Joshua Tree Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Yucca Valley, California.
- Location
- 8515 Cholla Ave, Yucca Valley, California 92284
- CMS Provider Number
- 555772
- Inspections on file
- 40
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Joshua Tree Post Acute during CMS and state inspections, most recent first.
A resident with Alzheimer's, dementia, and gout was found unable to reach their call light, which was on the floor. This was confirmed by a Resource Respiratory Therapist and was against the facility's policy, as noted by the Chief Nursing Officer.
A resident with dementia and hypertension was left unattended with an uncovered breakfast tray, contrary to her care plan which required assistance during meals. The oversight was confirmed by staff, including a CNA who admitted forgetting to assist the resident, and the CNO acknowledged the facility's policy was not followed.
The facility failed to administer a prescribed medication for constipation to a resident due to unavailability from the pharmacy, and the nurse incorrectly documented its administration. Additionally, another resident's wound care was not documented on specific days, suggesting it may not have been performed as ordered. Furthermore, a change in condition evaluation and SBAR communication for a positive wound infection were not completed, contrary to facility policy.
A resident with documented food allergies to cranberries was served cranberry juice, despite clear dietary restrictions. The oversight was acknowledged by staff, including the MDSN and CNO, who confirmed the allergy information was missed during meal service. The facility's policy on food allergies was not followed, posing a risk of allergic reaction.
The facility failed to maintain complete and accurate medical records for two residents. One resident's fall was not followed by an IDT investigation or care plan update, while another resident's MAR inaccurately documented medication administration despite the medication not being available. These actions violated the facility's policies, as confirmed by the CNO.
A resident with dementia was physically abused by an Activities Staff (AS) member who grabbed and yanked her onto her bed, causing fear and distress. The incident was witnessed by a CNA, who reported the AS's rough handling and derogatory comments. The Director of Nursing confirmed the abuse and acknowledged the facility's failure to protect the resident, despite having a policy to prevent such incidents.
A resident with dementia and high fall risk was left unsupervised, resulting in a fall and subdural hematoma. Staff interviews revealed a lack of communication and coordination, with no huddles or briefings occurring. The facility's fall prevention policies were not adequately implemented, leading to the incident.
The facility failed to ensure two rooms were clean, sanitary, and homelike. One room had missing wooden trim exposing unpainted drywall, while another had a section of wall, ceiling, and windowsill with exposed drywall and chipping paint. The Infection Control Practitioner acknowledged the damage and stated a work order had been submitted.
The facility failed to provide proper treatment and assistive devices for a resident with Alzheimer's and unspecified hearing loss. Despite documented hearing difficulties and a care plan intervention to refer to audiology, no order for a hearing consult was placed, resulting in the resident being unable to appropriately express his needs.
The facility failed to date the blood glucose monitor's control solutions, leading to potential inaccuracies in blood sugar monitoring. The LVN and DON confirmed that the controls were opened without being dated, which could result in expired solutions being used.
The facility failed to ensure proper hand hygiene during medication administration and resident care tasks for two residents. An LVN did not perform hand hygiene before moving the medication cart, preparing medication, entering or exiting the resident's room, or after disposing of refused medication. Additionally, the LVN did not perform hand hygiene between caring for two residents, including before and after blood glucose monitoring and glove removal.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure the call light was accessible for Resident 9, as observed during a survey. Resident 9, who was admitted with Alzheimer's disease, dementia, and gout, was found unable to reach the call light, which was on the floor next to the bed. This observation was confirmed during an interview with the Resource Respiratory Therapist, who acknowledged that the call light should not be on the floor. The facility's policy and procedure for answering call lights, which requires ensuring the call light is accessible to residents when in bed, was not followed, as confirmed by the Chief Nursing Officer during a review of the policy.
Failure to Assist Resident During Mealtime
Penalty
Summary
The facility failed to provide necessary assistance during mealtime for a resident, identified as Resident 50, who was unable to perform activities of daily living independently. Resident 50, a female with dementia and hypertension, was at risk for malnutrition according to her care plan, which required staff to set up her meal tray and provide assistance and verbal cues during meals. On the morning of September 18, 2024, Resident 50 was observed lying in bed asleep with an uncovered and untouched breakfast tray left on her bedside table for over twelve minutes, compromising the quality and temperature of the meal. Interviews with facility staff revealed that the breakfast tray was delivered by CNA 2, who admitted to leaving it uncovered and unattended, forgetting to return to assist Resident 50. The Procurement Director confirmed the tray was left unattended, and CNA 1, who was not assigned to Resident 50, acknowledged the oversight and offered assistance. The Chief Nursing Officer confirmed that the facility's policy and procedure for activities of daily living, which mandates providing necessary services to maintain good nutrition, was not followed by the staff.
Medication and Wound Care Documentation Deficiencies
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, resulting in deficiencies. For one resident, the medication Linzess, prescribed for constipation, was not available from the pharmacy and was not administered as ordered by the physician. This oversight occurred over a period of four days, during which the medication was not delivered, and the nurse mistakenly documented that it had been given. The facility's policy requires that medications be administered as prescribed, but this was not adhered to, placing the resident's health and safety at risk. Another resident did not receive proper wound care treatment as documented in the Treatment Administration Record (TAR). The TAR lacked documentation for wound care on specific days, indicating that the treatment may not have been performed as ordered by the physician. The facility's policy mandates that wound care be documented in the resident's clinical record at the time of administration, but this was not followed. The Chief Nursing Officer acknowledged the missing documentation and stated that the nurses are expected to carry out and document treatments as per physician's orders. Additionally, the facility failed to complete a Change in Condition Evaluation and an SBAR communication form for a positive wound infection in the same resident. The facility's policy requires documentation of any change in condition and the use of SBAR for communication, but these were not completed. The Chief Nursing Officer admitted that a change of condition should have been initiated for the wound infection, and the lack of documentation was an oversight. This failure to document and communicate changes in the resident's condition could lead to unidentified complications.
Failure to Adhere to Dietary Restrictions for Resident with Food Allergies
Penalty
Summary
The facility failed to adhere to dietary restrictions for a resident with documented food allergies, specifically to cranberries. The resident, who was admitted with conditions including paroxysmal atrial fibrillation, asthma, and gastroesophageal reflux disease, was served cranberry juice despite having a known allergy to it. This incident was observed when the resident complained about her breakfast tray containing cranberry juice, which was confirmed by the Medical Data Set Nurse (MDSN) who promptly removed the juice and acknowledged the oversight. Interviews with various staff members, including the Chief Nursing Officer (CNO) and Licensed Vocational Nurses (LVNs), revealed that the dietary restrictions were clearly stated on the resident's diet card, yet were overlooked during meal service. The facility's policy and procedure on food allergies, which mandates the identification and substitution of allergens, was not followed. Staff members admitted to missing the allergy information while focusing on other dietary aspects, leading to the potential risk of a serious allergic reaction for the resident.
Incomplete and Inaccurate Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for two residents, leading to potential risks. Resident 48 experienced a fall on August 21, 2024, which was not followed by an interdisciplinary team (IDT) investigation or recommendations, as required by the facility's policy. The resident's care plan, which should have been updated to reflect the fall and any new risk factors, remained unchanged since June 4, 2024. Interviews with the Minimum Data Set Nurse and the Chief Nursing Officer confirmed the absence of IDT meeting notes and the failure to adhere to the facility's fall prevention and management policies. Resident 49's medication administration record (MAR) contained inaccuracies, as it documented the administration of Linzess on September 17 and 18, 2024, despite the medication not being available from the pharmacy. During a medication cart inspection, the medication was not found, and the Licensed Vocational Nurse admitted to mistakenly documenting the administration. The facility's policies on documentation and medication administration, which require accurate and chronological recording of care and reasons for withheld medications, were not followed, as confirmed by the Chief Nursing Officer. These documentation failures for Residents 48 and 49 had the potential to result in missed interventions, inaccurate medication counts, and unaddressed adverse side effects. The facility's policies and procedures, reviewed in December 2023, were not adhered to, as acknowledged by the Chief Nursing Officer during interviews and record reviews.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from physical abuse by an Activities Staff (AS) member. During an unannounced visit, it was found that the AS grabbed the resident's right arm and yanked her down onto her bed, causing the resident to experience fear and abuse. The incident was witnessed by a Certified Nursing Assistant (CNA), who reported that the resident, diagnosed with dementia, was not supposed to walk without assistance. The CNA observed the AS enter the room, grab the resident roughly, and pull her towards the bed, leading to the resident stumbling onto it. The AS then left the room after making derogatory comments about the resident. The Director of Nursing (DON) confirmed that the AS acted abusively towards the resident and acknowledged the facility's failure to protect the resident from abuse. The AS resigned from her position via text message and was unavailable for an interview. The facility's policy on abuse prevention and prohibition, dated January 2024, states that residents have the right to be free from abuse and that the facility will provide oversight to ensure staff deliver care that respects residents' rights. However, this policy was not adhered to in this instance, resulting in the deficiency.
Failure to Implement Fall Prevention Policies
Penalty
Summary
The facility failed to implement their fall prevention policies and procedures for a resident, resulting in a fall and subsequent injury. The resident, who had dementia, lack of coordination, and muscle weakness, was admitted to the facility with a high risk for falls. Despite this, the resident was left unsupervised and was found on the floor with both wheelchair locks in the unlocked position, leading to a subdural hematoma and necessitating admission to the ICU for a higher level of care. Interviews with staff revealed a lack of communication and coordination regarding the resident's care. Certified Nurse Assistants (CNAs) reported that no huddles or briefings occurred on the day of the incident or on other days, which contributed to the lack of supervision. The facility's policies required high fall risk residents to be mentioned in every huddle for reinforcement, but this was not followed. The facility's policies and procedures for fall prevention and safety were not adequately implemented. The resident's care plan indicated the need for frequent visual checks and supervision, but these interventions were not effectively communicated or executed. The failure to adhere to these protocols directly led to the resident's fall and subsequent injury.
Facility Failed to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure two of 25 rooms were clean, sanitary, and homelike. In one room, an entire section of wooden trim was missing along the back wall and headboard wall, exposing unpainted drywall. In another room, a 2-foot by 4-foot section of wall, ceiling, and windowsill was unpainted with exposed drywall and chipping paint. During an observation and interview, the facility's Infection Control Practitioner acknowledged the damage and stated that a work order had been put in to fix it. The facility's policy on maintaining a homelike environment was not adhered to, as evidenced by the observed damage and lack of timely repair.
Failure to Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain hearing ability for Resident 10. Resident 10, who was admitted with Alzheimer's disease, dementia, and unspecified hearing loss, was observed without hearing aids and expressed difficulty in hearing. The Minimum Data Set (MDS) indicated moderate hearing difficulty and no hearing aid, and the care plan noted a communication problem related to hearing deficit with an intervention to refer to audiology for a hearing consult. However, no order for an audiology consult was ever placed, as confirmed by the Licensed Vocational Nurse (LVN) and the Medical Records Director (MRD). During interviews and record reviews, it was revealed that Resident 10's hearing difficulties had worsened over time, yet no action was taken to address this issue. The lack of an audiology consult order and the absence of hearing aids resulted in Resident 10 being unable to appropriately express his needs. This oversight highlights a significant deficiency in the facility's care for Resident 10's hearing needs.
Failure to Date Blood Glucose Monitor Control Solutions
Penalty
Summary
The facility failed to ensure that the blood glucose monitor's control solutions were dated with an open date. During an observation and interview at 06:00 AM, it was noted that the glucometer controls on medication cart #2 had been opened and used but did not have an open date written on the bottles or the box. The Licensed Vocational Nurse (LVN) stated that the controls were opened about a week ago and should have been dated but were not. The LVN further mentioned that registry personnel and other staff would not be able to identify when these controls were opened, and the control solution would be discarded after 90 days of opening. During a subsequent interview and record review at 10:00 AM, the Director of Nursing (DON) confirmed that the glucose controls are only good for three months after opening and should be labeled with the date opened and the date expired. The [name of brand] Glucose Monitoring System User's Guide also indicated that control solutions should be discarded three months after opening or by the expiration date on the bottle, whichever comes first. The failure to label the control solutions with the open date could lead to inaccurate blood glucose results for residents requiring blood sugar monitoring.
Failure to Perform Hand Hygiene During Medication Administration and Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during medication administration and resident care tasks for two residents. During an observation, a Licensed Vocational Nurse (LVN) did not perform hand hygiene before moving the medication cart, preparing medication, entering or exiting the resident's room, or after disposing of refused medication. Additionally, the LVN did not perform hand hygiene between caring for two residents, including before and after blood glucose monitoring and glove removal. In an interview, the LVN admitted to not recalling if hand hygiene was performed during these tasks and acknowledged that hand washing should be done to prevent infection spread. The facility's policy on hand hygiene, reviewed with the Director of Nursing (DON), indicated that hand hygiene is essential before and after resident contact, performing aseptic tasks, and glove removal. The DON confirmed that hand hygiene should be performed upon entering and exiting a resident's room and when administering medication or performing resident care.
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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