Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Pointe Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were involved in a peer-to-peer altercation when one resident pushed another to the floor, after which the injured resident complained of hip pain. A third resident, also cognitively impaired, reported witnessing the incident, and staff documented the event in progress notes and IDT documentation, including notification of the abuse coordinator, MD, responsible party, and Ombudsman. During a later interview and record review, the DON and Administrator confirmed the altercation occurred and acknowledged there was no documentation that this abuse incident was reported to the Department, despite facility policies prohibiting resident-to-resident abuse and requiring timely reporting of abuse and neglect.
The facility failed to report an allegation of resident-to-resident abuse to the state Department after two residents with cognitive impairment were involved in an altercation in which one pushed the other to the floor, causing pain to the hip area. Documentation in multiple residents’ records described the incident, including a witness report from another resident and notes indicating that the abuse coordinator, MD, responsible party, and Ombudsman were notified. During a later interview and record review, the DON and Administrator confirmed the peer-to-peer altercation and acknowledged there was no documentation that the incident was reported to the Department, despite facility policies requiring investigation and reporting of abuse, including resident-to-resident abuse, within required federal timeframes.
Surveyors found that a personal items cart containing broken glasses, dentures, and hearing aids was left unlocked and unattended in a hallway while several staff walked away and three residents passed by. A CNA reported using the cart to check out dentures, confirmed that three staff had been present before leaving it unlocked, and acknowledged that the cart should remain locked at all times. An LN confirmed that all medication and personal item carts are expected to be locked to prevent resident access, and the DON stated that all carts should be locked, that resident access could lead to accidents and missing items, and that the personal item log binder had missing pages and dates, showing items were not accurately monitored. Facility policy required minimizing environmental hazards and providing adequate supervision of assistive devices.
A resident with advanced cognitive impairment developed blisters on the right hand that were documented by the IDT as a scald injury of unknown origin, with associated pain on touch and subsequent physician orders for daily wound care. The treatment nurse and DON confirmed there was no witness and that the wound provider categorized the injury as a scald, making it an injury of unknown origin. The Administrator acknowledged that this unexplained scald injury was not reported to the state Department as required by facility policy and regulations, resulting in a delay in external investigation.
Failure to Prevent and Monitor Skin Injuries: Two residents with significant cognitive and mobility impairments developed worsening wounds after incomplete skin assessments and inadequate documentation. One resident’s mid-back skin tear was linked to bolster straps and progressed to a deeper wound with slough and surgical excision, while another resident developed an open, infected left elbow wound after daily skin checks and Braden assessments were not accurately completed.
Food Storage and Labeling Failures: Surveyors found wet utensils and wet metal pans stored in clean areas, along with unlabeled and undated food items in the kitchen. They also found expired sandwiches in a fridge in a med room and multiple personal food items in a resident's room that were not labeled or dated. The DM, RD, LN, and DON confirmed the items were not stored or labeled according to facility expectations.
Failure to Identify PTSD and Trauma Triggers: The facility did not identify trauma triggers for multiple residents with PTSD or documented trauma histories. Records showed residents with histories such as combat exposure, domestic violence, sudden loss, and institutionalization, along with behaviors like aggression and refusals of care, but the social history assessments and care plans did not document specific triggers. SSD and nursing staff stated triggers should be in the record, yet they could not locate them for the affected residents.
Staff failed to follow EBP for residents with indwelling urinary catheters by not wearing gowns during high-contact care, including transfers, personal care, and Foley catheter handling. A CNA and another staff member provided care to a resident on EBP with gloves only, and another CNA did the same for a second resident on EBP. The facility also had a clean clothes delivery cart with thick dust inside, and one resident who required EBP had no sign posted outside the room to alert staff and visitors.
A resident with dementia and limited ability to communicate had a court-appointed conservator who stopped paying the resident’s Medi-Cal share of cost while continuing to withdraw the resident’s monthly income. Business office staff repeatedly attempted to contact the conservator, received no response, and suspected financial abuse, notifying social services and requesting that a financial abuse report be made. The SSD contacted the county Public Guardian’s Office about the inability to reach the conservator but did not consider the situation to be financial abuse and did not file any abuse report. The ADM and DON acknowledged that nonpayment and lack of contact were red flags and that facility policy requires all suspicions of abuse, including financial exploitation, to be reported to the state agency, ombudsman, APS, and law enforcement, yet no such reports were made.
A resident with dementia and significant cognitive impairment had a court-appointed conservator who stopped paying the resident’s Medi-Cal share of cost while continuing to withdraw the resident’s monthly income. Business office staff recognized this pattern, suspected financial abuse, and notified social services, but no abuse report or internal investigation was initiated. The ADM acknowledged that the unpaid share of cost and inability to reach the conservator were red flags, yet the facility did not follow its own policy requiring thorough investigation and reporting of all suspected abuse, neglect, or exploitation.
A resident with dementia and metabolic encephalopathy was not protected from financial abuse by her sister, who served as conservator, when the sister failed to pay the resident’s share of cost for months and could not be reached by facility staff. BOA and BOM recognized the unpaid SOC and suspected abuse, but the SSD and ADM treated contacting the county Public Guardian as sufficient despite the ongoing nonpayment and later findings of fraudulent activity in the resident’s account.
A resident with Alzheimer’s disease, muscle weakness, and lack of coordination was observed sleeping with bilateral upper bed rails in place even though the record lacked a physician order, RP consent, a completed bed rail assessment for actual use, and a care plan addressing entrapment risk. The DON acknowledged the facility used bed rails for the resident, but there was no documented order or consent, and the existing assessment indicated bed rails were not planned for use.
Care plan not updated after discontinued splint and fluid restriction orders. A resident with dementia, metabolic encephalopathy, and right hand contracture remained on care plans for a right hand splint and strict fluid restriction even after both physician orders were discontinued. Records and observations showed the splint was still being applied daily and fluid restriction was still being documented, while the DON and UM confirmed the care plans were not revised to reflect the discontinued orders.
Two residents with significant ADL assistance needs were observed with long fingernails and blackish substance underneath while eating and in their rooms. One resident had schizophrenia and needed substantial help with bathing and personal hygiene, and the other had metabolic encephalopathy, diabetes, and severely impaired cognition with dependence for bathing and personal hygiene. Staff confirmed the nail care issue, and the record review showed no documented refusals of nail care.
A resident with an indwelling Foley catheter, severe cognitive impairment, and urinary retention was observed multiple times with the catheter drainage bag left on the floor. Staff confirmed the bag should be hanging off the floor to avoid infection and urinary complications, and the facility’s catheter care policy required the tubing and drainage bag to be kept off the floor.
Unlabeled Oxygen Tubing and Cannulas: A resident with COPD and moderately impaired cognition was observed using oxygen via multiple delivery systems, and the tubing/nasal cannulas for the concentrator, nebulizer, and wheelchair tank were not labeled with the date first used. The resident could not recall when the tubing had last been replaced, an LN confirmed the lack of labeling, and the DON stated tubing should be changed every 7 days and labeled with the date, resident identifier, and nurse initials.
A resident with diagnoses including HTN, DM, and metabolic encephalopathy, and with severely impaired cognition, was ordered a 2 Gm low sodium diet but was served a meal tray that included a packet of iodized salt. The resident said the salt was not requested, CNA confirmed staff provide salt packets to residents on 2g Na diets, and an LPN confirmed the resident should not have been given extra salt. The RD stated residents on a 2-gram sodium diet should not receive salt packets, and the DON stated prescribed diets must be followed.
Broken window blinds were found in three resident rooms, including rooms occupied by multiple residents. The ADON, DON, MAs, and CNAs confirmed the blinds were broken, with staff stating the issue should have been reported to maintenance and entered in the maintenance log. One CNA also reported a resident near the window was grabbing the blinds. The facility policy stated residents should be provided a safe, clean, comfortable, and homelike environment.
Excess Residents in Multiple Shared Rooms: Six resident rooms had more than four residents each, including rooms with 5 or 6 residents. Surveyors observed privacy curtains, bedside tables, and enough space for residents, assistive devices, and care equipment, and residents and staff stated the rooms had adequate space and privacy during care.
Resident rooms with six beds each did not meet the minimum square footage requirement per resident. During a tour, the rooms were observed to be uncluttered and usable for resident care, and residents and staff stated there was enough space for care and assistive devices. However, the Maintenance Supervisor measured the usable living space and confirmed both rooms were only 70.56 sq ft per resident, below the required 80 sq ft minimum.
A resident with cognitive impairment and limited mobility suffered multiple facial lacerations and bruising after being struck by another resident with a known history of verbal and physical aggression. Despite repeated documentation of threats and aggressive behaviors, interventions such as monitoring and redirection were not effective in preventing the incident, leading to significant injury and pain for the affected resident.
A resident with moderate cognitive impairment became physically aggressive toward a CNA, who then pushed the resident in the face, causing a fall and unresponsiveness. The resident was transferred to the hospital for evaluation. Staff interviews confirmed the CNA's actions were abusive and not in line with facility policy or training.
A resident with dementia and schizophrenia was abused by an LPN who hit her in the face, causing abrasions, after the resident refused medication and became agitated. Witnesses reported the incident, and the facility's administrator confirmed the nurse's behavior was unacceptable, leading to her termination.
The facility failed to maintain resident dignity and privacy, as observed in several incidents. A resident with cognitive impairment was not given privacy during phone calls, while another resident reported being ignored by staff and having their privacy invaded by other residents. During meals, residents were referred to as 'feeders' and not asked about wearing bibs, and a CNA fed residents while standing. Additionally, a resident was administered medication without privacy, exposing their body to others.
The facility failed to complete and update POLST forms for several residents, leading to potential non-compliance with residents' wishes during emergencies. Two residents had unsigned POLST forms lacking Advance Directive information, while two others had discrepancies between paper records and EMR regarding code status. Staff interviews revealed a lack of clear procedures for managing POLST forms.
A facility failed to provide a homelike environment for three residents by not having clocks in their rooms, affecting their ability to engage in activities and maintain orientation to time. Residents with severe memory impairments expressed the need for clocks, and staff confirmed their absence, despite facility policies emphasizing person-centered care.
The facility failed to maintain accurate pharmacy services, with an inaccurate controlled drug destruction log and unaccounted doses of lacosamide in a medication card. The DON confirmed the oversight in logging 20 syringes of Lorazepam and acknowledged the risk of drug diversion. Additionally, a medication card contained two doses in a single unit, posing a risk of double dosing a resident.
Two residents were prescribed psychotropic medications without adequate indication or documented attempts at non-pharmacological interventions. One resident was given Zyprexa despite not exhibiting behaviors that posed a danger, and another was prescribed risperidone without clear target behaviors. The facility failed to follow its policy on antipsychotic medication use, leading to unnecessary medication administration.
A LTC facility failed to maintain a medication error rate below five percent, with errors involving two residents. One resident with diabetes received insulin after breakfast instead of before, as per physician's orders, and another resident did not receive their prescribed folic acid due to its unavailability in the medication cart. The LNs involved did not follow facility policies regarding medication administration and documentation.
A resident with Type 2 Diabetes and severe cognitive impairment received insulin aspart not in accordance with physician orders. The insulin was administered based on a blood sugar reading taken before breakfast, and after the resident had eaten, contrary to the sliding scale order. The nurse confirmed the resident had refused insulin earlier, but this was not documented. The facility's policy required verification of insulin administration and notification of refusal, which was not followed.
The facility failed to properly store and label medications, with issues including improper storage of Acidophilus, expired and discontinued medications available for use, and loose pills and supplies in the medication cart. Additionally, refrigerator temperatures for medication storage were not maintained, resulting in frozen insulin.
The facility was found to have deficiencies in food storage and sanitation procedures, including dirty kitchen vents and floors, worn and unsanitary food preparation equipment, and improperly labeled and stored food items. Kitchen staff were unable to demonstrate proper sanitation testing procedures, posing a risk of contamination and food-borne illnesses.
The facility failed to maintain infection control measures, as a CNA did not perform hand hygiene between feeding residents, and Resident 20's nasal cannula and nebulizer mask were not stored properly. Additionally, food items and nail clippers were improperly stored in a medication cart, violating facility policy.
A resident with severe cognitive impairment and multiple diagnoses experienced acute vision loss, but the LTC facility failed to send her to the hospital promptly. Despite increased confusion and inability to see, the facility opted to monitor her condition rather than seek immediate medical intervention. The resident was eventually diagnosed with bilateral retinal detachment and macular holes, highlighting a deficiency in timely care.
A resident was found with nasal spray at the bedside without an assessment or order to self-administer medication. Despite being cognitively intact, the resident used his own medication due to unaddressed requests for a prescription. The facility's policy requires documented authorization for self-administration, which was not followed.
A computer on a medication cart was left open in a hallway, displaying confidential resident information, which was confirmed as a HIPAA violation by the Wound Nurse. Licensed Nurse 1 admitted to leaving the computer open, and both the ADON and DON stated that staff are expected to lock screens when not in use to protect resident privacy.
A resident with chronic lung disease and anxiety did not receive timely allergy medication due to the facility's failure to follow up on his requests. Despite being cognitively intact and repeatedly asking for Fluticasone, the medication was not ordered or administered. Interviews revealed a communication breakdown, as a physician's note approving the medication was not transcribed into the resident's record.
A resident with severe cognitive impairment was observed with black material under her fingernails, indicating a failure in grooming services. Despite requiring moderate assistance for personal hygiene, her nails were not cleaned as per facility policy. Staff confirmed the resident's nails were dirty, and the DON stated nails should be cleaned during showers and as needed.
A facility failed to follow the activity care plan for a resident with severe cognitive impairment, as documented in their MDS. The resident was often observed without sensory stimulation or interaction, and staff interviews revealed a lack of awareness and documentation of activities. The Activity Director admitted to documentation issues due to problems with the POC system, which was the only method used. The facility's policy required documentation of activities, which was not followed, leading to a deficiency.
A resident with a physician's order for a hand roll to prevent contracture did not receive it, as observed over several days. Staff were unaware of the order, and the care plan did not address the contracture. Nurses inaccurately documented the presence of the hand roll, and the facility lacked a policy on contracture prevention.
The facility was found to have six rooms accommodating more than the allowed number of residents, with some rooms having five or six residents. Despite adequate space and privacy measures, the occupancy exceeded regulatory limits. Staff and a resident's responsible party reported no issues with space or care provision.
Two resident rooms in an LTC facility were found to be below the required 80 square feet per resident, measuring only 70.56 square feet each. Despite staff and family members expressing no concerns about space adequacy, the facility did not meet federal physical environment standards. A program flexibility approval was in place, but the deficiency was confirmed by the Maintenance Supervisor.
A resident with severe cognitive impairment was slapped by a hospitality aide (HA) during mealtime assistance, despite having a care plan to manage potential aggression. The HA admitted to reacting inappropriately due to frustration. The incident was witnessed by a CNA and confirmed by facility staff, indicating a failure to protect the resident from abuse.
A resident with severe cognitive impairment and fall risk was not provided with hip protectors as directed by their care plan, leading to a fall and hip fracture. Despite the care plan's directive, there was no documentation of hip protector use, and staff were uncertain about their availability. This deficiency in implementing the care plan contributed to the resident's injury and subsequent death.
A resident with an ileostomy experienced increased redness and irritation at the stoma site due to the facility's failure to implement and update the care plan. Despite physician's orders and a care plan noting non-compliance with treatment, interventions were not effectively followed. The resident's ileostomy bag leaked, and staff did not adequately document or report the issue, leading to further skin irritation.
The facility failed to protect residents from abuse, resulting in one resident sustaining a hip fracture after another resident pulled his walker, and another resident being punched in the face during an altercation. Both incidents involved residents with cognitive impairments and behavioral issues, highlighting a failure to monitor and manage aggressive behaviors effectively.
A resident with dementia and chronic congestive heart failure was not properly monitored for fluid intake, despite having a fluid restriction order. The resident's eMAR showed consistent overconsumption of fluids, and staff were not adequately informed or monitoring the situation. The facility's policy on fluid restriction was not followed, and there was no care plan in place to address the resident's noncompliance.
A resident with Alzheimer's and other conditions was photographed in an undignified state by facility staff after a fall. The photo, taken with an unsecured facility cell phone, showed the resident with pants down, attempting to cover himself. Interviews revealed a lack of clear procedures for photographing residents, and the facility's policies emphasize dignity and privacy, which were violated in this incident.
A resident with Alzheimer's Disease experienced an unwitnessed fall, resulting in a lip injury, but the facility failed to notify the responsible party and physician until the next day. Despite the facility's policy requiring immediate notification, staff interviews revealed a delay in following the fall protocol, leading to a deficiency in handling the incident.
A resident with Alzheimer's and other conditions experienced an unwitnessed fall, but the facility failed to document the incident or initiate immediate neurological checks as required by protocol. Interviews with staff revealed that the checks were only started the following day, contrary to the facility's policy on fall management.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse when one resident pushed another resident to the floor, and the incident was not reported to the state agency as required. Resident 1, admitted in January 2025 with dementia and documented as having moderate cognitive impairment on an MDS dated 3/3/25, was pushed by Resident 2 on 2/6/25. A progress note for Resident 1 on that date documented that another resident (Resident 3) reported Resident 1 had been pushed by Resident 2, that Resident 1 was found lying on his back on the floor, and that when Resident 1 began walking he verbalized left hip pain. The abuse coordinator was notified. Resident 2’s record showed an admission diagnosis of bipolar disorder and severe cognitive impairment on an MDS, and a change-of-condition note dated 2/6/25 documented that Resident 3 reported Resident 2 pushed Resident 1 when he entered their shared room, causing Resident 1 to fall to the floor on his back. Staff responded after hearing loud voices and found Resident 2 standing in the room and Resident 1 lying on his back on the floor; both residents were unable to explain what happened. An IDT note for Resident 2 dated 2/7/25 reiterated that, per the licensed nurse, Resident 3 reported Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor on his back, and documented that the abuse coordinator, physician, responsible party, and Ombudsman were notified. Resident 3’s record showed admission in January 2025 with multiple left rib fractures and moderate cognitive impairment on an MDS dated 2/17/25, and a social services note dated 2/7/25 indicated Resident 3 reported witnessing a peer-to-peer altercation in her room. During an interview and concurrent record review on 3/27/25 with the DON and Administrator, they confirmed that a peer-to-peer altercation occurred between Resident 1 and Resident 2 on 2/6/25 and acknowledged there was no documented evidence that this peer-to-peer abuse incident was reported to the Department. This failure occurred despite facility policies stating that abuse of any kind, including resident-to-resident abuse, is prohibited and that allegations of abuse and neglect must be investigated and reported within required federal timeframes.
Failure to Report Resident-to-Resident Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state Department as required by regulation after one resident was pushed to the floor by another resident. Resident 1, admitted in January 2025 with dementia and documented moderate cognitive impairment on an MDS dated 3/3/25, was involved in a peer-to-peer altercation on 2/6/25. A progress note for Resident 1 dated 2/6/25 documented that, per Resident 3, Resident 2 entered the room and pushed Resident 1, causing Resident 1 to fall to the floor on his back and complain of left hip pain. The abuse coordinator was notified, but there was no documentation that the Department was notified of this abuse incident. Resident 2, admitted with bipolar disorder and severe cognitive impairment per an MDS, had a progress note dated 2/6/25 describing that Resident 2 pushed Resident 1, resulting in Resident 1 falling to the floor. An IDT note dated 2/7/25 further documented that a licensed nurse reported the 2/6/25 incident, and that the abuse coordinator, MD, responsible party, and Ombudsman were notified. Resident 3, admitted in January 2025 with multiple left rib fractures and moderate cognitive impairment, reported in a social services note dated 2/7/25 that she witnessed the peer-to-peer altercation in her room and felt uncomfortable. During an interview and record review on 3/27/25, the DON and Administrator confirmed the 2/6/25 altercation between Resident 1 and Resident 2 and acknowledged there was no documented evidence that the peer-to-peer abuse was reported to the Department, despite facility policies requiring investigation and reporting of abuse, including resident-to-resident abuse, within required federal timeframes.
Unlocked Personal Items Cart with Hazardous Contents Left Unattended in Hallway
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a personal items cart containing resident belongings was left unlocked and unattended in a hallway. During an observation near a resident room, three nursing staff were present at the personal items cart and then left it unlocked. A subsequent observation showed the cart still unlocked while three residents walked by it. The cart contained items such as a pair of broken glasses, resident dentures, and resident hearing aids, and was easily accessible to residents in the hallway. In a concurrent observation and interview, a CNA stated she had checked out resident dentures from the cart, confirmed that three nursing staff had been present when she left, and acknowledged that the cart remained unlocked with no staff present. The CNA stated the cart should be locked at all times and that residents could harm themselves with items such as the broken glasses or dentures if not supervised. An LN confirmed that all medication and personal item carts should be locked to prevent resident access and that accessing the personal items cart could result in an accident for residents who wander. The DON stated the expectation is for all carts in the facility to be locked, confirmed that resident access to the cart items could have led to an accident and missing resident items, and acknowledged that there were missing pages and dates in the personal item log binder, indicating items were not monitored accurately. Review of the facility’s Safety/Supervision policy showed it required making the environment as free from hazards as possible and targeting interventions to reduce risks related to environmental hazards, including adequate supervision of assistive devices.
Failure to Report Scald Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the state Department as required by regulation. A resident with Alzheimer's disease, admitted in June 2024, had an MDS dated 12/22/25 indicating no cognition score could be determined. On 2/19/26, staff notified a nurse of blisters on the resident's right hand with an unknown cause, and the resident exhibited facial grimacing when the area was touched. An IDT skin management note on the same date documented a right dorsal hand scald injury measuring 8.0 x 6.0 x 0.1 cm, with the appearance consistent with a scald injury and no documentation of the cause. A physician order dated 2/27/26 directed daily treatment to the right dorsal hand scald injury with cleansing, bacitracin ointment, xeroform, and dry dressing until 3/12/26. On 3/4/26, the resident was observed in the dining room with a bandage on the right hand. During interviews, the treatment nurse confirmed that the wound provider identified the wound as a scald injury and that the injury was of unknown cause. The DON confirmed there was no witness to the incident, that the resident sustained an injury of unknown origin, and that the wound doctor categorized the injury as a scald. The Administrator confirmed the injury was of unknown cause and acknowledged that he did not report the incident of unknown origin to the Department, resulting in a delay of the Department’s investigation. Facility policies on identifying types of abuse and unusual occurrence reporting defined physical abuse to include unexplained injuries and required reporting of allegations of abuse and unusual occurrences to appropriate agencies within 24 hours, but this incident was not reported as required.
Failure to Prevent and Accurately Monitor Skin Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and monitor skin injuries for two residents who were at risk for pressure injuries and other wounds. Resident 4 had multiple diagnoses including metabolic encephalopathy, dementia, and functional quadriplegia, and was non-ambulatory, totally dependent for ADLs, and incontinent. A Braden Scale placed the resident at high risk for pressure ulcer development, with inability to communicate discomfort and frequent sliding in bed or chair. Although the care plan addressed daily body assessments and monitoring for skin injury, it did not include interventions for friction and shearing risk, and it did not address the bolster mattress overlay or the need to check the resident’s skin under bolster straps and Velcro. Resident 4 developed a skin tear to the mid lower back that was later documented as an abrasion and then classified as a pressure injury. The wound documentation did not consistently include the wound description, measurements, surrounding skin, drainage, or signs of healing as directed by the care plan. The wound progressed from a skin tear to a deeper wound with slough, and a surgical consult documented that the resident developed a traumatic injury to the back due to exposure to bolster straps and required a surgical procedure to remove dead, damaged, or infected tissue. During interviews, the DON acknowledged that the bolster straps caused the skin tear and that the wound worsened, and stated that the resident’s wound could have been avoided if staff had assessed the position of the bolster straps when repositioning the resident. Resident 32 was admitted with dementia, communication deficit, and muscle weakness, and was assessed as having severely impaired cognitive skills and risk for pressure injuries, but no open wound on admission. The care plan directed staff to check the resident’s skin during daily care and later added shift assessments for the left elbow wound, including size, depth, tissue type, drainage, odor, and surrounding skin. However, Braden Scale assessments were incomplete, daily bathing flowsheets and nursing evaluations documented no open areas or clear skin before the wound was identified, and the DON acknowledged those records were not accurate. When the left elbow wound was discovered, it was already a full-thickness open wound with exposed subcutaneous tissue, later showing drainage, slough, redness, swelling, and infection requiring antibiotics. The DON stated the wound could not have developed overnight and that nurses were expected to perform thorough skin assessments to identify skin issues.
Food Storage and Labeling Failures
Penalty
Summary
The facility failed to ensure food was labeled, prepared, stored, served, and distributed in accordance with professional food safety standards. During kitchen observations, multiple wet kitchen utensils were stored in a bin labeled for utensils, and multiple large metal pans used for distributing food were stacked wet in the clean and ready-to-use area. Surveyors also found an unlabeled container with a food product inside, a maple syrup container without an expiration date, and two opened pancake mix bags that were not labeled with an open date. The Dietary Manager and Registered Dietitian confirmed that utensils and pans should have been properly dried before storage and that opened food items should have been clearly labeled with an open date. In the medication storage room of Nursing Station 2, a bag containing six sandwiches was observed in the refrigerator with a use-by date of 1-5-26. The Licensed Nurse confirmed the date was past the use-by date and stated the sandwiches should have been removed. The Registered Dietitian and Director of Nursing later confirmed that resident food items are to be labeled with a use-by date and removed when past that date, and that nurses are expected to check the refrigerator each shift for expired items. In Resident 90's room, personal food items were observed at bedside without labels or dates, including canned diet soda, chocolate pudding containers, opened bags of chips and crackers, coffee creamers, and other dry food items. Resident 90 stated the food had been delivered by her daughter and that staff had not labeled it, and she reported that another resident had previously taken cereal from her room. The DON later observed the same items unlabeled and undated and confirmed that all personal food items needed to be labeled and dated with an expiration date. The facility policy stated that resident-owned foods kept on the nursing units must be labeled with the resident's name, the item, and the use-by date.
Failure to Identify PTSD and Trauma Triggers
Penalty
Summary
The facility failed to identify trauma triggers for six sampled residents with PTSD or documented traumatic events: Resident 2, Resident 9, Resident 29, Resident 113, Resident 93, and Resident 152. The report states that these residents had diagnoses such as PTSD, dementia, bipolar disorder, schizophrenia, depression, anxiety, Parkinson’s disease, hemiplegia, and vascular dementia, and several had moderate cognitive impairment based on BIMS scores. Their records showed trauma histories including combat or exposure to a war-zone, domestic violence, sudden unexpected death of a spouse, institutionalization for mental illness, a transportation accident, severe human suffering, and other stressful life events. For Resident 2, the record showed PTSD, moderate cognitive impairment, and a social history listing traumatic events such as a transportation accident, combat or exposure to a war-zone, life-threatening illness or injury, severe human suffering, and sudden unexpected death of someone close to the resident. The care plan referenced anger, poor impulse control, and repeated physical and verbal aggression, and later trauma-informed care interventions, but the record did not identify PTSD triggers. The SSD stated the PTSD assessment was included in the social history assessment but acknowledged there was no indication of Resident 2’s triggers in that assessment, and staff interviews showed nurses did not know where to locate trigger information in the record. For Resident 9, the record showed chronic PTSD, dementia, and behaviors including verbal aggression and refusals of care. The resident’s social history identified the resident as a veteran, but the trauma history section did not mark combat, captivity, or severe human suffering and instead indicated none of the listed events had occurred. The trauma-informed care plan did not contain triggers or behaviors related to combat or war-zone exposure. For Resident 29 and Resident 113, the records showed trauma histories including institutionalization, loss of a child to CPS, combat or exposure to a war-zone, and PTSD, but their care plans stated no triggers were identified. For Resident 93, the record documented PTSD related to domestic violence with a husband many years ago, but neither the social history assessment nor the care plan identified triggers. For Resident 152, the social history documented combat or exposure to a war-zone, and the care plan referenced PTSD and trauma, but no trigger(s) were identified; the SSD confirmed the record did not identify what to avoid to prevent re-traumatization. The facility policy required trauma-informed care, screening, and identification of trauma history and triggers, but the records and staff interviews showed these triggers were not identified for the sampled residents.
Infection Control Failures With EBP Use and Dirty Linen Cart
Penalty
Summary
The facility failed to follow its infection prevention and control program for residents on enhanced barrier precautions (EBP) and for clean linen handling. Resident 38 had diagnoses including dementia, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, urinary retention, catheter use, and muscle weakness. His MDS indicated severely impaired cognition and use of an indwelling urinary catheter. His care plan and physician orders required EBP for the Foley catheter, and EBP signage was posted outside his room stating that gloves and a gown were required for high-contact care activities such as dressing, transferring, hygiene, changing briefs, and device care. During an observation in Resident 38’s room, two staff members changed his shirt, put on his briefs, transferred him from a shower chair to his bed, and handled his Foley catheter while wearing gloves only and not wearing gowns. Afterward, they emptied his catheter bag into a urinal while still wearing only gloves. In interview, CNA 3 confirmed that she and another staff member did not wear gowns during those tasks and stated they should have worn gowns to prevent possible infection. The IP and DON stated that staff should wear both gloves and gowns when providing high-contact care to a resident on EBP, including transferring, assisting with personal care, and handling the Foley catheter. The facility also failed to maintain a clean delivery cart used for resident clothing. During observation, a staff member was delivering clean resident clothes using a cart covered with reddish mesh tarp, and thick layers of dust were observed on the inside surface of the cart. Laundry staff confirmed the dust and stated the cart should always be clean to prevent contamination of clean resident clothes. The Laundry Director and IP stated the delivery cart should be cleaned before and after use and should not have dust inside because dirty carts can contaminate clean linen and contribute to infection. Resident 32 also had an indwelling urinary catheter and an order for EBP every shift. Although EBP signage was posted outside the room indicating gloves and gowns were required for high-contact care and catheter care, CNA 16 entered the room wearing gloves only and did not wear a gown while assisting with transfer from wheelchair to bed, handling the urinary catheter, and rearranging linens and blankets. CNA 16 acknowledged not following the facility’s process and not wearing a protective gown. Resident 125 had an indwelling urinary catheter and care plan instructions for EBP with signage near the room doorway, but during observation there was no EBP sign posted outside the room. CNA 7 and LN 6 confirmed the missing sign, and LN 6 stated the resident should have had EBP signage at the door.
Failure to Report Suspected Financial Exploitation to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and exploitation reporting policies and procedures when staff suspected financial exploitation of a resident. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and a need for assistance with personal care, and an MDS assessment indicated the resident was rarely or never understood. The business office identified that the resident’s conservator, who was also the resident’s sister and responsible person, had not paid the resident’s Medi-Cal share of cost since it began generating, while the Public Conservator’s office later found that the sister had been withdrawing the resident’s full monthly income except for bank fees. Despite these circumstances, no report of suspected financial abuse was made to the state agency, local ombudsman, APS, or law enforcement as required by facility policy and section 1150B of the Act. The Business Office Assistant stated that she called the resident’s sister weekly or every other week without response and suspected financial abuse, which she reported to the Social Services Director (SSD). The Business Office Manager confirmed that the share of cost had not been paid since March 2024 and documented an internal communication to the SSD requesting a financial abuse report for the resident. The SSD acknowledged difficulty reaching the sister and documented contacting the county Public Guardian’s Office to ask if a referral was appropriate, learning that the court had already initiated a process to transfer conservatorship. However, the SSD stated she did not suspect financial abuse at that time and confirmed that no abuse report was made regarding this resident. The Administrator reported that the facility’s process for any suspicion of abuse was to notify him first, then report the suspicion and conduct an internal investigation, and that the facility’s policy required reporting all suspicions of abuse, including financial abuse, to specified agencies. The Administrator agreed that the lack of response from the conservator and the nonpayment of share of cost for months were red flags, and confirmed that the resident’s share of cost started in March 2024 and was not paid by the conservator. The Director of Nursing stated that all suspicions of resident abuse should be reported so they can be thoroughly investigated. Review of the written policy confirmed that suspected abuse, neglect, exploitation, or misappropriation must be reported immediately to the Administrator and to state licensing/certification, the ombudsman, APS, and law enforcement, but no such reports were made in this case despite staff suspicions and internal communications referencing possible financial abuse.
Failure to Investigate and Report Suspected Financial Abuse by Conservator
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation reporting and investigation policies in response to a reasonable suspicion of financial abuse of a resident under conservatorship. The resident was admitted with diagnoses including metabolic encephalopathy, dementia, and a need for assistance with personal care, and an MDS cognitive assessment indicated the resident was rarely or never understood. A complaint letter from the Department of Justice stated that the resident’s sister, who was the conservator, had not paid the resident’s share of cost since March 2024, while bank records showed the sister withdrawing the resident’s full monthly income minus bank fees. The Business Office Assistant and Business Office Manager confirmed that the resident’s share of cost had not been paid since it began generating and that repeated calls to the resident’s sister/responsible person went unanswered. The Business Office Manager documented that she suspected financial abuse and, through the facility’s internal communication system, requested that the Social Services Director complete a financial abuse report for the resident. The Social Services Director acknowledged being contacted about the issue and stated that she reached out to the county Public Guardian’s Office because the facility could not reach the conservator and there were outstanding balances, but she reported that she did not suspect financial abuse at that time and confirmed that no investigation was conducted by the facility regarding this resident’s case. The Administrator stated that the facility’s process for any suspicion of abuse was to notify him first, then report the suspicion and conduct an internal investigation, and that the facility’s policy required all allegations of resident abuse, neglect, exploitation, or misappropriation to be reported to appropriate agencies and thoroughly investigated. The Administrator acknowledged that the lack of response from the conservator and nonpayment of the share of cost for months were red flags but stated there was no evidence of fiduciary abuse, and therefore the issue was not reported as abuse. The Administrator further confirmed that the resident’s share of cost started in March 2024 and was not paid by the conservator, that multiple attempts were made to contact the conservator, and that after contact with the Public Guardian’s Office, the facility did not conduct its own investigation into possible financial abuse. The Director of Nursing stated that all suspicions of abuse should be thoroughly investigated to prevent further abuse, underscoring that the facility did not follow its own policy and procedures in this case.
Failure to Protect Resident from Financial Abuse by Conservator
Penalty
Summary
The facility failed to protect one resident from financial abuse by a family member/legal representative when the resident’s sister, who was also the conservator, did not pay the resident’s share of cost for an extended period. Resident 42 was admitted in May 2023 and had diagnoses including metabolic encephalopathy, dementia, and need for assistance with personal care. The resident’s MDS cognitive patterns dated 11/24/25 indicated the resident was rarely/never understood. Facility staff identified that the resident’s sister had not paid the share of cost since March 2024. The Business Office Assistant stated she called the sister weekly or every other week without response and suspected financial abuse, which she reported to the Social Services Director. The Business Office Manager confirmed the unpaid share of cost and stated she contacted social services on 4/22/25 to request a financial abuse report. The Social Services Director stated she contacted the county Public Guardian’s Office on 1/30/25 because the facility could not reach the sister, but she did not suspect financial abuse at that time because she only knew the sister could not be contacted and there were remaining balances. The facility’s transaction report showed unpaid share of cost amounts of $15,594 from March 2024 to January 2025 and $21,412 from March 2024 to May 2025. The Administrator stated contacting the Public Guardian’s Office was enough action and said there was no evidence of fiduciary abuse, despite acknowledging it was a red flag that the conservator was not answering calls and was not paying the share of cost for months. The Adult Protective Services Supervisor later stated the Public Conservator’s Office found fraudulent activities in the resident’s account. The facility policy stated residents have the right to be free from abuse by anyone, including family members and legal representatives.
Unapproved Bed Rail Use Without Assessment or Care Plan
Penalty
Summary
The facility failed to ensure Resident 149 was free from the use of physical restraints when bilateral upper bed rails were in use without a physician order, without approval from the resident’s representative, without a completed bed rail assessment for the actual use of the rails, and without a care plan addressing entrapment risks. Resident 149 was admitted in 2023 with diagnoses including Alzheimer’s disease, muscle weakness, and lack of coordination. The record also included a physician order dated 8/15/25 stating the resident was not capable of understanding rights and responsibilities. The clinical record contained a Bed Rail and Entrapment Risk Observation/Assessment dated 5/16/25, but it indicated bed rails were not currently in use and were not considered to be used, with the medical conditions section left blank. The order summary did not contain a physician order for bilateral bed rails, and the MDS dated 11/10/25 indicated the facility did not use physical restraints, including bed rails. Despite this, surveyors observed Resident 149 sleeping in bed with both upper side rails up on 1/6/26 and again on 1/8/26. During interviews, the DON stated the facility used bed side rails for some residents, acknowledged there was no physician order or documented consent from the resident’s RP for Resident 149, stated the assessment was not completed because it indicated no bed rails were planned, and confirmed there was no care plan with resident-specific interventions addressing bed rails.
Care plan not updated after discontinued splint and fluid restriction orders
Penalty
Summary
The facility failed to update and revise Resident 4’s care plans after physician orders for a right hand splint and strict fluid restriction were discontinued. Resident 4 was admitted in 2015 with diagnoses including metabolic encephalopathy, dementia, muscle weakness, and contracture of the right hand. The resident’s MDS dated 9/29/2025 indicated severely impaired cognitive skills, limitations to the upper extremities, and total dependence on staff for all ADLs. A review of the resident’s records showed that the care plan for splinting, last revised on 12/23/25, still stated that Resident 4 required splinting to the right hand for 2 hours a day, 7 days a week, even though the physician order for the splint to the right upper extremity had been discontinued on 12/2/25. During observation on 1/6/26, Resident 4 was in bed with a splint on the right hand, and flow sheets from 12/11/25 through 1/8/26 showed the splint was applied every day. Licensed staff and restorative staff confirmed that the splint continued to be applied and that they were not aware the order had been discontinued. The resident’s care plan for nutrition and fluid restriction, initiated 4/2/24 and last revised on 12/23/25, still identified fluid restriction of 1.5 liters as an intervention even though the physician order for strict fluid restriction had been discontinued on 10/31/25. Flow sheets from 12/11/25 through 1/8/26 continued to document strict fluid restriction of 1.5 liters in 24 hours. The DON stated care plans were required to be reviewed and revised after a change in condition or when an order was discontinued, and the UM confirmed that licensed staff did not revise or update the care plans addressing the resident’s splint and fluid restriction.
Failure to Provide Nail Care for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received nail care as part of assistance with activities of daily living. Resident 13 had diagnoses including schizophrenia, muscle weakness, and need for assistance with personal care. Her MDS indicated she was rarely or never understood and needed substantial to maximal assistance with showering/bathing and personal hygiene, with supervision or touching assistance for eating. Her care plan identified her as at risk for ADL/mobility decline and included an intervention to trim nails with the bathing schedule. Resident 146 had diagnoses including metabolic encephalopathy, diabetes, lack of coordination, and muscle weakness. His MDS showed a BIMS score of 7 out of 15, indicating severely impaired cognition, and he needed supervision or touching assistance with eating and was dependent for showering/bathing and personal hygiene. His care plan also identified ADL/mobility decline risk and need for assistance, and the facility shower schedule showed both residents were scheduled for bathing on Wednesdays and Saturdays. During observations, both residents were seen with long fingernails and blackish substance underneath their nails while eating meals and in their rooms. Each resident stated he or she wanted the fingernails cleaned and trimmed properly. A LN confirmed Resident 13 had long fingernails with blackish substance underneath and stated the nails should be trimmed and cleaned to prevent infection or skin injuries. A CNA confirmed the same for Resident 146 and stated nail care should be done daily and especially during shower days. Record review showed no documented refusals of nail care, and the DON stated nail care would be expected during shower days and every Sunday, with all residents' fingernails trimmed and cleaned properly.
Foley Catheter Drainage Bag Left on Floor
Penalty
Summary
The facility failed to ensure appropriate catheter care for one resident with an indwelling Foley catheter. Resident 38 was admitted with diagnoses including dementia, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, urinary retention, catheter use, and muscle weakness. The resident’s MDS indicated severely impaired cognition and use of an indwelling catheter. The care plan identified the resident as at risk for urinary system complications related to the indwelling catheter and directed staff to provide catheter care and empty the catheter every shift and as needed. During observations, Resident 38 was found lying in bed with the urinary catheter tubing attached to a drainage bag that was on the floor. This was observed on 1/6/26 at 9:24 a.m., again during a concurrent observation and interview at 12:51 p.m. with LN 2, and again on 1/8/26 at 10:32 a.m. with CNA 4. LN 2 confirmed the bag should not be left on the floor because it may cause infection and urinary complications. CNA 4 also confirmed the bag should be hanging and off the floor to prevent backflow of urine and risk for infection. The DON stated urinary catheter bags should always be hanging and off the floor because of the risk of infection and to prevent urine from flowing back, which could cause urinary complications. The facility’s catheter care policy stated the catheter tubing and drainage bag should be kept off the floor.
Unlabeled Oxygen Tubing and Cannulas
Penalty
Summary
Proper handling and delivery of respiratory care was not ensured for one resident who was admitted in June 2025 and had diagnoses including COPD and muscle weakness. The resident’s MDS indicated a BIMS score of 10 out of 15, showing moderately impaired cognition. The resident had active orders for oxygen at 0.5-3 lpm via nasal cannula for COPD/SOB, along with ipratropium-albuterol nebulizer treatments three times daily, and orders to change the humidifier bottle and tubing every night and change the nasal cannula every Wednesday. During observation and interview, the resident was using an oxygen concentrator at 3 lpm via oxygen tubing/nasal cannula, and the tubing/nasal cannulas for the oxygen concentrator, the nebulizer by the bed, and the oxygen tank on the wheelchair were not labeled with the date first used. The resident confirmed the tubing was not labeled and could not recall when it had last been replaced. An LN confirmed the tubing was not labeled and stated it should have been dated when first opened. The DON stated the expectation was for nurses to change tubing for all oxygen delivery systems every seven days and label it with the date, resident identifier, and nurse initials. The facility policy stated oxygen cannulae and tubing are to be changed every seven days or as needed.
Salt Packet Served With Prescribed Low-Sodium Meal
Penalty
Summary
The facility failed to provide food in accordance with the physician’s prescribed diet for one resident who was ordered a 2 gram low sodium diet. The resident had diagnoses including metabolic encephalopathy, diabetes, and hypertension, and the MDS indicated severely impaired cognition, therapeutic diet use, and a need for supervision or touching assistance with eating. The resident’s care plan directed that diet be provided as ordered, and the active physician’s order specified a 2 Gm low sodium diet with minced and moist texture and moderately thick consistency pureed fruits and vegetables. During lunch observation, the resident was seen eating a meal tray that included a packet of iodized salt, and the meal ticket identified the diet as 2g Na. The resident stated the salt packet was served with the meal and was not requested. CNA 1 confirmed the resident was served a salt packet and stated staff provide salt packets to residents with 2g Na diet orders. LN 1 also confirmed the salt packet was served despite the diet order and stated the resident should not be provided extra salt. The RD stated residents on a 2-gram sodium diet should only have 2 grams of salt intake for the whole day and should not be provided salt packets, and the DON stated the prescribed diet should always be followed because the resident’s medical condition could be affected and get worse.
Broken Window Blinds in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe and homelike environment when horizontal blinds in three resident rooms were observed broken. On 1/6/26, the blinds in one room were broken, and the room housed 5 residents. Later that day, the blinds in another room had broken edges, and that room housed 4 residents. During the observations, the Assistant Director of Nursing confirmed the broken blinds in both rooms and stated that maintenance rounds were made daily and staff who found broken blinds should write in the maintenance log. A CNA stated the blinds in one room were already broken when she came in and that she did not write a note in the maintenance log. Another CNA later confirmed the blinds in a room were broken and stated she had observed the resident closest to the window grabbing on the blinds. Additional observations on 1/7/26 and 1/8/26 found broken horizontal blinds in a third room, including a view of the broken blinds from the parking lot. The Maintenance Supervisor confirmed one set of blinds had been replaced the prior day but another set remained broken and had not been replaced. He stated that if blinds were broken, they had to be fixed to make it homelike. The DON reviewed photos of the broken blinds and stated they did not look good and were not safe if broken, and that staff were expected to report broken blinds or equipment to the Maintenance Supervisor and document the issue in the maintenance log. The facility policy titled Homelike Environment stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Excess Residents in Multiple Shared Rooms
Penalty
Summary
Six of 53 resident rooms, including Rooms 15, 16, 22, 23, 24, and 25, had more than four residents in each room. During the Entrance Conference, the Administrator stated the facility would renew an existing room waiver to allow more than four residents in these six rooms. A facility letter dated 1/6/26 stated the six rooms would accommodate more than four residents per room and indicated the rooms provided adequate space for resident care, storage, and privacy. During multiple observations, surveyors found 5 residents in Rooms 22, 23, 24, and 25, and 6 residents in other identified rooms. The beds were separated with privacy curtains, and each resident had a bedside table. Surveyors observed that the rooms were not cluttered and had enough space for residents to move in and out, as well as for assistive devices and resident care equipment. Residents and staff interviewed stated there was enough space in the rooms, that assistive devices could be maneuvered, and that privacy was maintained by closing doors and pulling privacy curtains during care.
Resident Rooms Did Not Meet Minimum Square Footage Requirements
Penalty
Summary
Two of 53 resident rooms, room [ROOM NUMBER] and room 16, did not meet the minimum requirement of 80 square feet per resident in multiple-occupancy rooms. During an initial tour of the facility on 1/6/26 at 9:01 a.m., both rooms were observed to have six beds each. The rooms were uncluttered, and residents were able to move in and out of the rooms, with space for beds, wheelchairs, side tables, and other resident care equipment. During interviews, Resident 117 in room [ROOM NUMBER] stated he was okay with his room and had enough space for himself and when staff were taking care of him, and had no concerns about having five other residents in the room. Resident 85 in room [ROOM NUMBER] stated there was enough space for him and when staff were taking care of him, and had no concerns about having five other residents in the room. Resident 38 stated his room had enough space for him and his assistive devices. Staff interviewed, including LN 4, LN 5, CNA 3, and CNA 6, stated there was sufficient space in the rooms to provide care and use assistive devices. On 1/7/26, the Maintenance Supervisor measured the usable living space in rooms [ROOM NUMBERS] and confirmed both rooms measured 70.56 square feet per resident, below the required minimum of 80 square feet per resident. A review of the facility’s request letter to renew existing waivers, dated 1/6/2024, showed the rooms had six beds each with less than 80 square feet per resident and stated the rooms provided adequate space for resident care, storage, and privacy.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with dementia and cognitive impairment, who was non-ambulatory and required staff assistance, sustained multiple facial lacerations, swelling, and bruising after being struck in the face by another resident. The injured resident was unable to explain the cause of the injuries due to cognitive limitations. Clinical documentation and staff interviews confirmed the presence of significant injuries, including lacerations to the eyebrow, nose, and cheek, as well as pain and visible bruising. The incident was reported to the resident's physician, and the resident was sent to the emergency department for evaluation. The resident who committed the abuse had a documented history of dementia, anxiety, depression, and frequent episodes of verbal and physical aggression, particularly toward his roommate. Progress notes and care plans indicated repeated threats, aggressive statements, and attempts at physical aggression toward the injured resident over several weeks. Staff and therapy personnel observed ongoing verbal aggression and threats, and the care plan for the aggressive resident included interventions such as monitoring, redirection, and reporting behaviors to the physician. Despite these interventions, the aggressive resident was able to strike his roommate, resulting in injury. Facility records and staff interviews revealed that the administration was aware of the ongoing verbal aggression and threats but had not observed prior physical violence. The facility's abuse prevention policy emphasized the right of residents to be free from abuse by anyone, including other residents. However, the measures in place were insufficient to prevent the escalation from verbal to physical abuse, resulting in harm to a vulnerable resident. The facility acknowledged responsibility for resident safety and supervision but did not provide evidence that effective interventions were implemented to prevent the incident.
Resident Physically Abused by Staff Following Aggressive Incident
Penalty
Summary
A facility staff member failed to protect a resident from physical abuse when a CNA pushed the resident in the face, causing the resident to fall to the ground. The resident, who had moderate cognitive impairment and lacked decision-making capacity, had become physically aggressive toward the CNA during care, striking the staff member in the face. In response, the CNA pushed the resident, resulting in a fall and subsequent unresponsiveness. The resident was transferred to the hospital for further evaluation after being found nonverbal and unable to move extremities, which was not at his baseline. Interviews with facility staff confirmed that the CNA's actions constituted physical abuse and were not in accordance with the facility's abuse prevention policy or the abuse training the CNA had received. The Director of Nursing acknowledged that the CNA should have known how to manage residents with dementia and that the staff member's actions placed the resident's safety at risk. Facility policy emphasized the right of residents to be free from abuse and the importance of compassionate care, particularly for those with behavioral and cognitive issues.
Resident Abuse by Licensed Nurse
Penalty
Summary
The facility failed to protect a resident from abuse when a licensed nurse hit the resident in the face, causing abrasions. The resident, who had been admitted in 2017 with diagnoses including dementia, anxiety, and schizophrenia, had a BIMS score indicating moderately impaired cognition. The resident's care plan included interventions for managing potential aggressive behaviors, such as maintaining a calm approach and respecting the resident's right to refuse care. However, during an incident in the dining room, the resident became agitated and resistive when the nurse attempted to administer medication, leading to the nurse retaliating and causing injury to the resident's face. Witnesses, including two CNAs, reported hearing a commotion and seeing the nurse hit the resident after the resident refused medication and became agitated. The resident was found crying with scratches on her face and reported being attacked by the nurse. The facility's administrator confirmed the incident and acknowledged that the nurse's behavior was unacceptable, leading to her termination. The facility's abuse prevention program emphasizes protecting residents from abuse and instructs staff on de-escalation techniques, but these measures were not effectively implemented in this case.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of several residents, as evidenced by multiple observations and interviews. Resident 77, who has severe cognitive impairment, was not provided privacy when using the phone, as he had to use the phone at the nursing station where others were present. The facility lacked handheld phones for private use, which was acknowledged by the Administrator. This lack of privacy during phone calls was contrary to the facility's policy on resident rights, which guarantees communication privacy. Resident 119, who is cognitively intact, reported being ignored by staff when seeking assistance. He described incidents where other residents entered his room uninvited, taking his belongings and invading his privacy. Despite reporting these issues to staff, he felt humiliated and disrespected, as staff laughed at his concerns. The facility's policy mandates treating residents with kindness, respect, and dignity, which was not adhered to in this case. Additional deficiencies were noted during meal times and medication administration. Residents were referred to as 'feeders' and were not asked if they wanted to wear bibs during meals, which goes against the facility's dignity policy. CNA 6 was observed feeding residents while standing, rather than sitting at eye level, which is required for a dignified dining experience. Furthermore, Resident 6 was administered medication without privacy, as the nurse exposed the resident's body in front of others, violating the facility's policy on maintaining resident privacy during treatment procedures.
Deficiencies in POLST Form Completion and EMR Updates
Penalty
Summary
The facility failed to ensure that the POLST (Physician Orders for Life-Sustaining Treatment) forms were completed and updated for several residents, which could lead to not acting in accordance with residents' wishes during emergencies. Specifically, two residents had POLST forms that were not signed by a physician or other authorized healthcare provider, rendering them invalid. Additionally, these forms lacked information regarding the existence of an Advance Directive, which is crucial for guiding healthcare decisions when a resident is incapacitated. Furthermore, the facility did not update the electronic medical records (EMR) to reflect changes in code status for two other residents after new POLST forms were completed. This discrepancy between the paper records and the EMR could result in confusion and failure to follow the correct code status during a medical emergency. The Unit Manager confirmed that the new POLST forms were not uploaded into the electronic records, and the Director of Nursing acknowledged the expectation for code status to be updated in the clinical records. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and auditing of POLST forms. The Director of Nursing admitted that there was no specific policy and procedure for POLST forms, and the facility relied on the directions provided on the back of the POLST form itself. This lack of a formalized process contributed to the deficiencies observed, as staff were unsure of the steps needed to ensure the forms were completed and updated correctly.
Lack of Clocks in Residents' Rooms
Penalty
Summary
The facility failed to provide a homelike environment for three residents by not having clocks available in their rooms. This deficiency was identified during observations and interviews with the residents and staff. Resident 18, who has Alzheimer's disease and severe memory impairment, expressed frustration about not having a clock, which is important for her to engage in activities and choose her own bedtime. Similarly, Resident 41, with Alzheimer's disease and severe memory impairment, and Resident 74, with schizoaffective disorder and severe memory impairment, also lacked clocks in their rooms, affecting their ability to know the time and participate in activities. Interviews with the Unit Manager, Assistant Director of Nursing, and Director of Nursing confirmed the absence of clocks in the residents' rooms. The Unit Manager acknowledged the importance of orientation to time for the residents, while the Assistant Director of Nursing was unaware of the reason for the absence of clocks. The Director of Nursing stated there were no contraindications for having wall clocks in the rooms. The facility's policies on dignity and a homelike environment emphasize providing person-centered care that meets residents' comfort and personal needs, which was not adhered to in this case.
Inaccurate Pharmacy Services and Medication Management
Penalty
Summary
The facility failed to maintain accurate pharmacy services for two residents, leading to potential risks in medication management. In the first instance, the controlled drug destruction record log was found to be inaccurate. During a review, it was discovered that 20 syringes of Lorazepam gel, a controlled medication used for anxiety, were not recorded in the destruction log. The Director of Nursing (DON) confirmed that the syringes were not documented and acknowledged that this oversight could lead to the diversion of controlled drugs. The DON admitted that the medication was handed to her by a nurse but was not logged as required, which should have included two nurses' signatures. In the second instance, an inspection of a medication cart revealed that a medication card for lacosamide, used for seizures, contained two doses in a single dose unit. The Licensed Nurse (LN) confirmed that the extra dose was not accounted for in the narcotic sheet record, posing a risk of administering a double dose to a resident. The DON stated that the expectation was for the LN to contact the pharmacy to replace the medication card if issues were identified. The facility's policy on controlled medication storage, dated March 2018, requires adherence to federal, state, and other applicable laws and regulations, which was not followed in these cases.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Resident 38 was prescribed Zyprexa, an antipsychotic medication, without specific manifested behaviors of danger to self or others. The resident, who had severe cognitive impairment and dementia-related psychosis, was observed talking to herself but was not aggressive or a danger to herself or others. Despite the care plan's directive to attempt non-pharmacological interventions before administering the medication, there was no documented evidence that such interventions were attempted. The facility's policy required that antipsychotic medications be used only when necessary to treat specific conditions and when behavioral symptoms present a danger, which was not the case for Resident 38. Resident 150 was prescribed risperidone, another antipsychotic medication, without adequate indication and target behavior. The resident had severe cognitive impairment and was diagnosed with Alzheimer's disease and dementia with behavioral disturbance. However, there was no documentation of potential indicators of psychosis or target behaviors that warranted the use of risperidone. The facility's policy stated that antipsychotic medications should only be used for specific conditions and when symptoms present a danger to the resident or others, which was not documented for Resident 150. The facility's failure to adhere to its policy on antipsychotic medication use resulted in the administration of unnecessary psychotropic medications to both residents. The facility did not document attempts at non-pharmacological interventions for Resident 38, and there was no clear indication or target behavior for the use of risperidone in Resident 150. These deficiencies could lead to adverse consequences for the residents, as the medications were not approved for the treatment of dementia-related psychosis and could increase the risk of negative side effects.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, as evidenced by two medication errors out of 29 opportunities during medication administration for two residents. Resident 6, who has Type 2 Diabetes and severe cognitive impairment, was administered 2 units of insulin aspart based on a blood sugar level reading taken at 7:07 a.m., prior to breakfast. The Licensed Nurse (LN 2) did not document that Resident 6 had refused insulin earlier in the morning, and the insulin was administered after breakfast, contrary to the physician's order and facility policy, which required insulin to be administered 15-30 minutes before meals. Resident 71, who has severe cognitive impairment and anemia, did not receive their prescribed folic acid during the morning medication pass. The Licensed Nurse (LN 1) acknowledged that the folic acid was not in the medication cart and stated that the issue would need to be followed up with the pharmacy. However, LN 1 was unable to explain why the medication was unavailable. The Director of Nursing (DON) stated that the expectation is for the LN to contact the pharmacy if a medication is not available, as per the facility's policy on administering medications.
Insulin Administration Error Due to Non-compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a licensed nurse administered insulin aspart not in accordance with physician orders. The resident, who was admitted with a diagnosis of Type 2 Diabetes and had severe cognitive impairment, was observed receiving 2 units of insulin aspart based on a blood sugar level of 154 mg/dl. However, the blood glucose reading was taken at 7:07 a.m., prior to the resident eating breakfast, and the insulin was administered at 8:30 a.m., after the resident had already eaten. The nurse confirmed that the resident had refused insulin earlier in the morning, but there was no documented evidence of this refusal. The physician's orders specified a sliding scale for insulin administration, which was not followed in this instance. The Director of Nursing stated that the expectation was for blood glucose to be checked prior to insulin administration and for insulin to be given 15-30 minutes before meals. The facility's policy required verification of insulin type, dosage, and administration method before administration, and to notify a supervisor if insulin was refused. The failure to adhere to these protocols put the resident at risk for adverse consequences from the medication.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during an inspection of Medication Cart B. Medications were not stored according to manufacturer instructions, with a bottle of Acidophilus found in the cart instead of the refrigerator. Expired and discontinued medications, such as erythromycin ointment and Arformoterol nebulizer treatments, were still available for use, contrary to the facility's policy. Loose pills and medical supplies were also found in the medication cart, indicating a lack of organization and adherence to storage protocols. Additionally, the facility did not maintain appropriate refrigerator temperatures for medication storage. During inspections, the refrigerator's temperature was found to be outside the required range, with one instance showing a temperature of 51 degrees Fahrenheit and another at 29 degrees Fahrenheit, leading to frozen insulin. These findings were confirmed by the staff, who acknowledged that the medications were not safe for administration due to improper storage conditions.
Deficiencies in Food Storage and Sanitation Procedures
Penalty
Summary
The facility was found to have several deficiencies in food storage, service, and distribution, which were not in accordance with professional standards. During observations, kitchen vents, fans, and floors were noted to be dirty and dusty. The Dietary Assistant Manager (DA) and Registered Dietitian (RD) acknowledged the presence of dirt and dust, which could potentially contaminate food and clean plates. The facility's policy and the US FDA Food Code require that all equipment and surfaces be kept clean and free from contamination, but these standards were not met. Additionally, worn food preparation equipment was found in storage and not discarded, despite being unsanitary. Items such as a rusty strainer, a warped cutting board, and a damaged plastic container were identified. The DA acknowledged these items could not be properly sanitized and needed to be replaced or discarded. The facility's policy and the US FDA Food Code emphasize the importance of maintaining equipment in good repair to ensure proper sanitation. The facility also failed to properly label and store food items. Expired and improperly sealed food items were found in storage, posing a risk of contamination. The DA admitted that the labeling was incomplete and that open food packages should be sealed to prevent contamination. Furthermore, kitchen staff were unable to demonstrate the correct procedure for testing sanitation concentration levels, which is crucial for preventing cross-contamination and food-borne illnesses. The RD confirmed that all staff should be knowledgeable about sanitation procedures to ensure food safety.
Infection Control Deficiencies in Hand Hygiene and Equipment Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as observed during a dining session where a Certified Nursing Assistant (CNA) did not perform hand hygiene between feeding multiple residents. CNA 6 was seen feeding several residents consecutively without using hand sanitizer or washing hands, instead using wipes intended for peri care, which were not suitable for hand hygiene. This was confirmed by the Director of Staff Development and the Infection Preventionist, who reiterated the importance of using appropriate hand hygiene methods between tasks and residents. Additionally, the facility did not ensure that Resident 20's nasal cannula and nebulizer mask were stored in a sanitary manner. The nasal cannula and nebulizer mask were not labeled or covered, and there was no documented evidence that the nebulizer mask and tubing had been changed since the physician's order was given. The Unit Manager and Director of Nursing confirmed that the equipment should be dated, bagged, and changed regularly to prevent infection. Furthermore, the inspection revealed improper storage of food items and nail clippers inside a medication cart. Licensed Nurse 4 confirmed the presence of a sandwich, pudding, and nail clippers stored alongside medications, which is against the facility's policy. The Director of Nursing acknowledged that food items should be stored separately, and nail clippers should not be kept in medication carts due to sanitary concerns.
Failure to Address Acute Vision Loss in Resident
Penalty
Summary
The facility failed to provide timely care to maintain vision for a resident, identified as Resident 143, who experienced an acute onset of vision loss. Despite the resident's severe cognitive impairment and multiple diagnoses, including dementia and diabetes, the facility did not send her to the hospital when she exhibited signs of significant vision problems. On 7/27/24, the resident showed increased confusion and inability to see objects in front of her, prompting a nurse to assess her vision. The physician was notified, and new orders were given to monitor the condition, with instructions to send the resident to the hospital if it worsened. The resident's condition did not improve, and subsequent progress notes indicated ongoing vision difficulties. Despite this, the resident was not referred to an optometrist until 8/2/24, and an ophthalmologist diagnosed her with bilateral retinal detachment and macular holes on 8/13/24. Interviews with the resident's family and facility staff revealed that the family had requested the resident be sent to the hospital, but the facility opted to monitor her condition instead. The facility's policy required notifying the physician of significant changes in a resident's condition, but the decision to send the resident to the hospital was ultimately left to the physician and the responsible party. Interviews with the facility's staff, including the Administrator, Director of Nursing, and Medical Doctor, indicated uncertainty about the acuity of the vision loss due to the resident's dementia. The Medical Doctor acknowledged that acute vision loss should be treated as an emergency, but due to the resident's cognitive impairment, it was challenging to determine the nature of the vision change. The facility's inaction in promptly addressing the resident's acute vision loss led to a delay in receiving necessary medical intervention.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident, who was observed with cold and allergy nasal spray at the bedside, was assessed and had an order to self-administer medication. The resident, admitted in August 2024 with diagnoses including chronic lung disease and anxiety, was cognitively intact according to the Minimum Data Set. Despite this, a nursing assessment indicated that the resident did not want to self-administer medications, and there was no documented evidence supporting the resident's ability to self-administer medications. During an interview, the resident explained that he had been using his own nasal spray brought from home because his request for a prescription was not followed up by the nursing staff. The nasal spray was found on the resident's nightstand, with the resident's name printed on it by a staff member. The Director of Nursing stated that it was unsafe for the resident to keep medication at the bedside, as it could be accessed by other residents. The facility's policy requires that self-administration of medications be determined safe by the interdisciplinary team and documented in the medical records, which was not done in this case.
Failure to Secure Resident Information on Computer
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records, as observed during a survey. A computer on medication cart B was left open, displaying confidential clinical information, including residents' pictures, names, and medications. This occurred in a hallway where multiple residents and staff were present, creating the potential for unauthorized access to sensitive information. The Wound Nurse confirmed the observation, acknowledging it as a HIPAA violation. Licensed Nurse 1 admitted to leaving the computer open while attending to a resident, recognizing the importance of securing such information. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility's expectation is for staff to lock computer screens when not in use to prevent unauthorized access. The facility's policies on dignity, resident rights, and confidentiality emphasize the protection of resident information, prohibiting unauthorized release or access.
Failure to Provide Timely Allergy Medication
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards. The resident, who was admitted with multiple diagnoses including chronic lung disease and anxiety, was cognitively intact and had no memory issues. Despite the resident's repeated requests for allergy medication over six days, the facility did not follow up on these requests. The resident expressed frustration that the staff ignored his requests, and the clinical records showed no active order for the allergy medication Fluticasone. Interviews with facility staff, including a Licensed Nurse and the Director of Nursing, revealed that there was a breakdown in communication and follow-up regarding the resident's request for medication. Although a physician's note approving the medication was found, it was undated and had not been transcribed into the resident's clinical record. This oversight resulted in the resident not receiving the prescribed allergy medication in a timely manner, highlighting a failure in the facility's process for managing medication requests and orders.
Failure to Maintain Proper Nail Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary grooming services for a resident, identified as Resident 138, who was observed with black material under her fingernails. Resident 138 was admitted to the facility with multiple diagnoses, including dementia, and had a severe cognitive impairment with a BIMS score of 5 out of 15. The resident required moderate assistance for personal hygiene, as indicated in her Minimum Data Set (MDS) assessment. Despite this need, observations on consecutive days revealed that the resident's fingernails were not cleaned, which was confirmed by both a Licensed Nurse (LN) and a Certified Nursing Assistant (CNA). The LN suggested that the black material might have been from a soiled brief, as the resident had a behavior of ripping off her brief. The CNA confirmed that the resident's nails were dirty after breakfast and acknowledged that nails should be cleaned during showers, which occur twice a week, and clipped, cleaned, and filed on Sundays. The Director of Nursing (DON) stated that nails should be cleaned during showers and as needed, according to the facility's policy. However, the failure to maintain proper nail hygiene for Resident 138 was evident, as the facility's policy required appropriate support and assistance with hygiene for residents unable to carry out activities of daily living independently.
Failure to Provide Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing activity program to meet the needs and interests of a resident, identified as Resident 44, whose activity care plan was not followed. The resident's comprehensive Minimum Data Set (MDS) indicated severe cognitive impairment and highlighted preferences for activities such as listening to music, engaging in favorite activities, and going outside. However, observations revealed that the resident was often left without any sensory stimulation or interaction, such as being placed in a hallway or lying in bed awake without access to a television or radio. Interviews with staff, including a Licensed Nurse and the Activity Director, indicated a lack of awareness and documentation regarding the resident's participation in activities. The Activity Director admitted that there was no documentation of activities for the resident for several months due to issues with the Point of Care (POC) system, which was the sole method for documenting activities. The facility's policy required room visits or group activity attendance to be documented three times a week, but this was not adhered to. The Director of Nursing confirmed that activities should be documented if performed. The lack of documentation and adherence to the care plan resulted in a deficiency that potentially affected the resident's psychosocial well-being.
Failure to Apply Hand Roll as Ordered
Penalty
Summary
The facility failed to provide appropriate care for a resident with a physician's order to apply a hand roll or soft cloth in her right hand every shift to prevent further contracture. Despite the order, observations over several days revealed that the resident did not have a hand roll in her contracted right hand, which was tightly closed with long nails digging into her skin. Interviews with multiple CNAs and a licensed nurse indicated a lack of awareness regarding the need for a hand roll, and the resident's care plan did not address the contracture or the use of a hand roll. The resident's medication administration records showed that nurses documented the presence of a hand roll every shift, except for one instance, despite the absence of the hand roll during observations. The Director of Nursing confirmed the lack of a care plan addressing the hand contracture and acknowledged that the nurses should not have documented the presence of a hand roll if it was not in place. The facility did not have a policy on the prevention of contractures, contributing to the oversight in the resident's care.
Excessive Room Occupancy in Facility
Penalty
Summary
The deficiency identified in the report pertains to the accommodation of more than four residents in certain rooms within the facility, which is contrary to the regulatory requirements. Specifically, six rooms were found to have more than the allowed number of residents, with some rooms accommodating five or six residents. This was confirmed through a review of the facility's 'Approval of Program Flexibility' letter and the facility's census, as well as direct observations during a facility tour. Despite the presence of privacy curtains and sufficient space for movement and care, the room occupancy exceeded the regulatory limits. Interviews with staff, including CNAs and LNs, indicated that there was adequate space to provide care and respond to emergencies, and no issues were reported regarding the maneuverability of assistive devices or the storage of personal belongings. Additionally, a responsible party for one of the residents noted that while the rooms could be noisy, there were no concerns about space. The facility had requested a continuation of a room waiver, contingent upon compliance with federal regulations regarding resident rights and physical environment.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The deficiency identified in the report pertains to the failure of two resident rooms in a long-term care facility to meet the minimum space requirements. Specifically, rooms 15 and 16 did not provide the required 80 square feet per resident, as they were measured to have only 70.56 square feet per resident. Despite observations indicating that the rooms were uncluttered and allowed for resident movement and care activities, the facility did not comply with the federal regulation for physical environment standards. Interviews with staff, including CNAs and a Licensed Nurse, revealed that they perceived the space as sufficient for providing care and responding to emergencies. Additionally, a Responsible Party for one of the residents expressed no concerns about the space, although they noted the noise levels due to the number of residents. The facility had previously received a program flexibility approval letter, allowing for more beds in certain rooms, contingent upon compliance with federal regulations. However, the Maintenance Supervisor confirmed that the space in rooms 15 and 16 was below the required standard, leading to the deficiency finding.
Failure to Protect Resident from Abuse by Hospitality Aide
Penalty
Summary
The facility failed to protect a resident from abuse when a hospitality aide (HA) became upset and slapped the resident on the cheek repeatedly. The resident, who was admitted with diagnoses including dementia, depression, muscle weakness, and severe cognitive impairment, required supervision or touch cueing assistance while eating. The care plan for the resident indicated potential for physical aggression and outlined strategies for staff to manage agitation, such as intervening before escalation and walking away if the response was aggressive. However, during an incident, the HA, while assisting the resident with eating, became frustrated and slapped the resident, which was witnessed by a CNA. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurse 2 (LN 2), and the Assistant Director of Nursing (ADON), confirmed the incident. The HA admitted to reacting inappropriately due to frustration and acknowledged the action was wrong. The facility's policy on abuse prevention, revised in 2011, emphasizes the responsibility of the Administrator and DON to prevent abuse and neglect. Despite this policy, the incident occurred, highlighting a failure in protecting the resident from abuse.
Failure to Implement Care Plan Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to implement and monitor a comprehensive care plan for a resident, leading to a deficiency in care. The resident, who had severe cognitive impairment and was at risk for falls, was not consistently provided with hip protectors as outlined in their care plan. Despite the care plan's directive to use hip protectors to minimize fall-related injuries, there was no documented evidence that these were applied, and staff interviews revealed uncertainty about their availability and use. The resident experienced multiple falls, including a witnessed fall that resulted in a right hip fracture. The care plan and interdisciplinary team notes indicated the need for hip protectors, but there was no documentation confirming their use at the time of the incidents. The Director of Nursing and other staff members acknowledged the lack of documentation and implementation of the hip protector intervention, which was a critical component of the resident's fall prevention strategy. The facility's policies on care plans and fall risk management emphasized the importance of implementing resident-specific interventions to prevent falls and minimize their consequences. However, the failure to document and apply the hip protectors as per the care plan contributed to the resident's fall and subsequent hip fracture, which ultimately led to the resident's death. This deficiency highlights a significant lapse in the facility's adherence to its own policies and procedures regarding fall prevention and care plan implementation.
Failure to Implement and Update Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to ensure the comprehensive care plan was implemented and updated for a resident with an ileostomy, leading to increased redness and irritation at the ileostomy site and surrounding skin. The resident was admitted with diagnoses including dementia, Crohn's disease, and ileostomy status. Physician's orders included specific care instructions for the ileostomy site, but these were not adequately followed or documented. The care plan noted the resident's non-compliance with treatment and the abdominal binder, but interventions were not effectively implemented or updated. The resident's ileostomy bag was leaking, and there was increased redness at the stoma site. The Treatment Nurse and Licensed Nurse 1 confirmed the presence of rashes on the resident's stoma, private area, and leg. The Certified Nursing Assistant observed the leaking ileostomy bag and applied tape and cream but did not report these observations to the Licensed Nurse. The resident's care plan did not address her behavior of scratching, which contributed to the skin irritation. The Director of Nursing acknowledged the lack of a care plan for the resident's scratching behavior and expected specific behaviors to be included in the care plan. The facility's policy required documentation of ileostomy care and notification of any abnormal findings, but there was no documented evidence of the abdominal binder being offered and refused by the resident. The Treatment Nurse admitted the care plan should have been updated to reflect the resident's refusal of the abdominal binder.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in significant harm to one and potential harm to another. Resident 1, who had severe cognitive impairment and a history of physical behavioral symptoms, pulled Resident 2's walker, causing him to fall and sustain a right intertrochanteric fracture. This incident occurred despite Resident 1 having a care plan in place to monitor and manage his aggressive behaviors. The staff's inability to intervene before the altercation escalated led to Resident 2 undergoing hip arthroplasty. In a separate incident, Resident 3 punched Resident 4 in the face during an altercation. Both residents had cognitive impairments and behavioral issues, with Resident 4 exhibiting both physical and verbal aggression. The altercation was not witnessed by staff until after it had begun, indicating a failure to monitor and manage the residents' behaviors effectively. The Director of Nursing acknowledged that both residents had aggressive tendencies and that staff were expected to follow care plans to prevent such incidents. The facility's policies on resident-to-resident altercations and abuse prevention emphasize the need for staff to monitor residents for aggressive behaviors and protect them from abuse. However, the incidents involving Residents 1, 2, 3, and 4 demonstrate a failure to adhere to these policies, resulting in harm and potential harm to the residents involved.
Failure to Monitor and Communicate Fluid Intake for Resident
Penalty
Summary
The facility failed to accurately monitor and communicate the fluid intake of a resident with dementia and chronic congestive heart failure, leading to potential health risks. The resident was admitted with a fluid restriction order of 2000 ml per day, which was later changed to 1000 ml per day. However, the resident's electronic Medication Administration Record (eMAR) showed that the resident consistently consumed more than 1 liter of fluids on multiple days across several months, with no documented evidence that the physician was informed of this noncompliance. Observations and interviews revealed that the resident had access to fluids beyond the restricted amount, and there was a lack of communication and monitoring by the staff. The Certified Nursing Assistant (CNA) and Licensed Nurse (LN) were not adequately informed about the fluid restriction, and the Director of Nursing (DON) was unaware of the conflicting fluid restriction orders. The facility's policy required the removal of water pitchers from the room for residents on fluid restriction, but this was not followed, and there was no care plan in place to address the resident's noncompliance.
Resident's Dignity Violated by Unauthorized Photograph
Penalty
Summary
The facility failed to protect a resident's right to be free from mental abuse when a staff member took a photograph of the resident in an undignified state. The resident, who was admitted with Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was found lying on the floor with his pants around his ankles and without undergarments. The photograph was taken with an unsecured facility cell phone, and the resident was attempting to cover his naked buttocks with his nightshirt. This incident was observed by the resident's responsible party and the Department, who noted the undignified nature of the photograph. Interviews with facility staff revealed a lack of clear procedures regarding the photographing of residents after falls. A Certified Nursing Assistant mentioned that nurses typically take pictures of residents' positions after a fall. However, a Licensed Nurse and the Unit Manager acknowledged that taking such photographs with residents' pants down is a dignity violation. The Unit Manager stated that the practice of taking photographs was a part of the training they received, although it was not a formal policy. The Director of Nursing confirmed that there was no official process for taking photographs after falls, and the Director of Staff Development indicated that taking such photographs could be considered abuse. The facility's policies and procedures emphasize treating residents with dignity and respect, protecting them from abuse, and ensuring privacy and confidentiality. The policy on videotaping and photographing residents specifically states that any image that could be construed as humiliating or demeaning is considered abuse. Despite these policies, the photograph of the resident was taken and shown to family members, highlighting a significant breach of the resident's rights and dignity.
Failure to Notify Responsible Party and Physician After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party and physician for a resident who experienced an unwitnessed fall, resulting in bleeding and an injury to the lip. This incident delayed prompt medical monitoring and treatment, leaving the family unaware of the situation. The resident, who was admitted with Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was not capable of making their own decisions. The resident's family member was designated as the responsible party. The incident was documented in the resident's progress notes, indicating that the fall occurred during the night, but the physician and responsible party were not notified until the following day. Interviews with facility staff, including CNAs and licensed nurses, revealed that the standard procedure was to notify the doctor and responsible party immediately after a fall. However, in this case, the notification was delayed, and the facility's fall protocol was not followed promptly. The Director of Nursing confirmed that there was no documentation of the fall or notification to the doctor and responsible party on the day of the incident. The facility's policy requires prompt notification of changes in a resident's condition, but this was not adhered to in this case. The lack of timely notification and documentation highlights a deficiency in the facility's handling of the resident's fall and subsequent injury.
Failure to Monitor Neurological Changes After Unwitnessed Fall
Penalty
Summary
The facility failed to monitor a resident for neurological changes after an unwitnessed fall, which was not documented in the electronic health record (EHR). The resident, who had Alzheimer's Disease, major depressive disorder, lack of coordination, muscle weakness, and anxiety disorder, was found on the floor with dark red spots next to their face. Despite the facility's protocol requiring immediate neurological checks after a fall, there was no documentation of the fall, neurological assessment, or notifications to the physician or responsible party on the day of the incident. Interviews with various staff members, including licensed nurses, the unit manager, the assistant director of nursing, and the director of nursing, revealed that the expected procedure was to start neurological checks immediately after a fall. However, the checks were only initiated the day after the fall. The director of nursing confirmed the lack of documentation and acknowledged that the nurse on duty at the time of the fall did not follow the protocol. The facility's policy on managing falls emphasized the importance of identifying interventions to prevent falls and minimize complications, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 558 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Care Center Of Sacramento | 0 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Sacramento | 3.2 mi | ★★★★★ | 13 | 0 |
| Gramercy Court | 3.8 mi | ★★★★★ | 16 | 0 |
| Sherwood Healthcare Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Woodside Healthcare Center | 4.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for North Pointe Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.