New Orange Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Orange, California.
- Location
- 5017 E. Chapman Avenue, Orange, California 92869
- CMS Provider Number
- 555286
- Inspections on file
- 52
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at New Orange Hills during CMS and state inspections, most recent first.
Two residents did not receive appropriate monitoring and documentation for diabetic care. One resident was not monitored for insulin side effects or signs of hyperglycemia, and another did not have daily glucose checks completed as ordered, with no documentation explaining the missed checks. Both the RN and DON confirmed these deficiencies in care and recordkeeping.
A resident's Fall Risk Evaluation was inaccurately completed by a licensed nurse, failing to document a recent fall despite facility policy and supporting documentation indicating the incident occurred. Both RN and DON confirmed the omission during record review and interviews.
A resident with severe cognitive impairment and a history of falls was found on the floor with multiple leg fractures after their bed, which was supposed to be kept in the lowest position per care plan and physician orders, was left elevated. Staff and family confirmed the bed was hip-high at the time of the incident, and required fall prevention interventions were not fully implemented.
A resident with end stage renal disease and hypertension did not have blood pressure monitored according to physician orders and preferences. Staff used a wrist blood pressure machine, which the resident reported as inaccurate, and took readings from the resident's left arm with a hemodialysis access site, despite orders not to do so. The DON confirmed that only approved equipment should be used and that staff should follow physician orders.
A resident with a dehisced surgical wound did not have Enhanced Barrier Precautions (EBP) implemented, despite physician orders for wound care and facility policy requiring EBP for such cases. Observations revealed no PPE set-up or EBP signage, and staff confirmed that EBP was not in place. The DON and Administrator verified the absence of EBP and related precautions for the resident.
A resident with multiple complex diagnoses had severely abnormal lab results that were not properly addressed by nursing staff. An LVN reported the results to the physician without clarifying or highlighting the critical abnormalities, and no action was taken until another LVN later provided the lab values after the resident's condition worsened. Staff interviews revealed gaps in competency verification and understanding of lab value significance.
Two residents did not receive necessary care as ordered by their physicians: one was not taken to scheduled outpatient follow-up appointments due to transportation and insurance issues, and another received wound care involving betadine application without a physician's order. These failures were confirmed by facility staff, including the DON and an LVN.
A resident with anoxic brain damage and a stage 4 sacral pressure injury did not receive barrier cream as ordered, and wound assessments failed to document or address undermining. Nursing staff did not initially recognize the undermining or notify the physician, and the low air loss mattress was set incorrectly for the resident's weight, contrary to care plan and physician orders.
Surveyors found that a resident's clean isolation gown contained soiled gloves and that a soiled trach tie was not changed after wound care, despite facility policy and staff acknowledgment that soiled ties should be replaced. These lapses in infection control practices were confirmed through observation and staff interviews.
A resident's medical record showed that care tasks and medication administration were documented as completed after the resident had already been discharged. The MAR included check marks for daily heel protectors, apical pulse monitoring, pacemaker site checks, and potassium chloride ER administration, all recorded for a date following discharge. Both an LVN and the DON confirmed these inaccuracies during review.
The facility failed to provide necessary wound care for three residents, including incorrect treatment orders for a resident's wound, inappropriate mattress for another's pressure injury, and incorrect wound care sequence for a third resident. These deficiencies were confirmed by staff and involved miscommunication and failure to follow physician orders.
A facility failed to provide a resident with bilateral floor mats at the bedside as ordered by a physician, despite the resident being at high risk for falls. The absence of these mats was confirmed during an observation and interview with the ADON, and the DON verified the findings. The resident's care plan and medical records indicated the necessity of these mats following a previous fall.
The facility failed to follow physician's orders for GT feedings for two residents, starting the feedings two hours earlier than prescribed. Despite orders to begin at 1500 hours, the feedings were initiated at 1300 hours, as confirmed by LVNs and the DON. This discrepancy was acknowledged by the facility's administration.
The facility failed to maintain sanitary conditions in the kitchen, with utensils in poor condition, improper cleaning and storage of equipment, and inadequate maintenance of the ice machine and kitchen hood. These deficiencies, verified by the Dietary Manager, posed a risk of cross-contamination and foodborne illnesses for residents consuming food prepared in the facility.
The facility failed to ensure that call lights were within reach for four residents, potentially delaying care and impacting their well-being. Observations revealed call lights were out of reach for these residents, with staff only addressing the issue after verification. Two residents lacked decision-making capacity, highlighting the importance of accessible call lights. The DON acknowledged the need for staff to ensure call lights are within reach.
The facility failed to notify the physician timely about changes in two residents' conditions, leading to delayed interventions. One resident experienced difficulty swallowing, which was reported by family but not promptly communicated to the physician. Another resident had vomiting episodes and tube feeding was held without physician notification, despite low weight. The DON confirmed the need for timely physician notification.
A resident's right to a safe and comfortable environment was violated when staff searched their belongings without consent. The resident, who is legally blind but cognitively intact, was unaware of the intrusion until informed by their roommate. The DON confirmed that staff were instructed to check bedside areas but should have obtained permission first.
The facility failed to follow up on a dermatologist's recommendations for a resident's skin condition and did not monitor another resident's weight loss every shift for 72 hours as required. These oversights could have delayed necessary interventions.
A resident's new pressure ulcer was not reported or documented in a timely manner. CNA 1 observed the wound during a shower but delayed reporting it to Treatment Nurse 2 until after lunch. Treatment Nurse 1 was unaware of the wound, and CNA 2 had previously seen a callous but did not report it, assuming it was not new. This led to a delay in treatment and intervention.
A resident experienced another fall due to the facility's failure to implement the recommended two-person assistance for ADL care. Despite a previous fall and the Fall Committee's recommendation, a CNA provided bedside care alone, leading to the resident sliding off the bed. The DON confirmed the CNA's non-compliance with the two-person assistance directive.
A facility failed to prevent UTIs for a resident with an indwelling urinary catheter by positioning the urinary drainage bag above the bladder, contrary to policy. This was confirmed by a CNA and an LVN, despite the resident's care plan specifying the correct positioning to prevent complications.
A resident in an LTC facility was administered the incorrect enteral formula, receiving Vital 1.2 instead of the prescribed Vital 1.5. This error resulted in the resident receiving fewer calories than ordered, potentially impacting their well-being. The issue was identified during an observation and interview with an LVN, who noted the discrepancy after holding the feeding due to the resident vomiting.
The facility failed to provide necessary respiratory care for four residents, including not dating oxygen tubing for three residents and not administering oxygen as ordered for another. Observations and interviews confirmed these deficiencies, which did not adhere to the facility's policies, potentially putting residents at risk.
The facility failed to properly assess and document the use of side rails for three residents, leading to potential safety risks. One resident used side rails for positioning without documented alternatives being attempted. Another resident requested side rails for mobility, but the facility did not document any alternatives. A third resident had side rails despite being unable to self-position, making their use inappropriate. These deficiencies put residents at risk for entrapment and injuries.
The facility failed to ensure proper documentation and accounting of controlled medications. An inspection revealed discrepancies in the Narcotic Count Sheet and Medication Count Sheets for two residents, with missing or incorrect entries. LVN 3 admitted to errors in documentation, and the Administrator and DON acknowledged the findings.
A facility failed to accurately monitor orthostatic blood pressure for a resident on Zyprexa, as ordered by the physician. The medical records showed identical blood pressure readings for lying and sitting positions, indicating non-compliance with the procedure. Interviews with the DON and an LVN confirmed the readings should differ, and the LVN admitted to not following the correct procedure, potentially impacting the resident's treatment.
A facility's medication error rate was found to be 25%, exceeding the acceptable threshold. An LVN made eight errors by leaving residual medication in cups after administration to a resident. Additionally, the LVN incorrectly administered eye drops to another resident, applying them to only one eye instead of both as per the physician's order.
The facility failed to ensure proper storage and disposal of medications across multiple medication carts, leading to potential risks of unsafe administration and cross-contamination. Used syringes, topical creams, and various medications were improperly stored together, as confirmed by nursing staff. The Administrator and DON were informed and acknowledged these deficiencies.
A resident with intractable epilepsy had a low valproic acid level, but the facility failed to make repeated attempts to notify the physician. Despite a recommendation from the Consultant Pharmacist to clarify the medication's use and obtain a level, the medical record lacked evidence of follow-up actions. The DON stated that staff should make multiple attempts to contact the physician for abnormal lab values, but this was not documented.
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs. A resident's IV fluid intake and weight refusal were not documented, another's MAR was incomplete, a third's hospice visitation log was missing entries, and a fourth's flu vaccination consent was improperly filed. These issues were confirmed by facility staff and acknowledged by administration.
The facility failed to implement an effective infection prevention and control program, neglecting to include residents not on antibiotics in their surveillance. Resident 775 lacked necessary precautions for wound care, and tracheostomy supplies were improperly stored. Additionally, a urinal was unlabeled, and a blood glucose meter was not cleaned after use, posing risks for infection transmission.
The facility failed to implement its Antibiotic Stewardship Program effectively, as it did not conduct proper assessments using McGeer's criteria for infections and used incorrect Surveillance Data Collection Forms for several residents. This led to inaccurate identification of infections and inappropriate antibiotic prescriptions. The IP and DON acknowledged these deficiencies.
A resident's rights were violated when a CNA used a personal cell phone while feeding a legally blind resident. Another resident observed this behavior and reported it as disrespectful. The facility's policy prohibits personal electronic device use during work hours, which the CNA acknowledged violating.
A resident with a Stage 4 sacral coccyx wound received improper wound care when an LVN failed to change gloves and perform hand hygiene between steps. The LVN did not sanitize the bedside table before placing clean supplies and acknowledged the lapse in infection control practices. The DON confirmed the breach in protocol.
The facility failed to ensure a resident's call light was within reach, as observed on multiple occasions. The resident, who had impaired speech but could verbalize needs, was found unable to reach the call light, which was wrapped around the bedrail and hanging halfway to the floor. Staff confirmed the call light should have been accessible, and the ADON acknowledged the findings.
Failure to Monitor and Document Diabetic Care and Glucose Checks
Penalty
Summary
The facility failed to provide quality care and services for two residents by not ensuring proper monitoring and documentation related to diabetic management. For one resident with Type 2 diabetes and no decision-making capacity, the facility did not document monitoring for side effects or effectiveness of prescribed insulin, nor did they monitor or document for signs and symptoms of hyperglycemia as outlined in the resident's care plan. Both the RN and DON confirmed that there was no evidence of such monitoring or documentation in the medical record, and that clarification with the physician regarding blood sugar monitoring was not obtained. For another resident, the facility did not complete physician-ordered daily glucose monitoring on several specified dates, as evidenced by missing documentation in the medication administration records. The RN verified the omissions and acknowledged that reasons for missed glucose checks were not documented. The DON also confirmed these findings, stating that refusals or other reasons should have been recorded to ensure proper tracking of the resident's blood sugar status.
Inaccurate Fall Risk Evaluation Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the Fall Risk Evaluation for one resident. The resident, who lacked decision-making capacity, experienced a fall as documented in the SBAR Communication Form. However, the Fall Risk Evaluation completed on the same day did not reflect this incident, instead indicating that the resident had no falls in the past three months. This discrepancy was confirmed during interviews and record reviews with both a registered nurse and the Director of Nursing, who acknowledged that the fall should have been included in the evaluation. Facility policies required that post-fall assessments and care plan changes be completed for all residents who experienced a fall, and that medical records provide a concise and accurate account of care and resident condition. The licensed nurse responsible for the Fall Risk Evaluation did not document the recent fall, resulting in an inaccurate record. This inaccuracy was verified by facility staff during the survey process.
Failure to Maintain Bed in Low Position Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in the low position as required by the resident's care plan. The resident, who had a diagnosis of Alzheimer's dementia, a history of falls, severe cognitive impairment, and was dependent on staff for all activities of daily living, was identified as being at high risk for falls. The care plan and physician orders specified the use of bilateral bolster pillows, floor mats, and keeping the bed in the lowest position to minimize injury risk. Despite these interventions, the bed was found elevated at the time of the incident. On the day of the event, a family member visiting the resident observed that the bed was elevated and subsequently found the resident on the floor, in pain, and with visible injuries. Multiple staff members, including CNAs and LVNs, confirmed that the bed was elevated to hip height when they responded to the incident. The resident sustained fractures to the left lower leg, as confirmed by hospital records, and required transfer to an acute care hospital for treatment. Facility documentation, interviews, and medical record reviews all indicated that the required fall prevention interventions were not fully implemented, specifically the failure to keep the bed in the low position. The facility's own policies and procedures mandated that residents at risk for falls have appropriate interventions in place, including maintaining the bed in the lowest position, but this was not adhered to at the time of the incident.
Failure to Follow Physician Orders and Use Approved Equipment for Blood Pressure Monitoring
Penalty
Summary
The facility failed to provide necessary care and services by not monitoring a resident's blood pressure according to physician orders and resident preferences. Specifically, staff used a wrist blood pressure machine, which the resident reported as inaccurate, and repeatedly obtained low systolic readings. The resident expressed concerns about the accuracy of the device and stated that nurses often had to retake his blood pressure multiple times to get an accurate reading. Additionally, the resident reported that staff were obtaining blood pressure readings from his left arm, which contained a hemodialysis access site, despite a physician order prohibiting blood pressure measurements from that site. Medical record review confirmed the resident had diagnoses of end stage renal disease on hemodialysis, hypertension, and a history of diabetes. Physician orders included instructions to hold antihypertensive medication if systolic blood pressure was below a certain threshold and a specific order not to obtain blood pressure readings from the left arm with the hemodialysis access. During interviews, a nurse admitted to using a wrist blood pressure machine and to taking readings from whichever arm the resident offered, while the DON confirmed that only facility-approved machines should be used and that staff should follow physician orders regarding blood pressure monitoring.
Failure to Implement Enhanced Barrier Precautions for Resident with Surgical Wound
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for a resident with a surgical wound. The resident, who had a history of cranioplasty and a slowly healing, dehisced surgical wound, was admitted and readmitted to the facility. Physician orders were in place for daily wound care, including cleansing and dressing changes for both the scalp and left temple wounds. However, there was no physician order for Enhanced Barrier Precautions (EBP), which are required for residents with wounds at high risk for colonization with multidrug-resistant organisms (MDROs). During observations, the resident was found in bed with wound dressings but without any PPE set-up or EBP signage outside the room. Interviews with the LVN and Infection Preventionist (IP) confirmed that EBP was not implemented, despite both acknowledging that EBP should have been in place due to the resident's surgical wound. The IP also verified the absence of a physician's order for EBP and the lack of necessary precautions. Further review and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident had a surgical wound and that EBP, including PPE set-up and signage, was not implemented as required. The facility's failure to follow its own infection prevention and control policies and procedures resulted in the deficiency, as the necessary precautions to prevent the transmission of communicable diseases or organisms were not in place for the resident.
Plan Of Correction
F0880 signage, orders and care plans were in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Infection Preventionist/Designee conducted an in-service from 8/5/25 - 8/12/25 to licensed nurses regarding EBP practices and the criteria that would require implementation. Infection Preventionist will make daily rounds and audit new admissions and current residents on EBP, Monday - Friday x 3 months to ensure proper implementation of EBP on the floor that includes signage, orders and care plans are in place. DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025 DON/Designee will conduct audit for at least 3-5 residents a week x 4 weeks x 3 months to ensure Enhance Barrier Precautions have been implemented and care planned. How the facility plans to monitor its performance to make sure that solutions are sustained. The Infection Preventionist/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 8/13/2025
Failure to Ensure Nursing Staff Competency in Interpreting and Reporting Critical Lab Values
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident with complex medical needs. A resident with chronic respiratory failure, tracheostomy, ventilator dependence, and anemia of chronic disease was admitted and had laboratory tests ordered. The results showed severely abnormal values, including a high WBC, low hemoglobin, and low hematocrit. The LVN on duty sent a picture of the lab results to the resident's physician via text but did not clarify or address the abnormal findings beyond reporting the results and responding to a question about water flushes. The physician's response only addressed fluid status, and no further clarification or action was taken regarding the critical lab abnormalities at that time. Later, another LVN contacted the physician due to the resident's low blood pressure and, after some confusion about the resident's identity, provided the lab values when prompted by the physician. Only then did the physician order additional diagnostic tests and treatments, including blood cultures, a urine test, chest x-ray, antibiotics, and IV fluids. The resident's condition continued to deteriorate, leading to a transfer to an acute care hospital. Interviews with facility staff revealed that the LVN responsible for initially reporting the lab results did not express concern about the abnormal values and stated she was just following orders. Other nursing staff indicated that proper procedure would have included assessing the resident, highlighting significant lab results, and ensuring the physician was aware of the critical findings. The Director of Nursing and the Director of Staff Development both acknowledged that nurses are expected to question unclear orders and have a basic understanding of lab values, but orientation only included a brief review of lab values without specific competency verification.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained. The DON/Designee will track, trend, and report findings to the QAA/QAPI Committee monthly for 3 months or until substantial compliance is achieved. Completed Date: 7/30/25
Failure to Ensure Physician-Ordered Appointments and Wound Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents, resulting in deficiencies related to physician-ordered follow-up and wound care. For one resident with acute and chronic respiratory failure, tracheostomy, and congenital malformation of the skull and facial bones, the facility did not ensure attendance at scheduled outpatient appointments for a speech evaluation and a plastic surgeon. Documentation showed that transportation for the appointments could not be arranged due to insurance issues, and the resident ultimately did not attend either appointment, despite physician orders and acknowledgment from the Director of Nursing (DON) that follow-up should have occurred. For another resident, the facility did not follow physician orders regarding wound care after surgery. The resident's order specified removal of a Prevena dressing, but during the procedure, betadine was applied to the surgical incision without a physician's order. This was confirmed by both a Licensed Vocational Nurse (LVN) and the DON, who acknowledged that betadine application required a physician's order. The Administrator and DON confirmed these findings during the survey.
Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident. During wound care, licensed vocational nurses did not apply barrier cream to the resident's sacrum as ordered by the physician. Additionally, the wound care assessment did not document the presence of undermining in the sacrococcyx pressure injury, despite direct observation of undermining from 8 o'clock to 12 o'clock. The nurses involved did not initially recognize or document the undermining, and the physician was not notified of this change in the wound's condition at the time of assessment. The resident, who had a diagnosis of anoxic brain damage and was non-verbal, was dependent for mobility and had a documented stage 4 pressure injury to the sacrum. Medical records and care plans indicated the need for regular assessment, documentation, and communication regarding the wound's status, including the presence of undermining. However, the initial admission record lacked measurements and staging of the pressure injury, and subsequent skin evaluations did not address the undermining observed during wound care. Furthermore, the facility did not ensure that the low air loss mattress (LALM) settings were correctly adjusted according to the resident's weight. The mattress was set for a weight of 180 pounds, while the resident weighed 116 pounds. This discrepancy was confirmed by both nursing staff and the Director of Nursing, who acknowledged that the mattress settings should correspond to the resident's actual weight as part of wound management interventions.
Infection Control Deficiencies in Linen Handling and Tracheostomy Care
Penalty
Summary
Surveyors identified deficiencies in infection prevention and control practices for one of eight sampled residents. During an observation of wound care for a resident with a tracheostomy and a neck wound, a clean isolation gown was found to contain soiled gloves inside the sleeve. This was verified by the LVN present. Interviews with the infection prevention (IP) nurse and Maintenance Director revealed that gowns should be checked for foreign objects before being placed in clean linen storage, but gloves sometimes remained inside gowns after laundering, with the Maintenance Director acknowledging that gloves could melt during washing if not removed. Additionally, the same resident had a physician's order for daily tracheostomy care and wound management. During wound care, the LVN was observed moving a visibly soiled trach tie to access the wound, but did not change the tie after completing the wound care. The soiled trach tie, which had visible discoloration and debris, was only changed after the surveyor's observation and verification by staff. Interviews with the respiratory therapist, IP nurse, and DON confirmed that trach ties should be changed if soiled, regardless of the regular schedule. The facility's policies required staff to minimize the spread of infection, handle linens properly, and change trach ties as needed if soiled. The observed failures to ensure clean linens and to change a soiled trach tie after wound care did not align with these policies, resulting in a deficiency related to infection control practices.
Inaccurate Medical Record Documentation After Resident Discharge
Penalty
Summary
The facility failed to maintain accurate medical records for one of eight sampled residents. Specifically, a review of the closed medical record for a resident who had been discharged revealed that multiple care tasks and medication administrations were documented as completed on the medication administration record (MAR) for a date after the resident had already left the facility. These tasks included daily use of heel protectors, monitoring of apical pulse and pacemaker site, observation for pacemaker malfunction, and administration of potassium chloride ER tablets. Both the LVN and the DON confirmed that the MAR indicated these tasks as completed after the resident's discharge, and the facility's policy required clinical records to be a concise and accurate account of care and treatment provided.
Deficiencies in Wound Care and Treatment Orders
Penalty
Summary
The facility failed to provide necessary wound care and services for three residents, leading to deficiencies in their treatment. For Resident 2, there was a lack of communication and clarification between two physicians providing different wound care orders. The resident's treatment plan was not updated in the electronic health record (EHR) to reflect the wound specialist's recommendations, resulting in the discontinuation of mupirocin ointment without proper clarification. This oversight was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the failure to follow the correct treatment plan. Resident 3 did not receive the appropriate bed mattress to promote healing of a pressure injury. Despite a physician's order for a Low Air Loss (LAL) mattress, the resident was observed lying on a different type of mattress. This discrepancy was verified by the DON during an observation and interview, indicating a failure to adhere to the prescribed treatment for pressure injury management. For Resident 5, the facility did not follow the correct sequence of wound care treatment as ordered by the physician. The LVN applied the xeroform dressing before the collagen sheet, contrary to the physician's instructions to apply the collagen sheet first. This error in the wound care procedure was acknowledged by the LVN and confirmed by the DON, highlighting a failure to execute the physician's orders accurately.
Failure to Provide Safety Mats for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards by not providing the bilateral floor mats at the resident's bedside as ordered by the physician. This deficiency was identified during an observation and interview with the Assistant Director of Nursing (ADON), where it was confirmed that the resident, who was at high risk for falls, did not have the required safety mats in place. The resident's medical records indicated a physician's order for the mats dated 6/26/24, and the care plan initiated on 6/21/24 also included this intervention following an actual fall on that date. The resident's Quarterly Fall Risk Evaluation dated 12/19/24, classified them as high risk for falls, underscoring the necessity of the mats for safety. Despite these documented orders and care plans, the mats were not present during the observation on 2/26/25. The Director of Nursing (DON) was informed of these findings and verified the absence of the mats, confirming the facility's failure to adhere to the prescribed safety measures for the resident.
Failure to Follow Physician's Orders for GT Feedings
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of gastrostomy tube (GT) feedings for two residents, identified as Residents 3 and 5. According to the medical records, Resident 3 was supposed to receive enteral feeding starting at 1500 hours daily, delivering 1100 cc of Jevity 1.5 formula at a rate of 55 cc/hr for 20 hours. However, an observation on December 20th revealed that the feeding had commenced prematurely, with 39 ml already infused before the scheduled time. Similarly, Resident 5's orders indicated that enteral feeding should begin at 1500 hours, providing 1200 cc of water at 60 cc/hr for 20 hours. Despite this, the feedings for both residents were initiated at 1300 hours, two hours earlier than prescribed. Interviews with Licensed Vocational Nurses (LVNs) 1 and 3 confirmed the early administration of the feedings, with LVN 3 admitting to starting the GT feedings around 1300 hours. LVN 1 acknowledged that the feedings were ordered to start at 1500 hours, with a permissible window of one hour before and after the scheduled time. The Director of Nursing (DON) verified the discrepancy and stated that the licensed nurses should have followed the physician's orders. The facility's Administrator and DON acknowledged these findings, indicating a failure to provide necessary care and services as per the physician's directives.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several observations during a kitchen tour. The kitchen utensils, including spatulas, whisks, and scoops, were found to be in poor condition, with chipped edges, discoloration, and residues. These conditions were verified by the Dietary Manager, who acknowledged that such utensils should not be used as they can harbor bacteria. Additionally, the cutting board was heavily marred, discolored, and peeling, making it difficult to clean and sanitize, which could lead to the accumulation of pathogenic microorganisms. The facility also failed to ensure that equipment and utensils were properly cleaned and stored. During the kitchen tour, it was observed that some utensils were stored wet and dirty, and the heavy-duty blender was not air-dried before storage. The microwave used for warming food was found to have dry, crusted food residue, and the kitchen hood had black, greasy residue, indicating inadequate cleaning. The ice machine, used by residents and staff, had ice buildup, which was acknowledged by the Maintenance Supervisor, who stated that the machine was under warranty and required maintenance by an outside company. These deficiencies in maintaining sanitary conditions in the kitchen had the potential for cross-contamination and foodborne illnesses among the residents consuming the food prepared in the facility. The Dietary Manager and Maintenance Supervisor acknowledged the findings and the need for proper cleaning and maintenance of kitchen equipment and utensils to prevent bacterial growth and ensure food safety.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to provide reasonable accommodations for the call lights of four residents, which were not within their reach, potentially impacting their psychosocial well-being or delaying care. For Resident 96, the call light was found hanging at the back of the bed, out of reach, and was only placed within reach after verification by LVN 11. Similarly, Resident 108's call light was found underneath the pillow, out of reach, and was acknowledged by LVN 7 as needing to be accessible. Resident 775's call light was observed on the floor during two separate observations, both times out of reach, and was only placed within reach after CNA 2 verified the situation. Resident 775 was noted to lack the capacity to understand and make decisions, emphasizing the importance of having the call light accessible. Resident 78's call light was initially observed on the resident's right shoulder, not within reach, despite the resident having the ability to use the call light and movement in both hands. LVN 13 confirmed the call light's position and moved it under the resident's right hand. The Director of Nursing (DON) acknowledged that most residents in the Subacute Unit used call lights and emphasized the need for staff to place them within reach. The Administrator and DON were informed of these findings and acknowledged the deficiencies.
Failure to Timely Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding changes in the condition of two residents, leading to a delay in intervention and potential adverse outcomes. For Resident 51, the physician was not promptly informed about a change in the resident's swallowing status. The resident's family member had reported difficulty in swallowing liquids to the Social Services Department, which was supposed to notify the nursing staff. However, the physician was only notified several days later, after the Speech Therapist conducted a screening and recommended a swallow study. For Resident 56, the physician was not notified about the resident's episodes of vomiting and the decision to hold the resident's tube feeding. The resident had a history of vomiting, and the tube feeding was held without obtaining a physician's order, despite the resident's low weight. The nursing staff failed to communicate these changes to the physician, resulting in the resident receiving significantly less formula than ordered. The Director of Nursing confirmed that the physician should have been notified of these changes.
Unauthorized Search of Resident's Belongings
Penalty
Summary
The facility failed to honor a resident's right to a safe and comfortable environment by allowing staff to go through a resident's personal belongings without consent. This incident involved a resident who was legally blind but cognitively intact, as confirmed by their medical records. The resident was unaware of the intrusion until informed by their roommate, who witnessed the event. The roommate observed two individuals dressed like staff entering the room early in the morning, using a flashlight to search through the resident's belongings on the tray table, bedside table, and drawer while the resident was asleep. The Director of Nursing (DON) later confirmed that staff had been instructed to check residents' bedside areas for proper labeling and food expiration dates. However, the DON acknowledged that staff should have obtained permission from the resident before inspecting their belongings. This oversight led to the resident feeling upset upon learning about the unauthorized search, highlighting a breach in maintaining a homelike and respectful environment for the resident.
Failure to Follow Up on Consult Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to provide necessary care and services to two residents, resulting in potential delays in identifying changes in their conditions and implementing appropriate interventions. For one resident, the facility did not follow up timely on skin and wound consult recommendations. The dermatologist had recommended a specific skin care regimen, including the use of fragrance-free products and avoiding harsh soaps. However, the medical record did not show that the physician was notified of these recommendations, and the resident continued to experience severe itchiness. Another resident was not monitored every shift for at least 72 hours following a noted weight loss, as required by the facility's policy. The medical record review revealed that the resident was not monitored on specific shifts, which was confirmed by the ADON and RN. This lack of monitoring could have delayed the identification of changes in the resident's condition and the implementation of necessary interventions.
Failure to Timely Report and Address Pressure Ulcer
Penalty
Summary
The facility failed to ensure timely reporting and addressing of a new pressure ulcer for Resident 51, which was observed during a transfer to a wheelchair after a shower. The resident had an open area of approximately 2 cm on the right heel, which was not documented in the medical record. Treatment Nurse 1 was unaware of the wound, indicating a lack of communication and documentation regarding the resident's condition. CNA 1, who was assigned to Resident 51 for the first time, observed the wound during the morning shower and reported it to Treatment Nurse 2 only after lunch, which the DON acknowledged as untimely. Additionally, CNA 2, who had been assigned to the resident earlier in the week, noticed a callous on the right heel but did not report it, assuming it was not a new issue. This series of inactions and miscommunications led to a delay in treatment and intervention for the resident's pressure ulcer.
Failure to Implement Two-Person Assistance for ADL Care
Penalty
Summary
The facility failed to implement the recommended two-person assistance for Activities of Daily Living (ADL) care for a resident, which resulted in the resident experiencing another fall. The medical record review revealed that the resident had previously sustained a fall when a Certified Nursing Assistant (CNA) attempted to roll the resident in bed to place a mechanical lift sling, causing the resident to slide off the bed. Following this incident, the Fall Committee's Interdisciplinary Team (IDT) recommended two-person assistance for ADL care. Despite this recommendation, another fall occurred when a CNA was providing bedside care without assistance, and the resident began to slide off the bed. During an interview and concurrent medical record review with the Director of Nursing (DON), it was confirmed that the CNA was performing ADL care alone, contrary to the IDT's recommendation for two-person assistance.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. During an observation, it was noted that the urinary drainage bag and tubing for the resident were positioned above the bladder, contrary to the facility's policy and procedure, which requires the drainage bag to be below the bladder to prevent UTIs and other complications. This improper positioning was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), who acknowledged that the drainage bag should be lower than the bladder. The resident in question had a care plan addressing the use of an indwelling urinary catheter for neurogenic bladder, which included specific interventions to position the catheter drainage bag and tubing below the bladder. Despite this, the drainage bag was observed to be incorrectly positioned, posing a risk for the development of UTIs. The facility's policy, revised in November 2019, clearly outlines the correct procedure for catheter drainage bag positioning, which was not adhered to in this instance.
Incorrect Enteral Formula Administered to Resident
Penalty
Summary
The facility failed to administer the correct enteral formula to a resident, identified as Resident 56, who was receiving tube feeding. The medical record review revealed a physician's order for Vital 1.5 formula to be administered at a specific rate and volume. However, during an observation and interview with an LVN, it was discovered that the resident was receiving Vital 1.2 instead of the prescribed Vital 1.5. The LVN reported that the tube feeding was held due to the resident vomiting, and upon checking, it was found that the resident had received less than the ordered calories due to the incorrect formula being used. This discrepancy had the potential to negatively impact the resident's well-being.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care and services for four residents, as observed during a survey. For three residents, the facility did not ensure that oxygen tubing was dated, which is a requirement according to the facility's policy. This oversight was confirmed through observations and interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON). The facility's policy mandates that oxygen tubing should be replaced and dated every seven days, but this was not adhered to for Residents 83, 725, and 726. Additionally, the facility did not administer oxygen as ordered by the physician for Resident 65. The resident was observed receiving oxygen at a rate of 4 liters per minute, contrary to the physician's order of 3 liters per minute. This discrepancy was verified through an interview with an LVN, who confirmed that the oxygen administration did not match the physician's order. The resident's care plan also indicated the need for humidified oxygen as prescribed, which was not followed. These deficiencies were identified through a combination of observations, interviews, and medical record reviews. The facility's failure to date oxygen tubing and administer oxygen as ordered by the physician had the potential to put residents at risk for adverse effects due to inaccurate administration of oxygen and improper care of oxygen equipment. The facility's policies were not followed, as confirmed by multiple staff members, including the DON and respiratory therapists.
Inadequate Assessment and Documentation of Side Rail Use
Penalty
Summary
The facility failed to ensure accurate and complete assessments and evaluations for the use of side rails for three residents, leading to potential safety risks. Resident 18 was observed using 1/4 side rails for positioning, but the medical record did not show any measures or interventions attempted before implementing the side rails. The Assistant Director of Nursing (ADON) confirmed that the least restrictive measures were not evaluated, and the necessary documentation was incomplete. For Resident 41, the facility did not document evidence of the least restrictive alternatives implemented before the use of side rails. The resident requested side rails to assist with bed mobility, but the Director of Nursing (DON) verified that the facility did not offer or document any alternatives before implementing the side rails. The DON acknowledged that the interventions on the evaluation form were not appropriate for the resident, and the facility failed to implement the least restrictive alternatives. Resident 56 had an order for bilateral padded 1/4 side rails for positioning and mobility, but the resident did not respond to verbal stimulation and had no purposeful movement. The DON confirmed that the use of side rails was inappropriate for this resident, as they were unable to self-position. These failures in assessment and documentation put the residents at risk for entrapment and serious injuries.
Failure to Document and Account for Controlled Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services by not ensuring all controlled medications were accounted for and documented properly. During an inspection of Medication Cart A, it was found that the Narcotic Count Sheet for a specific date had entries crossed out, indicating that a controlled substances count was not performed. LVN 3 admitted to filling out the row in error and confirmed that the documentation did not show that licensed staff performed the required count on that day. Additionally, there were discrepancies in the documentation of controlled medication administration for two residents. For one resident, the Medication Count Sheet showed an incomplete entry, with the time column left blank, as LVN 3 had started filling it out in anticipation of the next dose. For another resident, the count of lorazepam tablets did not match the physical count, as a dose was administered but not documented on the Medication Count Sheet. LVN 3 acknowledged these discrepancies and confirmed that documentation should be completed at the time of administration to ensure accurate counts and prevent drug diversion. The Administrator and DON were informed and acknowledged these findings.
Failure to Accurately Monitor Orthostatic Blood Pressure
Penalty
Summary
The facility failed to accurately monitor orthostatic blood pressure for a resident prescribed Zyprexa, an antipsychotic medication, for schizophrenia. The physician had ordered orthostatic blood pressure monitoring to be conducted while the resident was lying and sitting every Monday. However, the medical administration records from August to November showed identical blood pressure readings for both positions on multiple occasions, indicating that the procedure for taking orthostatic blood pressure was not followed correctly. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the orthostatic blood pressure readings should differ between lying and sitting positions. The DON acknowledged that the readings were not accurately monitored, and the LVN admitted to taking the blood pressure readings immediately after the resident changed positions, which is contrary to the facility's policy that requires a waiting period between position changes. This inaccuracy in monitoring had the potential to affect the resident's treatment and medication adjustments.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 25% due to nine medication errors out of 36 observations. During a medication pass observation, an LVN was seen administering eight medications to a resident by crushing them and mixing them with applesauce. After administration, residual medication was found in each of the eight cups, resulting in eight medication errors. Additionally, the same LVN administered dorzolamide eye drops to another resident, applying the drops only to the right eye despite the physician's order to administer them to both eyes. The LVN acknowledged the discrepancy but stated the resident preferred drops only in the right eye. However, the resident expressed a preference for drops in both eyes, leading to another medication error.
Improper Medication Storage and Disposal in Facility
Penalty
Summary
The facility failed to ensure proper storage and disposal of medications and biologicals across multiple medication carts, leading to potential risks of unsafe medication administration and cross-contamination. During an inspection of Medication Cart E, a used syringe of saline was found stored with unopened injection sites, and hydrocortisone cream was stored with safety needles. These findings were verified by RN 1, who acknowledged that the syringe should have been discarded and the cream should not have been stored with needles. In Medication Cart D, nitroglycerin sublingual tablets were improperly stored with lubricant jelly, which was confirmed by RN 1, who removed the medication from the cart. Medication Cart A had several issues, including a sharps container filled above the full line and various medications stored together despite different routes of administration. LVN 3 confirmed these findings, noting that such storage practices could lead to cross-contamination. Medication Cart C contained topical gel stored with pre-filled syringes and vials, and transdermal patches stored with oral supplements, with the latter observed in an unclean condition. LVN 5 verified these issues. Similarly, Medication Cart B had lubricant eye gel stored with heparin vials, and various medications with different administration routes stored together. These findings were confirmed by LVN 6 and the ADON. The Administrator and DON were informed of all these deficiencies and acknowledged them.
Failure to Follow Up on Abnormal Lab Results for Seizure Medication
Penalty
Summary
The facility failed to follow up with the physician regarding abnormal laboratory results for a resident with intractable epilepsy. The resident, who was readmitted to the facility, had a physician's order for divalproex sodium to manage seizure activity. A review of the resident's laboratory results showed a valproic acid level of 37 mcg/ml, which was below the reference range of 50-100 mcg/ml, and flagged as low. Despite this, the medical record did not show repeated attempts to notify the physician about the low laboratory results. The Consultant Pharmacist had previously recommended clarifying the use of valproic acid for seizures and obtaining a valproic acid level. A nursing note indicated that the nurse communicated with the physician about the low valproic acid level and recommended increasing the dose, but they were awaiting a response. During an interview, the Director of Nursing stated that the expectation for abnormal laboratory values was to make two to three attempts to notify the physician and, if unsuccessful, to contact the medical director. However, the facility's records did not reflect these actions.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to potential unmet care needs due to incomplete documentation. For Resident 33, there was no documentation of intravenous fluid intake every shift, despite orders to monitor intake and output. Additionally, Resident 33's refusal to be weighed was not documented, as the RNA did not know how to record the refusal in the PointClickCare system. This lack of documentation was verified by both RN 3 and the DON, who acknowledged the oversight. Resident 49's medication administration record (MAR) was incomplete, missing documentation for insulin administration, Prevacid, artificial tears, and the use of a left-hand mitten. LVN 15 confirmed the missing entries for two consecutive days, and the DON explained the process for medication administration and the importance of daily audits to capture missing documentation. The charge nurse was responsible for completing audits within 72 hours, but the missing entries were not addressed in a timely manner. For Resident 105, the hospice visitation log was incomplete, missing signatures and dates for visits by hospice staff. The DSD confirmed the missing entries and had contacted the hospice provider to address the issue. Additionally, Resident 41's updated flu vaccination consent was not filed in the appropriate medical records folder. The IP and DON both acknowledged that the consent should have been stored in the resident's medical record, but it was instead kept in a separate binder. These documentation failures were acknowledged by the facility's administration.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies in their practices. The infection control surveillance program was not fully implemented from January 2024 through September 2024. The facility only conducted surveillance on residents who were prescribed antimicrobials, neglecting those who showed signs and symptoms of infection but were not on antibiotics. This oversight was confirmed during an interview with the Infection Preventionist (IP), who admitted that residents not prescribed antibiotics were excluded from the surveillance logs. Additionally, the facility did not ensure proper infection control practices for specific residents. For instance, Resident 775, who had wounds, did not have a physician's order or a care plan for enhanced barrier precautions, which are necessary to prevent infection. Furthermore, tracheostomy supplies in the respiratory carts were not stored properly, as observed during an inspection with the Administrator. The supplies were found without secure closure packages, which the Administrator acknowledged should have been discarded. Other deficiencies included the failure to label a urinal for Resident 43, as required by the facility's policy on disposable equipment. The blood glucose meter in Medication Cart A was also found to be soiled and not cleaned after use, contrary to the facility's policy and the manufacturer's guidelines. These lapses in infection control practices posed a risk for not identifying infections and controlling the transmission of communicable diseases within the facility.
Deficiencies in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP) effectively, as evidenced by several deficiencies in the use of McGeer's criteria for infection assessment and the correct Surveillance Data Collection Forms. Specifically, the facility did not conduct an assessment for McGeer's criteria to determine a true infection for one nonsampled resident. Additionally, the facility used incorrect Surveillance Data Collection Forms for two final sampled residents and four nonsampled residents, which could lead to inaccurate identification of infections. Furthermore, the facility did not properly apply the Surveillance Data Collection Form criteria to indicate a true infection for one final sampled resident and three nonsampled residents. These residents were prescribed antibiotics without meeting the necessary McGeer's criteria for healthcare-associated infections (HAI), as indicated on their Surveillance Data Collection Forms. The Infection Preventionist (IP) and the Director of Nursing (DON) acknowledged these findings during interviews, confirming the failure to adhere to the established infection prevention and control protocols.
Resident Rights Violation Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to respect the resident rights of a nonsampled resident, identified as Resident 35, by allowing a certified nursing assistant (CNA 3) to use a personal cell phone while feeding the resident. This action was observed and reported by another resident, Resident 325, who noted that CNA 3 was on his cell phone multiple times during the feeding process. Resident 35, who is legally blind and cognitively intact, was unaware of the CNA's actions, but Resident 325 found the behavior disrespectful. The facility's employee handbook, which CNA 3 had signed, explicitly prohibits the use of personal electronic devices during work hours. The Director of Nursing (DON) confirmed that staff should not use personal cell phones while providing resident care. During a telephone interview, CNA 3 admitted to using his cell phone three to four times while feeding Resident 35, acknowledging that this was against the facility's policy.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a wound care dressing change for a resident with a Stage 4 sacral coccyx wound. The licensed nurse, identified as LVN 8, did not change gloves or perform hand hygiene between steps of the wound care process. Specifically, after cleaning the resident's stool with a gauze dressing and having stool on his gloves, LVN 8 proceeded to pull back the sacral coccyx wound dressing without changing gloves or performing hand hygiene. Furthermore, after removing the wound dressing, LVN 8 removed his gloves but did not perform hand hygiene before leaving the room to get supplies. Upon returning, LVN 8 donned new gloves and placed clean supplies on the bedside table without sanitizing it. He then cleaned the resident's wound with a clean gauze with saline and covered it with a new dressing. During an interview, LVN 8 acknowledged that he should have changed gloves and performed hand hygiene during the wound dressing change. The Director of Nursing confirmed that LVN 8 did not follow the facility's infection control practices by failing to change gloves and perform hand hygiene between steps of the wound care process.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure the call light for Resident 1 was within the resident's reach, which had the potential for the resident to not be able to call for assistance when needed. During an observation and interview on 5/24/24, Resident 1 was found lying in bed with the call light cord wrapped around the elevated right bedrail and the call light button hanging halfway to the floor, out of reach. Resident 1, who had impaired speech but could verbalize needs and answer simple questions, stated she did not know where her call light was. CNA 1 confirmed that the call light was not within reach and acknowledged that it should have been accessible to the resident. The facility's policy and procedure (P&P) on call lights, revised in May 2007, mandates that the call device be placed within the resident's reach before leaving the room. However, this policy was not followed in Resident 1's case. A follow-up observation on 5/30/24 revealed that Resident 1 was again unable to reach her call light, which was still wrapped around the bedrail and hanging halfway to the floor. Resident 1 was found crying and stated she wanted to be changed because she felt wet. CNA 2 also verified that the call light was not within reach and stated it should have been clipped within Resident 1's reach. The Assistant Director of Nursing (ADON) confirmed that the call device should always be within the resident's reach and acknowledged the findings. This repeated failure to ensure the call light was accessible to Resident 1 indicates a lapse in adhering to the facility's P&P, potentially compromising the resident's ability to call for assistance when needed.
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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