Kaweah Health Skilled Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 1633 South Court Street, Visalia, California 93277
- CMS Provider Number
- 555396
- Inspections on file
- 19
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Kaweah Health Skilled Nursing Center during CMS and state inspections, most recent first.
Three residents and their legal representatives were not given prior written notice before new roommates were assigned to their rooms. The DON confirmed that there was no documentation of advance notification, which was required by facility policy. This resulted in a violation of residents' rights regarding roommate choice and notification.
A resident with contracted hands was observed to have long, thick, yellow fingernails, and staff interviews confirmed that nail care had not been provided for an extended period. Nursing and CNA staff acknowledged the ongoing condition and discomfort in addressing the resident's nail care needs, despite facility policy requiring such care.
Multiple infection control lapses were identified, including damaged linen cart covers exposing clean linen, lack of documented infection surveillance by the IPN, improper wound care technique by a WTN who failed to change gloves and wore a gown in poor repair, a used urinal placed on a bedside table with personal items, and the use of unapproved wipes to disinfect a glucometer, contrary to manufacturer instructions.
A resident who was alert and had a history of lumbar laminectomy experienced prolonged delays in staff response to her call light requests for bathroom assistance, especially around shift changes. Staff sometimes turned off the call light without providing help, and the resident reported feeling unimportant and fearful of incontinence due to these delays, contrary to facility policy requiring prompt response.
A resident with severe pain was repeatedly administered pain medication without a physician's order for severe pain, and staff did not notify the physician as required. Licensed staff were unaware of the correct method to verify GTube placement before medication administration for three residents, and a nurse failed to flush a GTube with water between medications, all contrary to facility policy.
A medication cart containing insulin vials was found unlocked and unattended outside the medication room. Both the DON and DOR confirmed that the cart should have been locked, in accordance with facility policy requiring secure storage of medications.
Three unopened pro source protein nutrition products with expired dates were found in a medication room and confirmed by an RN to be available for resident use, contrary to facility policy prohibiting the provision of expired nutrition products.
The facility failed to document potentially hazardous food, remove expired food, date frozen food storage, and sanitize the ice machine according to guidelines. Cooked pasta was not logged, expired Salisbury steak was found, and undated raw chicken was stored improperly. The ice machine was not sanitized as required.
The facility failed to follow its policy on Advance Directives for a resident, resulting in the absence of a documented AD in the resident's EHR. Interviews with staff and the resident confirmed that the process was not followed, posing a risk of inappropriate treatment in an emergency.
A facility failed to accurately complete the MDS for a resident on a planned weight gain regimen. The Registered Dietitian assessed the resident's nutritional needs and determined a daily intake of 2,700 calories to promote weight gain. However, the MDS inaccurately coded the resident's weight gain status, which could impede care planning. The RD acknowledged the error and the facility's policy emphasized the need for accurate assessments.
A facility failed to ensure a resident's head of bed was elevated at least 30 degrees while receiving enteral tube feedings, as required by policy and the resident's individual plan of care. The resident was observed with the head of bed elevated to only 15 degrees, which could lead to aspiration and lung problems.
The facility failed to dispose of expired medications and properly label medications with expiration dates. An expired mouthwash was found in the medication storeroom, and eye drops were administered without an open or expiration date label.
The facility failed to follow individualized meal tray directions for a resident, resulting in the resident receiving mixed vegetables that were not chopped as specified in their meal tray ticket. This was confirmed by the Certified Dietary Manager and was contrary to the resident's physician orders and the facility's diet manual and policy.
The facility policy failed to address residents' right to store outside food, potentially not honoring a resident and/or families' request to store food for later consumption. Staff confirmed that outside food must be approved by a nurse and consumed immediately or discarded, as the facility lacks a refrigerator for storing such food. Policies indicated that potentially hazardous food not consumed by a patient would be discarded within four hours and not stored in patient floor stock refrigerators.
The facility failed to implement proper infection prevention and control measures when two Environmental Service Aides did not ensure that high-touch surface areas were disinfected daily. Observations and interviews revealed inconsistencies in the use of Vindicator disinfectant, with one aide stating handrails were disinfected only once per week, contrary to facility policy and manufacturer's guidelines requiring daily disinfection and a 10-minute dwell time.
The facility failed to maintain the walk-in freezer in Kitchen 1, resulting in persistent ice buildup despite recent repairs. The issue was not reported back to maintenance, and no further repairs were pending, contrary to the manufacturer's guidelines and the facility's preventative maintenance policy.
The facility failed to ensure that empty vials of Heparin were discarded in a designated waste bin for two residents. An LVN confirmed that an empty vial was left unattended on a medication cart and should have been disposed of immediately after administration, contrary to the facility's policy.
Failure to Notify Residents of New Roommates
Penalty
Summary
The facility failed to provide prior written notification to three residents or their legal representatives before assigning new roommates to their rooms. Record reviews showed that after one resident was placed on comfort care and moved to a private room, a new admission was placed in the same room without informing the family. Additionally, documentation for other residents did not show evidence that they or their representatives were notified in advance of new roommates being assigned to their rooms. During interviews, the Director of Nursing confirmed the absence of documentation regarding advance notice for the affected residents. The facility's own policy requires that residents' families or legal representatives be informed prior to any in-room transfers, but this procedure was not followed in these cases. The lack of notification resulted in a violation of the residents' rights to be informed and to have a choice regarding their roommates.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident who was unable to perform self-care, specifically in the area of nail care. During an observation, the resident was found in bed with both hands contracted and all ten fingernails long, thick, and yellow. The Assistant Director of Nurses confirmed the condition of the resident's fingernails. Interviews with a Registered Nurse and two Certified Nursing Assistants revealed that the resident's fingernails had consistently been in this condition, and neither CNA recalled cutting or filing the resident's nails. One CNA expressed discomfort in providing nail care due to the presence of thick, yellow, possibly fungal nails. Review of the facility's policy indicated that nail care is a covered personal service for residents.
Infection Control Failures in Linen Handling, Surveillance, Wound Care, and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to infection prevention and control standards in several key areas. Observations revealed that two of four linen carts in the hallway had damaged vinyl covers with multiple tears and holes, exposing clean linen. Staff, including the Infection Preventionist Nurse (IPN), acknowledged awareness of the issue, and facility policy required daily monitoring and replacement of soiled or damaged covers. Additionally, the IPN was unable to provide documentation or evidence of regular infection control surveillance, audits, or data collection, despite facility policy mandating surveillance data be summarized and reviewed by the Infection Prevention Committee. During wound care for a resident, the Wound Treatment Nurse (WTN) wore a cloth gown missing the necessary ties, which caused the gown to fall off her shoulders and fail as a protective barrier. The WTN also did not change gloves or perform hand hygiene when moving from dirty to clean tasks, contrary to CDC guidelines and facility expectations. The Laundry Manager confirmed that gowns in poor condition should be discarded, and the IPN agreed that such gowns do not provide adequate protection. Further deficiencies included a used urinal being placed on a bedside table next to a resident's personal items, which staff acknowledged was improper, and the use of unapproved disinfectant wipes (CAVI wipes) to clean the glucometer machine after use on two residents. The glucometer's manufacturer required bleach-containing wipes for disinfection, but staff and leadership were unaware of this requirement and used products that did not meet the manufacturer's recommendations. Facility policy required equipment to be cleaned according to manufacturer instructions, which was not followed.
Delayed Call Light Response and Lack of Resident Accommodation
Penalty
Summary
Staff failed to promptly respond to a resident's call light requests for assistance to the bathroom, resulting in prolonged delays of 45 minutes to an hour, particularly around shift changes. The resident reported that staff would enter the room, turn off the call light, and leave without providing assistance, only returning to help approximately thirty minutes after the shift change. The resident expressed fear of potentially urinating on herself due to these delays and described staff as making sighing noises before assisting her, which made her feel unimportant. The resident had a history of lumbar laminectomy and was alert and oriented at the time of the incident. Facility policy required staff to respond promptly to call lights to ensure resident safety and health needs were met in a reasonable amount of time. The facility's admission agreement also required reasonable accommodation of individual needs and preferences. Interviews with staff confirmed that call lights should be addressed when turned off, but this was not consistently done for this resident.
Failure to Meet Professional Standards in Pain Management and GTube Care
Penalty
Summary
The facility failed to provide services that meet professional standards of quality in several instances. One resident experiencing severe pain, as indicated by repeated pain scores of 7 or higher on a 0-10 scale, was administered Norco for pain relief without a physician's order for severe pain. The nurse did not notify the physician regarding the resident's severe pain, and there was no documentation of such communication, despite facility policy requiring staff to communicate unexpected pain findings to the healthcare team. Additionally, licensed staff were unaware of the correct process for verifying gastrostomy tube (GTube) placement prior to medication administration for three residents. Staff incorrectly believed that aspirating for residual formula or using a stethoscope were appropriate methods, whereas facility policy required checking tube markings to verify placement. Furthermore, a nurse failed to flush a GTube with water between administering multiple medications to a resident, contrary to facility policy that mandates a 5 ml water flush between each medication to prevent tube blockage.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart (Medication Cart 1) was observed unlocked and unattended outside the medication room, containing insulin vials. This was witnessed during a survey observation, and both the Director of Nursing and the Director of Rehabilitation confirmed in interviews that the cart should have been locked when not in use. Review of the facility's policy and procedure on medication security indicated that all medications are to be stored securely and that medication carts must be locked when not in use. The failure to keep the medication cart locked resulted in medications being accessible to unauthorized individuals.
Expired Nutritional Products Found Available for Resident Use
Penalty
Summary
The facility failed to ensure that nutritional products available for resident use were not expired. During an observation and interview in the Wing A medication room, three unopened pro source protein nutrition products were found with expiration dates that had already passed. The registered nurse present confirmed that these expired products should not have been available for resident use. A review of the facility's policy and procedure on recall and expired products indicated that expired food and nutrition products are not to be provided to patients and customers.
Food Safety and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and handling of potentially hazardous food, expired food, and frozen food storage. During an observation, a large container of cooked pasta was found in the walk-in refrigerator without being documented on the cool-down log. The Certified Dietary Manager (CDM) and Cook II (CK) confirmed that the pasta was not logged as required by the facility's policy. Additionally, an unopened package of Salisbury steak with an expired use-by date was found in the walk-in freezer, and a large container of frozen raw chicken was found undated. Both the CDM and Diet Clerk (DC) acknowledged these issues, which were against the facility's food labeling and storage policies. Furthermore, the facility failed to sanitize the ice machine in accordance with the manufacturer's guidelines. The Maintenance Employee (MT) stated that he used a product that he believed both cleaned and sanitized the ice machine, but he could not confirm this. Upon review, it was found that the manufacturer's guidelines required a separate sanitizing step, which was not being performed. The CDM confirmed that the ice machine was not sanitized as per the guidelines or the facility's policy on ice machine maintenance.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to follow its policy and procedure on Advance Directives (AD) for one of the 36 sampled residents, Resident 28. During a review of Resident 28's clinical record, it was noted that there was no documented AD. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) 3 revealed that the process for handling ADs was not followed correctly. The DON stated that licensed nurses ask patients about ADs during admission, and if a patient indicates they have one, the information is supposed to be forwarded to the social worker. However, RN 3 was unable to locate the AD in Resident 28's Electronic Health Record (EHR), indicating a breakdown in this process. Further interviews with Resident 28 and Social Services (SS) confirmed the deficiency. Resident 28 stated that he informed the staff about his AD upon admission. SS explained that when nurses mark the AD box during the admission assessment, it should generate a clinical order for the AD, but this did not happen in Resident 28's case. A review of the facility's policy and procedure on ADs, dated 10/16/2022, indicated that the process was not followed as required, leading to the potential risk of Resident 28 not receiving appropriate treatment in an emergency.
Inaccurate MDS Completion for Resident on Planned Weight Gain Regimen
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) for a resident (Resident 23) who was on a planned weight gain regimen. During an interview and record review, it was found that the Registered Dietitian (RD) had assessed Resident 23's nutritional needs and determined a daily intake of 2,700 calories to promote weight gain due to the resident's underweight status. However, the MDS completed on 8/31/23 inaccurately coded the resident's weight gain status as 'Yes, not on physician-prescribed weight-gain regimen' instead of 'Yes, on physician-prescribed weight-gain regimen.' The RD acknowledged the error and admitted uncertainty about who was responsible for obtaining a specific physician order for the weight gain regimen, ultimately recognizing it should have been her responsibility. Further review of the facility's policy indicated that all disciplines participating in the Resident Assessment Instrument (RAI) process are required to accurately complete their assessments and electronically attest to their accuracy. The MDS Coordinator (MDSC) confirmed that the section on weight gain was not completed accurately, which could lead to an inaccurate MDS and potentially impede care planning to meet the resident's needs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were also present during the review and interview process, highlighting the collaborative nature of the assessment process and the importance of accurate documentation.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure the head of bed (HOB) of one of 10 sampled residents was elevated at least 30 degrees while receiving enteral tube feedings. During an observation, the resident was found lying on his left side with the HOB elevated to only 15 degrees, as indicated by the measuring guide on the side of the bed. The resident's enteral tube feeding was running at 55 milliliters per hour at the time of the observation. Both a registered nurse and the assistant director of nursing confirmed that the HOB should have been elevated to a minimum of 30 degrees according to the facility's policy and the resident's individual plan of care (IPOC). The resident's order sheet indicated continuous tube feeding with a specific formula, and the IPOC highlighted the need to elevate the HOB during and after meals to prevent aspiration. The facility's policy on enteral nutrition also specified that the HOB should be elevated to 30-45 degrees to prevent complications such as aspiration. The failure to adhere to these guidelines had the potential to result in aspiration and lung problems for the resident.
Expired and Improperly Labeled Medications
Penalty
Summary
The facility failed to ensure that expired medications were disposed of and that medications were properly labeled with expiration dates. Specifically, one resident's expired mouthwash was found in the medication storeroom, despite the resident having been discharged from the facility. The facility's policy and procedure for the disposal of unusable medications indicated that such medications should be promptly returned to the pharmacy for proper disposal, which was not followed in this case. Additionally, another resident's eye drops were administered without being properly labeled with an open or expiration date. The facility's policy on labeling standards required that all medications include a beyond-use or expiration date, which was not adhered to. These lapses were identified during observations and interviews with the facility's licensed vocational nurse and pharmacist.
Failure to Follow Individualized Meal Tray Directions
Penalty
Summary
The facility failed to follow individualized meal tray ticket directions for one resident, identified as Resident 189. During an observation, it was noted that Resident 189's lunch plate included mixed vegetables that were not served in a chopped texture as specified in the resident's meal tray ticket. The Certified Dietary Manager confirmed that the vegetables were not chopped and should have been in accordance with the resident's individualized menu directions. The resident's physician orders indicated a need for chopped meats and vegetables due to chewing issues, which were not adhered to during meal preparation. The facility's diet manual for a chopped diet specifies that foods should be moist and in bite-size pieces no larger than 1/2 inch to meet the needs of patients with chewing or swallowing difficulties. Additionally, the facility's policy and procedure for tray assembly and distribution mandates that food items be placed on patient trays according to the items listed on the patient tray ticket. The failure to follow these guidelines resulted in the resident receiving a meal that did not meet their specified dietary needs.
Failure to Address Residents' Right to Store Outside Food
Penalty
Summary
The facility policy failed to address residents' right to store outside food, which had the potential to not honor a resident and/or families' request to store food from the outside for later consumption. During interviews, various staff members, including a Licensed Vocational Nurse (LVN), a Certified Nurse Assistant (CNA), a Certified Dietary Manager (CDM), and the Director of Nursing (DON), confirmed that the facility does not store outside food for residents. The staff indicated that outside food must be approved by a nurse and consumed immediately or discarded, as the facility does not have a refrigerator for storing such food. The DON mentioned that staff are trained to offer a bucket with ice for short-term storage, but this is not a long-term solution. Observations also revealed a sign on the nourishment refrigerator stating that no patient food from home is allowed in the fridge per policy number FNS.615. The facility's policies and procedures were reviewed, including the policy titled 'Storage of Leftover Patient Food' and 'Nutrition: Cafeteria and outside food.' These policies indicated that potentially hazardous food not consumed by a patient would be discarded within four hours and not stored in patient floor stock refrigerators. The Food and Nutrition Services department does not provide oversight over any outside food for patient use. This lack of a clear policy on storing outside food brought in by family members led to the deficiency, as it did not honor the residents' right to store such food for later consumption.
Failure to Properly Disinfect High-Touch Surfaces
Penalty
Summary
The facility failed to implement proper infection prevention and control measures when two Environmental Service Aides (EVS 1 and EVS 2) did not ensure that high-touch surface areas such as handrails, call lights, doorknobs, and pull cords were disinfected daily. During an observation and interview, EVS 1 stated that Vindicator, a disinfectant, was used for surfaces in residents' rooms and that the dwell time for Vindicator was one minute. However, EVS 2 revealed that handrails in the resident hallways were disinfected with Vindicator only once per week. This discrepancy was further highlighted by the Laundry Manager (LM), who stated that Vindicator should remain wet for 10 minutes and that high-touch areas like hallway handrails should be cleaned daily with Vindicator without wiping the surfaces afterward. The Infection Preventionist (IP) confirmed that high-touch surfaces should be disinfected daily according to facility policy and training provided to housekeeping staff. The facility's policies and procedures also indicated that high-touch surfaces should be disinfected daily and allowed to air dry without being wiped down prematurely. The manufacturer's guidelines for Vindicator also specified a 10-minute dwell time for effective disinfection. The failure to adhere to these guidelines and policies was observed during the survey, indicating a lapse in the facility's infection control practices. The facility's policy and procedure documents, as well as the manufacturer's guidelines for Vindicator, were reviewed and found to be consistent with the need for daily disinfection of high-touch surfaces and adherence to the specified dwell times. The inconsistency in the application of these procedures by the Environmental Service Aides posed a potential risk for the spread of infectious diseases among residents, staff, and visitors.
Failure to Maintain Walk-In Freezer in Good Repair
Penalty
Summary
The facility failed to ensure the walk-in freezer in Kitchen 1 was maintained in good repair, which had the potential to compromise food quality and safety. During an observation, ice buildup was noted on the plastic strip curtain, tubing on the door, and a cardboard box inside the freezer. The Certified Dietary Manager (CDM) acknowledged the issue and mentioned that a work order had been completed to repair the seals on the door, but the ice buildup persisted. The CDM had not reported the continued issue to maintenance, and there were no pending work orders for further repairs. Maintenance Staff (MS) believed the ice buildup was normal due to the door being opened and hot air entering, and considered the extensive ice buildup a sign of a properly working freezer. However, the manufacturer's guidelines indicated that ice buildup around doors might indicate leakage or heater failure, requiring immediate attention. The facility's policy on preventative maintenance emphasized the importance of routine maintenance to ensure equipment operates as designed, but this was not adequately followed in this case.
Failure to Properly Dispose of Heparin Vials
Penalty
Summary
The facility failed to ensure that empty vials of Heparin, a medication used to decrease blood clots, were discarded in a designated waste bin for two of the 36 sampled residents. During an observation, a vial of Heparin was found unattended on top of a medication cart. Licensed Vocational Nurse (LVN) 1 confirmed that the vial was empty and should have been disposed of immediately after administration. The Medication Administration Record (MAR) indicated that the Heparin was administered to two residents between 6:59 a.m. and 7:40 a.m. The facility's policy and procedure (P&P) for medication administration required used medications to be promptly placed in a pharmaceutical waste bin, which was not followed in this instance.
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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