Hillcrest Heights Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 4033 Sixth Avenue Ext, San Diego, California 92103
- CMS Provider Number
- 555630
- Inspections on file
- 46
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hillcrest Heights Healthcare Center during CMS and state inspections, most recent first.
A resident with vascular dementia and substance abuse history, identified as high risk for elopement, was able to leave the facility unnoticed through an unlocked and unalarmed front door. Staff responsible for monitoring the entrance were either not present or unaware of the resident's risk. After being found in the community and hospitalized, the resident was discharged back to the facility by taxi without supervision, and did not enter the building, remaining unattended until located by emergency services. The facility lacked procedures for ensuring safe transportation and adequate supervision for high-risk residents.
A resident with significant ADL needs and incontinence was discharged to a sober living facility that did not provide medical or physical assistance, despite staff and documentation indicating the resident required substantial support. The resident expressed concerns about the discharge, which were not addressed, resulting in an unsafe transfer, a 911 call, hospitalization, and readmission to the facility.
A resident with hemiplegia was discharged without an effective discharge plan, resulting in the resident feeling rushed, unheard, and unprepared. The Social Service Director scheduled the discharge and arranged transport without addressing the resident's concerns or creating a care plan, and staff were not properly informed of the discharge process.
Two residents were discharged without the development or implementation of required discharge care plans. One resident, admitted after surgery, and another with hemiplegia, both lacked documented discharge planning in their records. Staff interviews confirmed that care plans were not created as required by facility policy.
A resident with hypertension developed rashes and later reported a previous unwitnessed fall with a scalp wound. The LPN documented the rashes but did not notify the physician or monitor the skin changes, and failed to thoroughly assess or document the wound before hospital transfer. The fall incident was also not documented, resulting in delayed care and incomplete records.
A facility failed to ensure proper accountability and administration of medications. Controlled Drug Records did not match Medication Administration Records for several residents, leading to discrepancies in narcotic pain medication documentation. A resident did not receive Creon for 13 days due to an insurance issue, and another resident was given metformin without food, against prescriber's orders.
A resident with pancreatic insufficiency did not receive Creon for 13 days after re-admission to a facility, despite having physician orders. The medication was delivered but not administered, leading to symptoms like oily stool and abdominal pain. Facility records showed multiple entries of the medication being unavailable or incorrectly marked as given, and the resident's discomfort was documented.
The facility failed to honor the food preferences of five residents during a lunch service. A resident who dislikes fish was initially served it, another who prefers double portions received a single portion, and a vegetarian was served meat due to a shortage of veggie patties. Additionally, a resident who dislikes tomato soup was served it, and another who dislikes cranberries received a cranberry dessert. The facility's policy requires adherence to food preferences, which was not initially followed.
A facility failed to maintain accurate medical records for two residents, leading to potential inaccuracies in their medical history. One resident's MARs incorrectly showed doses of Creon administered when the medication was unavailable, while another resident's Dialysis Communication Forms inaccurately documented a graft instead of a Perma-cath. Interviews revealed a lack of training and discrepancies in documentation, highlighting a failure to adhere to the facility's standards for accurate record-keeping.
A resident with dementia was inaccurately coded as a non-smoker on their annual MDS, despite being observed smoking and identified as a smoker in the facility's Smoking Safety Evaluation. The MDSN admitted the oversight, and the DON emphasized the importance of accurate MDS assessments for CMS reporting.
A resident with severe cognitive impairment was observed smoking without the required protective apron, despite facility protocols mandating its use for safety. The smoking monitor, aware of the risk, did not enforce the apron use after the resident expressed displeasure. Facility records and staff interviews confirmed the necessity of the apron to prevent potential accidents.
The facility failed to follow the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. White rice was served instead of brown rice, and two residents did not receive the required fortified additives in their meals until it was pointed out. The facility's policies for menu changes and meal fortification were not properly followed.
A resident who primarily speaks Spanish experienced miscommunication and anxiety due to the facility's failure to develop a comprehensive care plan addressing language barriers. The facility did not utilize available translation resources, leading to confusion during care. The DON acknowledged the oversight, as the resident's admission data indicated the need for a communication care plan, which was not created.
A resident reported $2,400 missing from his room after selling his truck, but the facility failed to conduct a thorough investigation. The Administrator admitted to not interviewing all relevant staff or documenting the investigation properly. The resident's grievance was not resolved in writing, violating the facility's policy on handling grievances.
A resident with a history of falls, dementia, and polyneuropathy experienced unwitnessed falls on two occasions. The facility failed to update the care plan with new interventions, despite the Interdisciplinary Team not determining a specific root cause. The Director of Nursing acknowledged the oversight, which placed the resident at risk for continued falls.
The facility did not inform residents or their representatives about updates to care plans and physician's orders after water tested positive for Legionella bacteria. Despite having care plans for monitoring signs of Legionnaires' disease, residents with chronic conditions were not notified, violating the facility's policy on resident rights.
Failure to Prevent Elopement and Ensure Safe Return of High-Risk Resident
Penalty
Summary
A facility failed to provide adequate supervision and ensure a safe environment for a resident assessed as high risk for elopement. The resident, who had vascular dementia and a history of psychoactive substance abuse, was identified on admission as ambulatory with exit-seeking behaviors and a desire to leave the facility. Despite being listed as high risk in the facility's elopement binder, the resident was able to leave the facility unnoticed through an unlocked and unalarmed front door, which was routinely left open during the day. Staff responsible for monitoring the entrance, including receptionists and nursing staff, were either not present or unaware of the resident's elopement risk at the time of the incident. The resident was later found in the community and required emergency department evaluation after testing positive for methamphetamine. Further deficiencies were observed in the facility's handling of the resident's return from the hospital. The facility did not confirm the type of transportation arranged for the resident, who was discharged by taxicab without supervision, despite the known elopement risk. Staff did not meet the resident upon arrival, and the resident did not enter the facility, remaining unattended in the community until located by emergency services. The facility lacked a policy or procedure for ensuring safe or supervised transportation for high-risk residents returning from the hospital, and staff interviews revealed a lack of clarity and responsibility regarding this process. Observations and interviews also revealed that the facility's front entrance was frequently left unlocked and unalarmed, with the expectation that the receptionist would monitor the entrance. However, the reception desk was sometimes left unattended, and staff acknowledged this presented a safety issue for residents at risk for elopement. Additionally, some staff were unaware of which residents were classified as high risk for elopement, and the resident in question was not wearing a wander guard bracelet prior to the incident. The facility's elopement policy did not address verification of safe or supervised transportation for returning residents at risk for elopement.
Failure to Ensure Safe and Coordinated Discharge for Dependent Resident
Penalty
Summary
The facility failed to ensure a safe and coordinated discharge for a resident who required substantial assistance with activities of daily living (ADLs), including dressing, transferring, bathing, toileting, and was frequently incontinent of urine and bowel. Despite the resident's documented need for significant support and his own expressed concerns about the appropriateness of the discharge destination, facility staff informed him that he needed to leave due to insurance issues and being considered 'high functioning.' The resident was discharged to a sober living facility that did not provide any medical or physical assistance and required residents to be independent in all ADLs. Interviews with certified nursing assistants confirmed that the resident was always incontinent, never used the bathroom independently, and required help with showering, dressing, and transfers. The social services director acknowledged that the resident had voiced concerns about the lack of support at the sober living facility, but the case manager assured him that caregivers would be available, which was not accurate. Upon arrival at the sober living facility, staff there were surprised by the resident's care needs, as they had been informed he was independent and ambulatory. The facility representative stated they would not have accepted the resident had they known the extent of his needs. The resident was unable to receive necessary care at the sober living facility, leading to a 911 call and transfer to the hospital, after which he was readmitted to the skilled nursing facility. The facility's own policy required the care planning team to assess the availability and capability of caregivers at the discharge location and to address factors that could make the resident vulnerable to preventable readmission, which was not followed in this case.
Failure to Develop and Communicate Effective Discharge Plan
Penalty
Summary
The facility failed to develop an effective discharge plan that ensured a resident's discharge goals were identified and addressed. The resident, who had hemiplegia, was informed by the Social Service Director (SSD) only one day prior to discharge that he would be leaving the facility. Despite expressing concerns regarding finances and the need for a wheelchair, the resident felt that the SSD did not listen or address these issues. The resident was also unaware of his discharge destination and had to contact family members himself to inform them of the impending discharge. Staff interviews revealed a lack of communication and preparation for the discharge. The Certified Nursing Assistant (CNA) was not informed of the discharge by the licensed nurse, learning about it from another resident instead, and had to hurriedly gather the resident's belongings. The licensed nurse was also unaware of the discharge until reviewing the medical record, which showed that the SSD had scheduled the discharge and arranged transport without a care plan or physician's order. The SSD acknowledged that a discharge care plan should have been created and that the resident's preferences were not considered. The facility's policy requires advance preparation and a post-discharge plan, which was not followed in this case.
Failure to Develop and Implement Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement discharge care plans for two of three sampled residents. For the first resident, who was admitted following surgery, there was no evidence in the medical record that a discharge care plan was created prior to their discharge. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that a discharge care plan should have been completed at admission, but was not present for this resident. The second resident, admitted with hemiplegia, was observed on the day of discharge without knowledge of their discharge destination. A review of this resident's medical record also revealed the absence of a discharge care plan. The SSD confirmed that a discharge care plan was not developed for this resident, despite facility policy requiring a baseline care plan within 48 hours of admission and a comprehensive, person-centered care plan to be implemented for each resident.
Failure to Notify Physician and Document Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition and to monitor skin changes for a resident who developed rashes on the head and above the forehead. Documentation showed that a licensed nurse noted the rashes but did not provide evidence of physician notification or ongoing monitoring. Additionally, the same resident reported a previous unwitnessed fall and a wound on the scalp, but there was no detailed assessment or documentation of the wound's appearance or size prior to the resident's transfer to the hospital. The medical record also lacked documentation of the fall incident itself. An interview with the Assistant Director of Nursing confirmed that changes in condition, such as falls, rashes, or wounds, should be reported to physicians and thoroughly documented, including detailed wound observations. The facility's policy requires prompt physician notification and comprehensive documentation of observations prior to contacting the provider. The lack of documentation and physician notification resulted in delayed care and incomplete medical records for the resident.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications and the accurate and timely administration of resident medications. For four residents, the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR), leading to discrepancies in the documentation of narcotic pain medications. Specifically, doses of oxycodone and hydrocodone with acetaminophen were signed out but not documented as administered in the MAR, raising concerns about potential duplicate administration and lack of proof that residents received their medications. Additionally, the facility did not provide a resident with Creon, a medication for pancreatic insufficiency, for 13 days due to an insurance coverage issue. The resident was discharged from the hospital with a new prescription for Creon, but the facility failed to follow up with the pharmacy in a timely manner to resolve the insurance issue and obtain the medication. The resident did not receive the medication until the facility signed an authorization form to pay for the medication, resulting in a delay in the management of the resident's pancreatic insufficiency. Furthermore, a resident was administered metformin, a diabetes medication, without food, contrary to the prescriber's orders. The medication was given before lunch, which had not yet started, potentially leading to gastrointestinal side effects. The facility's policy requires medications to be administered in accordance with orders, including any specified time frames, but this was not adhered to in this instance.
Failure to Administer Creon Leads to Resident's Digestive Symptoms
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they did not administer Creon, a medication for pancreatic insufficiency, to a resident for 13 days. The resident had been discharged from the hospital with a new prescription for Creon to be taken with meals and snacks due to pancreatic insufficiency. Despite having physician orders for the medication, the resident did not receive it upon re-admission to the facility, leading to digestive symptoms such as oily stool, abdominal pain, and nausea. Interviews and record reviews revealed that the pharmacy delivered the medication to the facility, but it was not administered to the resident. The Consultant Pharmacist and other pharmacists confirmed the delivery and the importance of the medication for the resident's condition. The Director of Nursing and Medical Director were informed of the missed doses, and the facility's records showed multiple entries indicating the medication was not available or incorrectly marked as administered. The resident experienced significant discomfort and symptoms due to the lack of medication, including abdominal pain and oily stools. The facility's policies on medication administration and error handling were not followed, as the medication was not given in accordance with the physician's orders, and the physician was not promptly informed of the missed doses. The resident's medical records and care plans documented the missed doses and the subsequent notification to the medical staff, highlighting the facility's failure to administer the medication as prescribed.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of five residents during a lunch service, as observed on 1/8/25. Resident 1, who dislikes fish, was initially served fish before it was replaced with a hamburger patty. Resident 11, who prefers double portions of meat, fish, or eggs, was served a single portion of fish, which was later corrected. Resident 75, who dislikes tomato soup, was served it before it was removed. Resident 151, a vegetarian, was served a meat patty instead of a veggie patty due to a shortage, which was later rectified. Resident 49, who dislikes cranberries, was served a cranberry dessert, which was replaced with vanilla ice cream. Interviews with the residents revealed that some were losing weight and had specific dietary preferences that were not initially honored. The Food Nutrition Service Manager and the Registered Dietician both stated that resident food preferences should be respected, as it is a resident's right. The facility's policy mandates that food preferences be adhered to within reason, with initial screenings to be completed within seven days of admission. The failure to adhere to these preferences was identified during a lunch tray line observation and subsequent interviews with the residents and staff.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure accurate and concise medical records for two residents, leading to potential inaccuracies in their medical history and response to care. For Resident 30, the Medication Administration Records (MARs) incorrectly indicated that nine doses of Creon, a medication for pancreatic insufficiency, were administered between December 25, 2024, and January 9, 2025, when the medication was not available and had not been administered. Interviews with Resident 30 and the Director of Nursing (DON) confirmed that the first dose was given on January 7, 2025, contradicting the MAR entries. A physical count of the Creon capsules further verified the discrepancy, as the number of capsules remaining did not align with the documented administrations. For Resident 71, the facility's Dialysis Communication Forms inaccurately documented the presence of a graft instead of a Perma-cath, which is the actual dialysis access site for the resident. This error was found in five out of sixteen forms reviewed, spanning from December 3, 2024, to January 7, 2025. Interviews with the Director of Staff Development (DSD) and Licensed Nurses (LN) revealed a lack of in-service training regarding dialysis access sites, contributing to the documentation errors. The DON acknowledged the importance of accurate post-dialysis assessments to identify potential complications and confirmed the inaccuracies in the documentation. The facility's policies on charting and documentation emphasize the need for complete and accurate records to facilitate communication among the interdisciplinary team. However, the discrepancies in the MARs for Resident 30 and the Dialysis Communication Forms for Resident 71 highlight a failure to adhere to these standards, potentially leading to confusion and miscommunication regarding the residents' conditions and treatments.
Inaccurate MDS Coding of Resident's Smoking Status
Penalty
Summary
The facility failed to accurately assess and code a resident's smoking status on their annual Minimum Data Set (MDS), a clinical assessment tool required by the Centers for Medicare and Medicaid Services (CMS). The resident, who was admitted with a diagnosis of dementia, was observed smoking on multiple occasions, both with and without a protective smoking apron, under the supervision of a smoking monitor. Despite these observations and a facility Smoking Safety Evaluation identifying the resident as a smoker, the MDS inaccurately indicated that the resident was not a user of tobacco products. The Minimum Data Set Nurse (MDSN) acknowledged the error during an interview, stating that the resident's smoking status was missed during the assessment process. The Director of Nursing (DON) expressed an expectation for MDS assessments to be accurate to ensure CMS has a correct understanding of the resident's current health status. The inaccurate coding of the resident's smoking status on the MDS had the potential to misinform CMS about the resident's health condition.
Failure to Ensure Resident Safety During Smoking
Penalty
Summary
The facility failed to ensure the safety of Resident 50, who was identified as requiring a smoking apron while smoking, to prevent potential accidents. Resident 50, diagnosed with dementia and having severe impaired cognition, was observed smoking without the required protective apron on one occasion, despite being supervised by a smoking monitor. The smoking monitor admitted to not enforcing the use of the apron after Resident 50 expressed displeasure, even though the monitor was aware of the potential risk of the resident's clothing catching fire. The facility's records, including the Smoking Safety Evaluation and care plan, clearly indicated that Resident 50 was a smoker who required a smoking apron for safety. Interviews with the smoking monitor, a licensed nurse, and the Director of Nursing confirmed that the apron was a necessary safety measure. The facility's policy mandated that residents identified as needing assistance for smoking safety should not smoke unsupervised, and the apron was part of the required supervision. Despite these protocols, the failure to ensure Resident 50 wore the apron while smoking constituted a deficiency in resident safety measures.
Failure to Follow Menu and Provide Fortified Meals
Penalty
Summary
The facility failed to adhere to the posted menu and provide fortified meals as ordered for two residents, potentially compromising their nutritional needs. During a lunch tray line observation, it was noted that white rice was served instead of the brown rice listed on the menu. The cook admitted to not closely reviewing the menu and preparing white rice without notifying the Registered Dietician, who confirmed that brown rice is more nutritious. The facility's policy requires that any menu changes be approved by the Registered Dietician or the Food Nutrition Service Director, which was not followed in this instance. Additionally, two residents did not receive the fortified meals as prescribed. Resident 32, diagnosed with moderate protein-calorie malnutrition, was served a meal without the required fortified additive, which was only added after being pointed out. Similarly, Resident 86, with a diagnosis of a displaced fracture, was served a meal lacking the fortified additive until it was noticed and corrected. The Food Nutrition Service Manager and Registered Dietician both emphasized the importance of fortified foods for residents experiencing weight loss, as they provide necessary additional calories. The facility's policy outlines the process for identifying residents needing fortification and the addition of calories or protein to their meals, which was not properly executed in these cases.
Failure to Develop Comprehensive Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who primarily communicates in Spanish, which had the potential to cause psychosocial harm. During an interview, the resident expressed difficulty in communicating with a CNA who did not understand Spanish, leading to confusion and anxiety during care. The facility's procedure for language barriers was not followed, as the language line or other translation resources were not utilized, resulting in miscommunication about the resident's needs. The Director of Nursing acknowledged that the resident's admission Minimum Data Set indicated a need for a communication care plan, which was not created. This oversight was attributed to a missed step in the care planning process. The facility's policy required care plan interventions to be based on a comprehensive assessment, but in this case, the necessary communication care plan was absent, impacting the quality of care provided to the resident.
Inadequate Investigation of Missing Money Grievance
Penalty
Summary
The facility failed to thoroughly investigate an allegation of missing money for a resident, leading to a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal. The resident, who had a cognitive score indicating intact cognition, reported that $2,400 was missing from his room after he had hidden it in a shoe. The resident had received the money from selling his truck and had asked the Social Service Director for assistance in opening a savings account, which was not provided. The resident reported the missing money to a charge nurse and filed a grievance with the Social Service Director, but there was limited documentation of the investigation. The facility's investigation into the missing money was inadequate. The Administrator admitted to not conducting a thorough investigation, as only two staff members were interviewed, and no written statements were taken. The facility did not contact the family friend who sold the truck to verify the transaction, and there was no documented evidence of a written resolution to the grievance. The Business Office Manager stated that residents were provided with instructions about safeguarding valuables, but the resident was not informed of this policy. Interviews with staff revealed inconsistencies in the handling of the grievance. The charge nurse who received the initial report did not document the incident, and the Manager of the Day was unsure if the incident was reportable. The Administrator acknowledged that the investigation could have been more thorough and that documentation should have been attached to the grievance. The facility's policy required a written response to grievances, which was not provided in this case.
Failure to Update Care Plan for Resident with Falls
Penalty
Summary
The facility failed to update the care plan for a resident who was reviewed for falls, which resulted in a potential risk for further falls and injuries. The resident, who was admitted with diagnoses including repeated falls, dementia, and polyneuropathy, experienced unwitnessed falls on two separate occasions. Despite these incidents, the care plan was not updated with new interventions to prevent future falls. The Assistant Director of Nursing (ADON) acknowledged that the root cause of the falls was attributed to dementia, but no additional interventions were implemented beyond staff in-service training on falls. The Director of Nursing (DON) confirmed that the Interdisciplinary Team (IDT) did not determine a specific root cause for the falls and failed to update the care plan with patient-centered interventions. The facility's policy on falls, which requires continuous evaluation and reconsideration of interventions if falls persist, was not adhered to. This oversight placed the resident at risk for continued falls, as the care plan did not address new strategies to mitigate the risk of falling.
Failure to Inform Residents of Legionella Exposure
Penalty
Summary
The facility failed to notify residents and their representatives about updates to their care plans and physician's orders following exposure to Legionella bacteria. This deficiency was identified during an unannounced onsite visit, where it was discovered that the facility's water tested positive for Legionella bacteria. Despite this, the Assistant Director of Nursing (ADON) confirmed that residents and their families had not been informed of the exposure. The Director of Nursing (DON) also stated that residents did not need to be informed of physician's orders unless there was a change in their condition, although they should be involved in their care planning. Three residents were specifically mentioned in the report. Two of them were readmitted with chronic obstructive pulmonary disease, and one was admitted with chronic congestive heart failure. Physician's orders were obtained for all residents to be monitored for signs and symptoms of Legionnaires' disease, and care plans were developed accordingly. However, the residents and their representatives were not made aware of these updates, which is a violation of the facility's policy on resident rights, which mandates resident and family participation in care planning and notification of health conditions.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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