nutrition services will receive frequently scheduled consultations from a qualified dietitian. During observations in the kitchen, surveyors found a dietary aide without a hair net, a wet quarter pan stacked on another quarter pan, and ground beef thawing in the refrigerator without a pull/thaw date or use-by date. The CDM stated the RD checked in periodically and that he contacted her with kitchen or resident concerns as needed. The Administrator stated she expected the RD to visit weekly and described prior practice at another facility where the RD came in person, assessed new admits, observed meal service, reviewed sanitation, and provided reports. The consultation agreement for dietetic services stated the consultant would evaluate sanitation, safety, food handling practices, and meal service regulations, but the documentation reviewed did not show that the RD provided frequently scheduled consultation to the CDM or evaluated food service practices.
Excessive Residents in Shared Bedrooms
Penalty
Summary
The facility failed to ensure that eight of eight sampled bedrooms accommodated no more than four residents each. During the survey period, eight rooms in Building Two each had more than four residents, with eight beds in each room. The report states that the room arrangements were based on residents’ particular care needs and comfort, and that wheelchairs and toilet facilities were accessible to residents. Survey observations and resident and staff interviews also noted that a reasonable amount of privacy was provided, adequate closet and storage space were available, and there was sufficient space for residents to ambulate and for staff to provide care. Nursing care of the residents was not impacted.
Infection Control Failures With EBP, PPE, and Contaminated Equipment
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for multiple residents when Enhanced Barrier Precautions (EBP) were not implemented as written in the facility policy. In Resident 11’s, Resident 5’s, and Resident 40’s rooms, EBP signage was observed inside the room on the wall with EBP containers placed below the signage inside the room, while the facility policy stated signs were to be posted in the door or wall outside the resident room and PPE was to be available outside the room. The Infection Preventionist, DON, and Administrator all stated the EBP containers should have been outside the rooms and that the policy was not followed. PPE was not worn during care for residents who were on EBP. Resident 11 had a G-tube and was observed receiving medication through the G-tube while RN 3 wore gloves but no gown. Resident 40 was observed during feeding tube care while RN 2 did not wear a gown, and RN 2 stated she did not believe a feeding tube required EBP use. Resident 5 was observed during wound treatment while CNA 12 assisted with the care without wearing a gown, although CNA 12 later stated she should have worn one because she was involved in the wound care process. The facility records showed Resident 11 had gastrostomy status, dysphagia, and a G-tube feeding order; Resident 40 had gastrostomy status and dysphagia; and Resident 5 had a wound treatment order for a deep tissue pressure injury on the right fifth toe. Additional infection control concerns were observed with resident equipment and supplies. Resident 11 and Resident 40 had dried residue on the G-tube medication and feeding ports, and staff interviews confirmed the ports were not being properly flushed or cleaned. Resident 40’s feeding bag tubing was observed without a tube cover cap, left open to air, and clogged with dried formula buildup; RN 4 stated the cap should have been in place and the whole tubing set should have been changed. Resident 6’s yankauer suction catheter was not dated, had yellow substance inside and at the tip, and the storage package had dried yellow/brown substance. Resident 6’s oxygen tubing was also not labeled with a first-use date. During medication administration, RN 3 used the same blood pressure cuff for Residents 26, 14, and 34 without cleaning or disinfecting it between residents.
Quarterly smoking assessments not completed on time
Penalty
Summary
The facility failed to follow its own smoking policy and procedure when quarterly smoking assessments were not completed on time for three sampled residents. Resident 41 was admitted with diagnoses including pulmonary embolism, depression, seizures, and anxiety, and had a BIMS score of 15 out of 15, indicating no cognitive deficit. Resident 52 was admitted with diagnoses including COPD, DM, and seizures, and had a BIMS score of 13 out of 15, also indicating no cognitive deficit. Resident 54 was admitted with diagnoses including anxiety, depression, and pain, and had a BIMS score of 14 out of 15, indicating no cognitive deficit. During observation, Resident 41 stated he smoked after each meal and staff went outside with smokers to ensure safety. Resident 52 stated he smoked three times a day after meals, and Resident 54 was identified in the record review as a resident who smoked. RN 1 reviewed the records and stated the smoking assessments for Residents 41, 52, and 54 were completed on 10/31/25 and 3/17/26 for Residents 41 and 52, and on 10/27/25 and 3/17/26 for Resident 54, and she was not sure how often they were completed because she had not completed one. The MDS Nurse stated smoking assessments are completed initially on admission and quarterly, that she was responsible for completing them, and that the assessments for Residents 41, 52, and 54 were not completed until 3/17/26 even though they were supposed to be completed sooner. The DON and Administrator both stated smoking assessments should be completed quarterly, and the facility policy titled Smoking Policy-Residents stated resident smoking status is evaluated upon admission and re-evaluated quarterly, upon significant change, and as determined by staff.
Dignity Not Maintained During Feeding Assistance
Penalty
Summary
The facility failed to ensure staff provided care in a manner that maintained resident dignity during mealtime assistance for one resident who was admitted with diagnoses including cerebral infarction, dementia, depression, and bipolar disorder. During an observation, a CNA was seen standing directly over the resident while assisting with feeding at the bedside, with the resident positioned in bed and the head of the bed elevated. The CNA remained standing over the resident throughout the feeding assistance. During interviews, the CNA stated she preferred to remain standing while feeding the resident because the resident could be pushy and might attempt to fight, although she acknowledged staff were typically expected to sit next to residents during feeding to promote a homelike environment. The DSD and DON both stated staff should sit next to the resident and be at eye level during feeding, and that standing over a resident during mealtime was inappropriate and a dignity issue. The facility policy on Assistance with Meals stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Failure to Notify MD of Repeated Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to ensure physician notification of elevated blood glucose levels for one of four sampled residents, a resident with type 2 diabetes who was admitted with no cognitive impairment and was described as alert, oriented, and able to communicate her needs. During the resident’s stay, blood glucose readings were documented above 350 mg/dL on multiple occasions in March, including readings of 402 mg/dL at breakfast and dinner, 379 mg/dL at dinner, 366 mg/dL at lunch, 400 mg/dL at dinner, and 390 mg/dL and 393 mg/dL at breakfast and lunch. During an observation, the resident was seen eating lunch while a RN checked her blood glucose and administered 12 units of lispro insulin as ordered. The resident stated that her blood glucose had been higher. Review of the medication orders showed long-acting insulin in the evening and short-acting insulin with instructions to hold if blood glucose was less than 100 mg/dL, but there were no additional blood glucose parameters in the medical record. The RN stated that the facility used a standard blood glucose range for diabetic residents and that nurses should know when to notify the MD. The RN also stated the MD should have been notified of the resident’s elevated glucose readings on the dates when values were above 350 mg/dL, but there was no documentation that the MD had been notified. The DON stated that residents on insulin should have parameters in the medical record indicating when to notify the MD and that multiple readings above 350 mg/dL would be considered a change in condition. Facility policies required physician notification for changes in condition, significant sustained changes in blood sugars, and prompt reporting of fingerstick glucose results.
Inaccurate MDS Coding for Surgical Wound and Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected Resident 9’s health and functional status. During observation, Resident 9 was lying in bed watching a show on an electronic device while a CNA attempted to communicate with him using gestures; the CNA stated he did not speak and communicated only by signs, gestures, and pointing. The resident’s record showed diagnoses including paraplegia, chronic tubulo-interstitial nephritis, and infection and inflammatory reaction due to a nephrostomy catheter. His care plan also identified an infection at the right quadrants laparoscopic site due to kidney removal, with multiple abdominal wounds and daily dressing changes noted by staff. During record review and interview, the MDS nurse reviewed Resident 9’s quarterly MDS and stated the surgical wound was not coded in Section M (Surgical Conditions). She stated it should have been coded as yes because Resident 9 had a surgical wound and daily treatment was still being provided. The report also included the definition of surgical wounds as healing and non-healing open or closed surgical incisions, skin grafts, or drainage sites. The facility also failed to accurately code Resident 52’s oral/dental status on the annual MDS. During observation, Resident 52 was sitting in a wheelchair and had broken and missing natural teeth on the upper and lower gums; he stated he had recently been seen by a dentist, did not have mouth pain, and wanted his teeth fixed. The IP, who had completed the MDS, reviewed the assessment and stated Section L (Oral/Dental Status) was not coded correctly because Resident 52 had broken natural teeth and she should have checked L0200D for obvious or likely cavity or broken natural teeth. The DON and Administrator stated that each person completing a section of the MDS was responsible for ensuring the assessment accurately reflected the resident’s condition.
Failure to Update PASARR After Significant Change
Penalty
Summary
The facility failed to complete a level 1 PASARR screening and notify the state mental health authority or state intellectual disability authority promptly after a significant change in condition for one resident. Resident 36 was admitted with diagnoses including palliative care, dementia, and schizophrenia, and the record also showed admission to hospice care under a primary diagnosis of Alzheimer's dementia. During the initial tour, the resident was observed sitting at the edge of the bed, watching TV, calling for assistance, and appearing restless and unable to answer questions appropriately. During interview and record review, the MDS Nurse stated she began completing PASARR assessments in January 2026 and that she completes a new PASARR assessment for significant changes such as admission to or discharge from hospice care. She reviewed Resident 36's record and stated she did not find a PASARR level 1 completed when the resident was admitted under hospice care, and acknowledged that she should have completed one. The DON stated the MDS Nurse was responsible for creating PASARR assessments for significant changes and agreed that a new level 1 PASARR assessment should have been completed when the resident was admitted under hospice care. Facility documents and the DHCS PASARR reference indicated PASARR information should be provided on admission and updated when clinically indicated, including after significant changes in condition.
Missing Care Plans for Antibiotic Orders
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented to meet the identified needs of two sampled residents when care plans were not created for antibiotic use. Resident 9 was admitted with diagnoses including paraplegia, chronic tubulo-interstitial nephritis, and infection and inflammatory reaction due to a nephrostomy catheter. Resident 36 was admitted with diagnoses including palliative care, dementia, and schizophrenia. During the initial tour, Resident 9 was observed lying in bed watching a show on an electronic device while a CNA attempted to communicate using gestures; the CNA stated the resident did not speak and communicated only by signs, gestures, and pointing. Resident 36 was observed sitting at the edge of the bed watching TV, calling for assistance, and appearing restless and unable to answer questions appropriately. Record review showed Resident 9 had an antibiotic order on 3/2/26 and Resident 36 had an antibiotic order on 3/13/26. During interviews and record review, RN 1 stated licensed nurses are responsible for initiating a care plan when a new medication order, including antibiotics, is received. The LVN/ADON reviewed Resident 9's record and stated there was no care plan for the antibiotic and that one should have been initiated as soon as the antibiotic started. The MDSN reviewed both residents' records and stated she did not find antibiotic care plans for either resident. The IP stated licensed nurses receiving antibiotic orders were responsible for creating a care plan and that it was her responsibility to ensure they had care plans. The DON stated licensed nurses were expected to create a care plan as soon as a new order was received and that the MDT should have ensured care plans were reviewed and created if missing.
Care plans were not updated to match suctioning use and enteral feeding orders
Penalty
Summary
The facility failed to ensure care plans were reviewed and revised for two sampled residents. For one resident, the care plan addressed oral suctioning only, while the resident was observed keeping a Yankauer suction catheter on the dresser and stated he used it to suction extra saliva from his mouth and that he choked when saliva built up. The resident also stated he last used the suction catheter the day before the interview. The resident’s record showed diagnoses including cerebral infarction, COPD, dysphagia following cerebral infarction, and MRSA, and the MDS indicated he was cognitively intact. During record review and interviews, staff gave inconsistent information about the suction catheter’s use. The RN was unsure whether the catheter was for the nose or mouth, the CNA stated it was used for both, and the RT stated the resident had a lot of secretions in his mouth and a runny nose and used the catheter for both his mouth and nose. The RT also stated there should be two suction catheters for the resident, one for the mouth and one for the nose. The DON later reviewed the care plan and stated it did not reflect that the suction catheter was used for both the nose and the mouth, and that the care plan should have been revised accordingly. For the second resident, the care plan did not match the active physician order for enteral feeding. The resident was observed in bed with a G-tube and feeding pump at the bedside. The resident’s record showed diagnoses including hemiplegia, quadriplegia, gastrostomy status, dysphagia, gastrostomy infection, and gastrointestinal hemorrhage, and the MDS indicated severe impairment in decision-making. The active order called for enteral feeding formula at 40 mL per hour for 20 hours, but the care plan still listed the formula at 70 mL per hour for 20 hours and reflected older dates. The MDS nurse stated she was responsible for updating care plans and that the intervention should have been updated when the order changed, and the DON stated the care plan should have reflected the care being provided.
Inadequate Enteral Feeding Competency and Missing Staff Skills Checklist
Penalty
Summary
The facility failed to ensure that nurses were competent in the enteral feeding process when caring for a resident with a gastrostomy tube. During an observation in the resident’s room, the feeding pump and formula were set up, but the connector end of the feeding bag tubing was left open to air, had no tube cover cap, and showed dried formula buildup and clogging inside the tubing and around the tip. RN 4 was then observed taking that exposed, clogged tubing and connecting it to the resident’s G-tube feeding port. During the same observation, RN 4 stated the tubing should have been covered with a cap and acknowledged she was cleaning the tubing with the inside of her glove. When asked about the process, she stated she should have used gauze with normal saline, but also stated that method would not remove the dried formula. RN 4 later stated she had no training on feeding tubes, had only one day of orientation when hired, and had no skills or competency training, demonstration, or evaluation on feeding tube care. The Infection Preventionist stated RN 4 was not competent and should have changed the whole tubing kit. The facility also failed to complete the Licensed Nurse Competency/Skills Checklist for RN 4 upon hire. The DSD stated RN 4 had orientation training and that the CSC was done with the DON, but the DON later reviewed the records and found no CSC for RN 4. The DON stated RN 4 started in January 2026, that the CSC should have been completed after orientation and repeated after 3 months, and that RN 4 needed more skill testing. The Administrator also stated RN 4 should have had a skills checkoff before working independently and that competency testing and training should be completed upon hire.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility did not ensure completion of performance reviews/evaluations for nurse aides at least every 12 months for CNA 8 and CNA 9. During a concurrent interview and record review on 3/19/2026 at 1:57 p.m. with the DSD, the personnel file for CNA 8 showed a DOH of 12/9/24 and no performance evaluation in the file. The personnel file for CNA 9 showed a DOH of 6/6/23 and no performance evaluation completed since DOH. The DSD stated she was responsible for ensuring CNA performance reviews were completed and acknowledged the sampled CNAs did not have annual evaluations. During an interview on 03/20/2026 at 10:56 a.m., the DON stated performance reviews determine whether staff are able to do the job the right way and said evaluations should be done 3 months after hire, after one year, and yearly thereafter. Review of the facility’s Hiring Policy & Procedure indicated each employee file must include performance evaluations, and the Performance Evaluations policy stated each employee’s job performance shall be reviewed and evaluated at least annually, with a 90-day evaluation and annual evaluations thereafter.
Failure to Monitor Valproic Acid Levels and Notify MD/RP of Lab Refusals
Penalty
Summary
The facility failed to ensure appropriate monitoring and follow-up for a resident receiving valproic acid for mood stabilization related to bipolar disorder. The resident had diagnoses including cerebral infarction, dementia, depression, and bipolar disorder, and was observed in bed appearing confused and intermittently mumbling, though able to state his name and not appearing sleepy, drowsy, or sedated. The resident’s MDS indicated severe cognitive impairment, and staff described him as alert but very confused, with behaviors including combativeness, hitting, spitting, and refusing care and laboratory draws. The resident had an active order for valproic acid delayed-release sprinkle capsules, 125 mg, given twice daily, and the MAR showed the medication was administered from December 2025 through the review date. The record did not contain a documented valproic acid level after initiation of therapy, and the RNS stated that a valproic acid level should have been obtained when the medication was started. The RNS also stated that monitoring valproic acid levels was important to assess therapeutic range and potential toxicity, and that the resident had been receiving valproic acid since 12/4/25. The record showed progress notes on 3/11/26 and 3/18/26 documenting refusals of lab draws as the third refusal for lab testing, but the documentation did not indicate whether the blood draws were attempted or whether the refusals occurred before an attempt. The RNS stated that if there was no documentation showing the MD and RP were notified, then notification did not occur, and the care plan intervention to notify the MD and RP with each refusal was not followed. The March MRR recommended obtaining valproic acid and ammonia levels, but the resident refused the lab draw on the expected date, and there was no documentation that the MD or RP were notified of the refusal.
Medications Left Unlocked and Controlled Drug Record Incomplete
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles for two sampled residents. One resident with COPD, DM, and muscle weakness was observed in his room with medications kept on his bedside table and in a drawer. He had one MDI with no label showing the name, directions, open date, or used-by date, three OTC ointments in the top drawer of his bedside table, and two bottles of OTC eye drops on top of the bedside table. During observation and interview, the resident stated he used the MDI twice daily, used one puff instead of the two puffs prescribed by his primary doctor, applied the ointments as needed, and used the eye drops each morning. He also stated he had not told nursing staff about the medications and had kept them visible in his room for about two weeks. Staff interviews confirmed the medications should not have been left at bedside. The RNS stated all medications brought in from home or the hospital were to be removed from the bedside, taken to the medication room, inventoried, and then handled through the MD and pharmacy if approved. The IP stated medications should never be left on top of a bedside table, including OTC medications, because they had to be locked so other residents would not have access. RN 1 stated she had seen the medications at the bedside, believed the resident may have been allowed to keep them because they were OTC, and stated she did not know about the MDI at bedside. The DON stated the resident’s medications should have been labeled with the resident’s name, directions, open date, and used-by date. A second resident with palliative care needs and unspecified dementia had a BIMS score of 3, indicating severe cognitive impairment. The resident had an order for morphine sulfate concentrate oral solution 20 mg/ml, 0.25 ml by mouth every 2 hours as needed for mild pain or shortness of breath. Review of the controlled drug record sheet showed the resident’s name and medication name, but it did not include the administration instructions. RN 1 stated the record lacked dosage, direction, route, frequency/time, and reason for use, and that these parameters should have been included so licensed nurses would know the correct order. The DON and the Administrator also reviewed the record and stated it was missing the method of administration and other parameters. The facility policy for controlled medications required a controlled medication record accountability record to include specific information for scheduled II to V medications.
Kitchen Food Safety Lapses
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when kitchen staff worked without hair nets, wet quarter pans were stored stacked in the clean dish area, and ground beef was thawing in the refrigerator without a pull/thaw date or use by date. These conditions were identified during observation, interview, and record review in the kitchen serving 56 residents. During observation in the kitchen, one Dietary Aide was seen working without a hair net. Another Dietary Aide stated there were no hair nets available in the facility and that kitchen staff did not wear hair nets when none were available. The Dietary Aide also stated the facility policy was to wear hair nets always while in the kitchen. The Certified Dietary Manager stated kitchen staff were expected to wash their hands and put on a hair net as soon as they entered the kitchen, and the Administrator stated it was not acceptable for hair nets to be unavailable in the kitchen. A facility in-service document stated that consistent and correct use of hairnets was one of the most critical steps in preventing physical contamination. During a separate observation, a wet quarter pan was seen stacked on top of other quarter pans in the clean dish area. The Dietary Aide stated dishes should be washed, air dried, and stored only after they were dry, and stated wet dishes should not be stored because water could harbor bacteria. The Certified Dietary Manager stated dishes should be stored dry and that water on dishes could cause bacterial growth. The Administrator also stated dishes and pans should not be stored wet because wet stacking prevented adequate airflow and could cause bacteria to grow. A facility in-service document described wet stacking as stacking items while still damp, trapping moisture and preventing proper drying. During another observation, ground beef was found thawing in the refrigerator with no pull/thaw date and no use by date. The Certified Dietary Manager stated the meat had been pulled from the freezer and placed in the refrigerator to thaw, but there should have been a pull/thaw date so staff would know when it was removed and when to discard it. Other staff and the Administrator stated food items should always be labeled with dates to track when food was taken out, when it should be used, and to prevent bacterial growth. A facility in-service document stated that every item prepared in-house must have a label containing the product name, date opened or prepared, and discard date.
Incomplete wound and change-of-condition documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one sampled resident. Resident 9 was admitted with diagnoses including paraplegia, chronic tubulo-interstitial nephritis, and infection and inflammatory reaction due to a nephrostomy catheter. During observation, Resident 9 was in bed watching a show on an electronic device, and a CNA stated the resident did not speak and communicated only by signs, gestures, and pointing. Staff interviews confirmed that Resident 9 required assistance with turning and repositioning and had wounds on the back covered with dressings. Record review and staff interviews showed that Resident 9's weekly wound assessment and change of condition documentation were not completed on time. The LVN/ADON stated she was responsible for weekly wound measurements and reported that she completed a late entry for the wound assessment but did not realize the resident had been sent to the hospital and returned later that day, making the documentation inaccurate. RN 1 stated the change of condition was completed several days late, and the MDS coordinator and DON both stated that change of condition documentation should be completed the same day the event occurs. The facility's policies required prompt notification of the attending physician and documentation of changes in condition, as well as documentation of wound location, stage, length, width, and depth.
Failure to Assess and Supervise Wheelchair Use Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who self-propelled in a wheelchair. Nursing staff were aware that the resident used a wheelchair equipped with foot pedals and self-propelled throughout the facility, but did not assess the safety or appropriateness of the wheelchair for the resident's physical size, abilities, or declining mobility. The resident was not evaluated or fitted for a personal wheelchair and instead used wheelchairs available for general use in the facility. Staff did not identify or address the resident's declining upper and lower extremity mobility as documented in the Minimum Data Set (MDS), nor did they refer the resident for a physical therapy assessment or update the care plan to address wheelchair use and safety. As a result of these failures, the resident experienced an unwitnessed, avoidable accident in which their legs became entangled in the wheelchair while self-propelling, leading to severe pain and a right lower leg injury. The resident was subsequently diagnosed with acute right tibial and proximal fibular fractures, requiring hospitalization and resulting in loss of mobility and increased isolation. Interviews with nursing staff and CNAs revealed that none were aware of a safety assessment for the resident's wheelchair use, and there was no documentation of a physical therapy referral, physician notification regarding the resident's functional decline, or a care plan component addressing wheelchair safety. Facility policy required that recommendations for assistive device use be based on comprehensive assessment and documented in the care plan, including evaluation of appropriateness for the resident's condition and personal fit. However, these policies were not followed, as confirmed by staff interviews and record reviews. The lack of assessment, supervision, and individualized equipment fitting directly contributed to the resident's accident and subsequent injury.
Failure to Maintain Active License for Director of Nursing
Penalty
Summary
The facility failed to designate a full-time Registered Nurse (RN) as the Director of Nursing (DON) for all 58 residents when the current DON's license expired. The Assistant Director of Nursing (ADON) was aware of the inactive license but did not notify leadership, allowing the DON to continue working with an expired license. The Administrator (ADM) was unaware of the situation and confirmed that the DON should not have been working without an active license. The Owner/Operator RN 1 also confirmed the DON worked during the month with an inactive license and highlighted the failure of the Director of Staff Development (DSD) to communicate the issue to leadership. The facility's policy requires nursing service personnel to have the necessary qualifications, including an active RN license, to ensure quality resident care. The DON's job description mandates maintaining an active RN license and being onsite full-time. The lack of an active license for the DON resulted in a potential risk of inadequate supervision and guidance for staff, which could affect resident safety and care quality. The facility's policy and job descriptions were not followed, leading to the deficiency.
Medication Misappropriation by Nurse in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of their medications, which are considered their property. A licensed nurse, identified as LVN 1, was found to have removed various controlled medications from the medication cart without administering them to the residents or properly documenting their disposal. This included medications such as alprazolam, tramadol, hydrocodone-acetaminophen, and oxycodone, which are used for treating anxiety, pain, and other conditions. The discrepancies were discovered through a review of the medication inventory count sheets and electronic medical records, revealing that the medications were neither given to the residents nor wasted according to facility policy. The report highlights specific instances involving multiple residents, each with their own medical conditions and needs for the medications. For example, Resident 67, who was severely cognitively impaired, did not receive their prescribed alprazolam for anxiety, as the medication was removed by LVN 1 without proper documentation. Similarly, Resident 59, also severely impaired, was deprived of their alprazolam, which was crucial for managing their anxiety disorder. Other residents, such as Resident 69 and Resident 71, who suffered from chronic pain, did not receive their tramadol, leading to potential untreated pain. Interviews with the Consultant Pharmacist, Assistant Director of Nursing, and Director of Nursing confirmed that LVN 1 was responsible for the missing medications, and there were indications of forged signatures and altered dates on the inventory sheets. The facility's processes were insufficient to prevent or detect this diversion of medications, which posed a risk to the residents' health and safety. The report does not mention any corrective actions or follow-up measures taken by the facility to address these deficiencies.
Inadequate Controlled Drug Management and Documentation
Penalty
Summary
The facility failed to maintain adequate records for controlled drugs, leading to drug diversion and potential unmet needs for residents. Specifically, the facility could not account for 32 tablets of hydrocodone-acetaminophen 5-325 mg prescribed to a resident, who was admitted with a diagnosis including contracture of the right upper arm muscle. The resident was discharged without a record of the controlled drugs being transferred, and both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and the importance of maintaining accurate records to prevent medications from falling into the wrong hands. Additionally, the facility did not adhere to its policy and procedure for the destruction of controlled drugs. Controlled medications awaiting destruction were inadequately logged and stored, with the DON admitting to giving the key to the storage cabinet to nursing staff without a proper log of the medications stored. The Consultant Pharmacist (CP) confirmed that the facility's disposition log was inadequate for accurately tracking controlled drug medications, and the DON acknowledged the lack of a proper system to ensure controlled medications were not taken from the cabinet without authorization. The facility also failed to maintain an adequate system for the use and replenishment of the emergency kit (e-kit) containing controlled drugs. The DON was unable to provide e-kit usage records for several months, and the process for documenting and replacing used e-kits was not followed by nursing staff. The CP emphasized the importance of documenting every medication taken from the e-kit for billing, inventory tracking, and preventing drug diversion. The failure to replace the e-kit within the required timeframe could potentially impact the availability of necessary medications in emergency situations.
Inappropriate Medication Administration and Lack of Monitoring
Penalty
Summary
The facility failed to ensure that three residents were administered medications appropriately, leading to potential unnecessary drug use. Resident 55's oxycodone order was changed from as needed to routine without clinical justification, and there was no monitoring for side effects. Despite the resident not complaining of pain, the order was altered after only two days and five doses, without proper documentation or communication with the physician. The Medical Director did not recall authorizing this change, and the nursing staff did not update the care plan or document the rationale for the change. Resident 57's hydrocodone-acetaminophen order was similarly altered, with an additional routine order added without clinical justification. The resident, who was developmentally delayed, had only requested the medication three times as needed, yet a routine order was obtained. There was no documentation of a pain assessment or a diagnosis of chronic pain, and the Medical Director did not recall prescribing the routine order. The Assistant Director of Nursing acknowledged the inappropriateness of the routine order given the resident's limited use of the medication. Resident 59's tramadol order was increased from three times daily to four times daily without sufficient justification. The resident had only requested the medication four times as needed over a period of several weeks. The Assistant Director of Nursing admitted that the change was unwarranted based on the resident's usage. The Director of Nursing confirmed that the nursing staff did not follow proper procedures for documenting pain assessments or updating care plans, and there was no monitoring for side effects of the medications administered to the residents.
Suspended LVN Worked During Investigation
Penalty
Summary
The facility administration failed to prevent a Licensed Vocational Nurse (LVN) from working while suspended and under investigation for drug diversion. The LVN, suspected of diverting opioids and other medications, was suspended on September 25, 2024. Despite this, the Director of Nursing (DON) requested the LVN to return to work on September 28, 2024, to provide orientation to a newly hired LVN. This resulted in the suspended LVN working a 12-hour shift with approximately 30 residents, potentially compromising the integrity of the ongoing investigation. The Owner/Administrator (OA) had explicitly instructed the DON that the LVN should not be present in the facility during the suspension. The DON's decision to allow the LVN to work was against these instructions, leading to her suspension on October 7, 2024. The facility's policy mandates that any employee accused of resident abuse or theft is placed on leave with no resident contact until the investigation is complete. The DON's actions were considered insubordination, as there were other nurses available to provide the necessary orientation.
Improper Disinfection of Glucometers by Nursing Staff
Penalty
Summary
The facility failed to ensure proper disinfection of glucometers by two licensed nurses, RN 3 and LN 22, after obtaining blood samples from residents. This oversight was identified through observations, interviews, and record reviews. Both nurses were responsible for administering medications and performing blood glucose fingerstick tests on residents. RN 3, who had been employed for three months, and LN 22, who had been employed for one week, had not received competency-based training on the use of glucometers. During observations, RN 3 used a disinfecting wipe that was not approved for killing bloodborne germs, while LN 22 used an appropriate germicidal wipe but did not adhere to the required two-minute disinfection time as indicated on the product label. The Infection Prevention Nurse confirmed that the disinfecting wipes used by RN 3 were not suitable for eliminating bloodborne pathogens, and both nurses failed to follow the manufacturer's instructions for proper disinfection. The technical brief for the glucometer and the technical data bulletin for the germicidal wipes both emphasized the necessity of cleaning and disinfecting the glucometer after each use to prevent the transmission of bloodborne pathogens. The failure to properly disinfect the glucometers posed a risk of spreading bloodborne diseases to other residents undergoing blood glucose testing.
Deficiency in Staff Competency Training
Penalty
Summary
The facility failed to ensure that three nursing staff members, including a Licensed Vocational Nurse, a Licensed Nurse, and a Registered Nurse, received essential competency training. The Director of Staff Development (DSD) was responsible for overseeing the orientation of new nursing staff, which was supposed to include two classroom days before working on the floor. However, the Director of Nursing (DON) instructed one of the nurses to start working with residents after only one day of classroom orientation, bypassing the established protocol. This decision was made without consulting the DSD, as the DON needed a nurse on the floor immediately. Additionally, the facility did not provide competency-based training for the use of glucometers, which are essential for monitoring and treating diabetes, to the three nursing staff members. The DSD confirmed that there were no records of glucometer competencies for these staff members, despite the presence of residents requiring such monitoring. Furthermore, there were no records of medication administration competencies for these nurses, who were responsible for administering medications through various methods and routes. The facility's assessment indicated that all residents received medication management, and the training program was supposed to include medication administration and diabetic blood glucose testing.
Deficiency in QAPI Program Awareness and Implementation
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of awareness among staff members about the program and the absence of a tool for measuring performance improvement. During interviews, four staff members, including two Certified Nursing Assistants (CNAs), a Licensed Nurse (LN), and a Registered Nurse Supervisor, were unable to articulate knowledge of the facility's QAPI plan. The CNAs and LN were not aware of the program at all, while the Registered Nurse Supervisor knew the acronym but could not describe the plan or the performance improvement measurement tool. An observation of a facility bulletin board revealed a display related to QAPI, including an initiative to reduce pressure ulcers by 50% over the next quarter. However, during an interview, the Director of Nursing (DON) acknowledged that while the facility collects QAPI data on falls and pressure ulcers, they were unable to specify the performance improvement measurement tool used for pressure ulcers. This lack of awareness and understanding among staff members indicates a deficiency in the facility's implementation of its QAPI program, which is crucial for improving resident safety.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to conduct reference checks for two of the five sampled employees, specifically a Licensed Vocational Nurse (LVN) and a Licensed Nurse (LN), prior to their employment. During an interview, the Owner/Administrator expressed that it was expected for all candidates to have their previous employment and personal references checked. However, upon reviewing the personnel file of LVN 1, it was found that no reference checks were performed. The Director of Staff Development (DSD) acknowledged the absence of reference checks and admitted to not knowing where LVN 1's references were. Similarly, the personnel file of LN 22, who had just graduated from nursing school and had no prior nursing experience, showed that only personal references were listed, and these were not checked. The DSD confirmed that personal references for LN 22 were not verified, stating a preference for checking only employment references. The facility's policy and procedure document, dated March 2019, mandates background screening and reference checks for all applicants with direct access to residents, which was not adhered to in these cases.
Inadequate Infection Control Training for Nursing Staff
Penalty
Summary
The facility failed to implement an effective training program for infection control and prevention, specifically for two licensed nurses, a Licensed Vocational Nurse (LN 22) and a Registered Nurse (RN 3). During a review of their employee records, it was found that neither nurse had documented training on hand hygiene and personal protective equipment (PPE), which are critical components of infection control. The Director of Staff and Development (DSD) confirmed that the training was not completed as there were no signatures in the records to indicate otherwise. The Infection Preventionist (IP) acknowledged that hand hygiene and PPE training should be mandatory for all staff but admitted to not ensuring that all staff received this training. The facility's Facility Assessment, dated September 2, 2024, stated that staff training on infection control, including written standards, policies, and procedures, is part of their program. However, the lack of documented training for LN 22 and RN 3 indicates a failure to adhere to these standards, placing residents at risk for potential infection spread due to inadequate staff training.
Dietary Service Deficiencies in Portion Control and Food Preparation
Penalty
Summary
The facility failed to ensure that Dietary Cook (DC) 1 was competent in carrying out the functions of food and nutrition services safely and effectively. DC 1 served incorrect portion sizes for residents on large portion diets, providing one and a half servings of the main dish instead of the prescribed one serving. This was contrary to the facility's policy, which specified that large portions should include extra servings of vegetables, not the main dish. Additionally, DC 1 did not fortify foods for residents on fortified diets by failing to add the required extra butter to vegetables, which was necessary to meet the residents' higher nutrient demands. DC 1 also did not follow the pureed food recipe for residents on pureed diets, omitting the smooth Mexican tomato sauce that was supposed to enhance the flavor of the pureed foods. Furthermore, DC 1 neglected to check the temperature of pureed foods before serving, which is a critical step to ensure food safety and prevent foodborne illnesses. The facility's policy required all food temperatures to be checked prior to serving to ensure they were safe for consumption. Lastly, the kitchen ran out of the main dish, chile relleno casserole, and DC 1 had to serve an alternate meal, a beef, bean, and cheese burrito, to the last three residents. This was not in accordance with the facility's policy, which stated that alternates should only be provided upon resident request or if they did not like the main dish. The Dietary Service Supervisor (DSS) was responsible for ensuring that the kitchen staff were fully trained and that the menu was followed, but these deficiencies indicate a lack of proper oversight and training.
Nutritional Deficiencies in Meal Service
Penalty
Summary
The facility failed to ensure that the food served met the daily nutritional needs of several residents. Specifically, residents on large portion diets were served more than the required portion size of chile relleno casserole, which could lead to exceeding their recommended daily caloric intake. This was observed during a tray-line observation where the dietary staff served one and a half slices of the casserole instead of the prescribed one slice. The Registered Dietitian confirmed that the menu and portion sizes should have been followed to prevent potential weight gain or elevated lab levels. Additionally, the facility did not adhere to fortified diet orders for certain residents. During an observation, it was noted that the dietary staff failed to add extra butter to vegetables for residents on fortified diets, which was necessary to meet their additional caloric needs. The Dietary Service Supervisor acknowledged that the fortified diet order was not followed, and the expectation was to adhere to the menu and spreadsheet instructions. Furthermore, the facility ran out of the main dish, chile relleno casserole, and served alternate food to some residents without their request. This occurred because there was not enough of the main dish prepared, leading to the substitution of beef, bean, and cheese burritos. The Dietary Service Supervisor and Registered Dietitian both stated that it was not acceptable to provide alternate meals without resident requests, and the expectation was to have enough food to serve all residents according to the menu.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In one instance, Resident 4's wheelchair was found with dried fecal matter on the seat, which was not cleaned according to the facility's policies. Interviews with staff, including a Certified Nursing Assistant (CNA), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed that such contamination could lead to the spread of infections like C-Diff and E-Coli. The facility's policy required that resident-care equipment be cleaned and disinfected, but this was not adhered to in this case. Another deficiency was observed in Resident 33's room, where two used urinal bottles were found on the bedside table next to drinking cups and personal hygiene supplies. One of the urinals had brown matter buildup, indicating it had not been cleaned or replaced as per the facility's guidelines. Staff interviews revealed that urinals should be changed weekly and not placed on bedside tables to prevent cross-contamination. The presence of dirty urinals next to personal items posed a significant infection control issue, as confirmed by the IP and DON. Additionally, the facility's laundry room had a leak causing dirty water to pool on the floor, which could lead to contamination of freshly washed linens. Laundry staff and the Assistant Director of Nursing (ADON) acknowledged the unsanitary conditions and the potential for mold or pathogen growth. Furthermore, Resident 214's nephrostomy catheter bag was found on the floor, which could lead to contamination and infection. Staff interviews confirmed that the catheter bag should not have been on the floor, as it posed an infection risk. The facility's policies on infection control were not followed, contributing to these deficiencies.
Deficiencies in Privacy and Safety Measures
Penalty
Summary
The facility failed to maintain functional privacy curtains in eight resident rooms, compromising residents' privacy rights. Observations revealed that privacy curtains were either missing strings or had tangled strings, making them non-functional. Certified Nursing Assistants (CNAs) reported these issues to the Maintenance Supervisor (MS) and housekeeping, but the problems persisted due to a lack of parts for repairs. The MS confirmed the issues and stated that the facility had ordered new parts to address the problem. The Director of Nursing (DON) and the Administrator acknowledged the importance of maintaining privacy for residents, as it is a fundamental resident right. Additionally, the facility failed to address a water leak from one of the washing machines in the laundry room, leading to pooled water on the floor. This situation posed a safety hazard, with risks of slips, electrocution, and potential growth of mold and bacteria. Laundry staff and the Assistant Director of Nursing (ADON) were aware of the leak, which had been ongoing for about a year, but no repair request was documented in the maintenance log. The Maintenance Supervisor identified the source of the leak as a missing plug in the washing machine, and the DON emphasized the need for immediate action on such issues. The facility's policies and procedures for maintaining a homelike environment and ensuring safety were not effectively implemented. The maintenance department was responsible for keeping the building and equipment in safe and operable condition, but failed to address the reported issues in a timely manner. The lack of documentation and follow-up on maintenance requests contributed to the ongoing deficiencies, impacting the safety and comfort of residents and staff.
Deficiencies in Care Planning for Anticoagulant and Infection Control
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in their care. Resident 53, who was admitted with multiple diagnoses including End Stage Renal Disease, Acute Pulmonary Edema, Atrial Fibrillation, and Depression, did not have a care plan for the anticoagulant medication apixaban. This oversight was identified during a review of the resident's records, where it was noted that the care plan was missing despite the facility's policy requiring one for anticoagulant use. Interviews with the LVN, MDS, and DON confirmed the absence of the care plan, which is necessary to monitor for potential adverse reactions. Resident 51, who was admitted with heart failure, morbid obesity, and osteoarthritis, was placed on Enhanced Barrier Precaution (EBP) due to skin issues. However, there was no care plan in place to guide staff on how to manage the resident's needs under EBP. The Infection Preventionist, who was responsible for initiating such care plans, acknowledged the absence of the care plan during a review of the resident's clinical record. The DON and RNS also confirmed that the care plan was missing, emphasizing the importance of care plans in directing nursing staff on resident care. The facility's policy and procedure documents indicate that comprehensive care plans should be developed within seven days of completing a resident assessment. The lack of care plans for both residents 53 and 51 highlights a failure to adhere to these policies, potentially putting the residents at risk by not addressing their specific medical and care needs adequately.
Medication Safety and Bedrail Padding Deficiencies
Penalty
Summary
The facility failed to meet professional standards of practice for two residents, Resident 27 and Resident 44. For Resident 27, a medicine cup containing seven tablets was left unattended on the breakfast tray. This was observed during a visit, and the resident confirmed that the nurse left the medication for him to take after breakfast. The facility's policy and interviews with staff, including the LVN and DON, indicated that medications should not be left unattended at the bedside due to the risk of other residents accessing them or the resident not taking them. Despite this, the LVN responsible for Resident 27 admitted to leaving the medication at the bedside, believing it was safe for the resident to take after eating. For Resident 44, the facility failed to follow the physician's order for padded side rails. Observations on multiple occasions revealed that the resident's bedrails were raised without padding, despite having a condition that required such safety measures. Interviews with CNAs and the DON confirmed that the resident should have had padded side rails to prevent injury, especially given the resident's medical conditions, including epilepsy. The facility's policy emphasized the importance of implementing additional safety measures for residents at higher risk of injury, which was not adhered to in this case. The deficiencies in both cases were attributed to a lack of adherence to established policies and procedures. Staff interviews revealed a general understanding of the policies, yet the practices observed did not align with these standards. The failure to ensure medication safety for Resident 27 and the lack of padded side rails for Resident 44 highlighted lapses in the facility's compliance with professional standards of care.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored safely and labeled according to accepted professional principles. Specifically, medications administered via inhalers for 11 residents were not labeled with expiration or use-by dates. During observations and interviews, it was confirmed by two Licensed Vocational Nurses (LVNs) that the inhalers lacked expiration dates, which was acknowledged as a potential issue by the Director of Nursing (DON) and the Skilled Nursing Pharmacy Consultant (SN PC). The facility's policy required medication labels to include expiration dates, but this was not adhered to, raising concerns about the potential administration of expired medications. Additionally, one of the medication carts was left unattended in a hallway with keys on top, posing a risk of unauthorized access to medications. This was observed and confirmed by an LVN, the Assistant Director of Nurses (ADON), and the Administrator (ADM), all of whom acknowledged that the keys should not have been left on the cart. The facility's policy stipulated that medications should be stored in locked compartments, accessible only to authorized personnel, but this protocol was not followed, creating a risk of medication misuse or diversion.
Lack of Air Gap in Kitchen Sink Risks Resident Safety
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices for 54 out of 62 residents due to the absence of an air gap in the two-compartment prep sink in the kitchen. During an observation and interview, the Dietary Service Supervisor (DSS) acknowledged that the sink lacked an air gap, which is essential for backflow prevention. The Maintenance Supervisor (MS) was also aware of this issue. The DSS admitted that the absence of an air gap was noted in a previous survey, and although attempts were made to install one, they were unsuccessful. The Registered Dietitian (RD) explained that an air gap is necessary to prevent gases or bacteria from entering the prep sink area through the pipeline, which could contaminate food and potentially cause illness among residents. The facility's policy and procedure, as well as the FDA Food Code, require backflow prevention through an air gap to prevent contamination. Despite this requirement, the facility did not have the necessary air gap installed, posing a risk of food-borne illness to the residents.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) did not provide adequate privacy during personal hygiene care. During an observation, it was noted that the door to the resident's room was open, and the resident's buttocks were exposed and visible from the hallway. The privacy curtain was not fully drawn, leaving the resident exposed to visitors, staff, and other residents. The CNA acknowledged that the privacy curtain was stuck and admitted to not ensuring the door was closed to provide the necessary privacy. The resident involved had been admitted with diagnoses including unspecified dementia and psychosis, with a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Interviews with the Director of Staff Development and the Director of Nursing confirmed that the CNA should have ensured the resident was covered and the door was closed, especially since the privacy curtain was not functioning properly. The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Resident Neglect Due to Lack of Catheter Supplies
Penalty
Summary
The facility failed to ensure that Resident 19 was free from neglect when he did not receive the necessary supplies to conduct his suprapubic catheter care. Resident 19, who was diagnosed with quadriplegia, neuromuscular dysfunction of the bladder, and depression, was admitted to the facility with the ability to change his own suprapubic catheter with staff supervision. Despite being independent and having no cognitive impairment, as indicated by a BIMS score of 15, Resident 19 was left soiled with urine after requesting supplies from three staff members, none of whom provided the necessary items. Interviews with various staff members, including an LVN, CNA, RN, ADON, and DSD, confirmed that Resident 19 was independent and capable of managing his own catheter care. The staff acknowledged that they neglected to provide the supplies when requested, which led to Resident 19 being upset and embarrassed due to his soiled condition. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and ensuring they are free from neglect, which was not upheld in this instance.
Failure to Notify LTC-Ombudsman of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman office of a resident's transfer to the hospital. This deficiency was identified during a review of the records for a resident who was transferred to an acute care facility for treatment of a urinary tract infection. The resident, who had severe cognitive impairment, was admitted to the facility with diagnoses including hydronephrosis, infection due to nephrostomy, and diabetes mellitus. Despite the transfer, the facility did not send a copy of the transfer notification to the local LTC-Ombudsman office, leaving them unaware of the resident's emergency transfer. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the LTC-Ombudsman of hospital transfers. A Licensed Vocational Nurse and the Director of Staff Development both stated they were unaware of this requirement. The Director of Nursing acknowledged that the LTC-Ombudsman should have been notified, as they are there to assist residents in case issues arise. A professional reference from CMS clarified that notices for emergency transfers must be sent to the Ombudsman, highlighting the facility's failure to comply with this requirement.
Failure to Transmit MDS Assessment for Discharged Resident
Penalty
Summary
The facility failed to meet the required timelines for encoding, completion, and transmission of Minimum Data Set (MDS) assessments for a resident, identified as Resident 58. The Minimum Data Set Nurse (MDSN) did not complete or transmit the discharge MDS assessment for Resident 58, who was discharged to home. During an interview and record review, it was revealed that the last assessment for Resident 58 was a quarterly assessment dated April 11, 2024, and no discharge assessment was completed or transmitted when the resident was discharged on May 1, 2024. The MDSN admitted to not having reviewed the MDS schedules and was unaware of the missing discharge assessment until the review. The Director of Nursing (DON) and the Administrator (ADM) both acknowledged that the MDSN was responsible for ensuring all MDS assessments were completed and transmitted in a timely manner. The facility's policy and procedure on MDS Completion and Submission Timeframes indicated that assessments should be conducted and submitted in accordance with federal and state guidelines. The failure to complete and transmit the discharge assessment for Resident 58 resulted in the potential harm of the resident's needs upon discharge going unmet.
Failure to Re-evaluate and Document PASARR for Resident
Penalty
Summary
The facility failed to re-evaluate and document the current condition for Level I Preadmission Screening and Resident Review (PASARR) for a resident, which is a federal requirement to ensure residents with mental disorders or intellectual disabilities are not inappropriately placed in a nursing home. The resident in question was admitted with diagnoses including unspecified dementia, psychosis, depression, and anxiety. Despite these diagnoses and the prescription of psychotropic medications, the resident's PASARR Level I indicated no diagnosis of mental disorder, highlighting a discrepancy in the documentation. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASARR assessments. The Business Office Manager, who was new and part-time, was unfamiliar with the PASARR process, and the Assistant Director of Nursing was unsure who was responsible for completing the assessments. The Director of Nursing acknowledged the absence of a designated person for PASARR completion, and the Administrator expressed the need for staff training on PASARR assessments. The facility's policy required screening for mental disorders upon admission, but this was not effectively implemented, leading to the deficiency.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails for one resident, identified as Resident 59, who had moderate cognitive impairment. The resident was observed using the right side rail on multiple occasions to reposition himself and place his urinal. Despite this, there was no documented physician's order, care plan, safety evaluation, or informed consent for the use of the side rail. Interviews with staff, including CNAs and an LVN, confirmed that the necessary procedures and documentation were not completed prior to the use of the side rail. The facility's policy on bed safety and bed rails, dated August 2022, prohibits the use of bed rails unless specific criteria are met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. However, these steps were not followed for Resident 59, as confirmed by the MDS Coordinator and the Director of Nursing. The lack of proper assessment and documentation had the potential to place the resident at risk for decreased freedom of movement, entrapment, and/or injury.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide acetylsalicylic acid 325 mg to a resident who had an order for this medication to prevent blood clots. This deficiency was identified when the medication was found to be missing during an observation and interview with a Licensed Vocational Nurse (LVN) in front of the resident's room. The LVN confirmed that the medication was not available, and the Director of Nursing (DON) indicated that the Associate Director of Nursing (ADON) was sent to a local pharmacy to obtain the medication. Interviews with the Skilled Nursing Pharmacy Consultant (SN PC) and the ADON revealed that the responsibility for re-ordering medications lies with the facility's nurses. The SN PC stated that nurses should reorder medications before they run out, and the ADON confirmed that either the ADON or RN supervisor is responsible for ordering over-the-counter medications. The ADON also stated that a full bottle of medication should always be available before the supply runs out. A review of the resident's Medication Administration Record (MAR) confirmed the order for acetylsalicylic acid 325 mg daily, and the facility's policy indicated that medications should be reordered at least three days before the last dose is administered.
Failure to Maintain LAL Mattress Cover
Penalty
Summary
The facility failed to maintain a low air loss (LAL) mattress cover sheet in good condition for one of the residents, leading to a potential malfunction of the mattress. The LAL mattress, which is designed to prevent skin breakdown by distributing the patient's body weight, had a tear where the resident rested his head. This issue was identified during an observation and interview with a certified nursing assistant (CNA), who noted the wear and tear on the mattress cover and acknowledged the importance of the LAL mattress for the resident due to past skin problems. Interviews with various staff members, including CNAs, a licensed vocational nurse (LVN), the infection preventionist (IP), the director of nursing (DON), and the director of staff development (DSD), confirmed that the LAL mattress cover should not have been torn. They emphasized that a torn cover could affect the mattress's functionality and cleanliness, potentially leading to skin breakdown for the resident. The facility's policy on bed safety also indicated that any worn or malfunctioning bed system components should be repaired or replaced, which was not adhered to in this case.
Non-Compliance with Resident Room Capacity Regulations
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey conducted from September 9 to September 13, 2024, it was observed that eight rooms each housed more than four residents, specifically accommodating eight residents per room. This arrangement was made to cater to the residents' particular care needs and comfort. Despite the non-compliance, the facility ensured that wheelchairs and toilet facilities were accessible, and a reasonable amount of privacy and adequate storage space were provided. The staff reported no issues with providing care, and residents did not express concerns about personal space. Interviews with residents and staff revealed that the residents felt they had privacy when needed, and the staff did not encounter difficulties in delivering care. A resident expressed satisfaction with the shared room arrangement, and a CNA confirmed that each resident had personal storage space. An LVN noted that while the rooms were spacious enough for care, privacy curtains did not always close completely. An EVS staff member stated that there was ample room for cleaning. Despite these observations, the facility's room arrangements did not meet the regulatory requirements, leading to the deficiency noted in the report.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse in accordance with its Abuse Prevention Program policy. A Licensed Vocational Nurse (LVN) overheard a resident alleging on the phone that staff were hitting her and reported this to the Administrator (ADM) on 5/14/24. Despite this, the facility did not notify the appropriate agencies of the abuse allegation within the required 24-hour timeframe. The Social Service Director (SSD) was also aware of the allegation and informed the ADM on the same day. However, the ADM acknowledged that the report should have been made to the California Department of Public Health (CDPH) by 5/15/24, but it was not done within the stipulated time. The resident involved had a moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. During an interview on 5/16/24, the resident reiterated that staff were hitting her. The facility's policy on abuse prevention, which mandates timely and thorough investigations and reporting of abuse allegations, was not followed. The ADM confirmed that the facility follows an All Facilities Letter (AFL) guideline requiring abuse allegations to be reported within 24 hours, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twilight Haven | 2.2 mi | — | 0 | 0 |
| Stonehaven Senior Living | 2.2 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 2.7 mi | ★★★★★ | 18 | 0 |
| Pacific Gardens Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 30 | 0 |
| Evergreen Care Center | 3.1 mi | ★★★★★ | 2 | 0 |
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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.