Piners Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Napa, California.
- Location
- 1800 Pueblo Ave, Napa, California 94558
- CMS Provider Number
- 555207
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Piners Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, COPD, and other comorbidities was converted from scheduled hydrocodone-acetaminophen to a fentanyl 25 mcg/hr transdermal patch despite not meeting FDA-defined opioid-tolerant criteria, and without documented risk assessment for advanced age and chronic lung disease. The resident’s actual morphine equivalent (ME) exposure was significantly below the 60 mg/day threshold required for initiating this fentanyl dose. Later, after several days without a patch and variable PRN opioid use, the fentanyl dose was doubled to 50 mcg/hr soon after the resident received Norco and lorazepam 0.5 mg for restlessness and anxiety, contrary to manufacturer titration guidance and the facility’s own policy to avoid or closely monitor opioid–benzodiazepine combinations. The resident subsequently developed acute shortness of breath, hypoxia, somnolence, slow shallow respirations, and pinpoint pupils, required naloxone by EMS, and was diagnosed in the ED with accidental opiate overdose and hypoxia.
A resident became upset during a Bingo activity, threatened another resident, and was escorted away while yelling, which drew the attention of the Administrator and DON. Later, while the resident was nearby in the lobby, the DON approached the nurses’ station in an emotional and aggressive manner, stating that the resident was out of control and needed to be sent out, within earshot of the resident. A confidential witness reported that the DON’s physically and verbally aggressive behavior felt like bullying, and the resident began sobbing. Progress notes documented the resident’s emotional distress, including facial redness, shaking, SOB, and crying, and the resident was sent to the ED for further evaluation. The facility’s policy requires staff to treat all residents with kindness, respect, and dignity.
A resident with dementia, traumatic brain injury, chronic pain, bipolar disorder, and other comorbidities had her fentanyl patch increased and her Seroquel regimen intensified, including a higher scheduled dose and a PRN order, without her representative being informed or providing consent, despite the medical director’s determination that the resident lacked decision-making capacity. Nursing documentation showed the discontinuation of a 25 mcg/hr fentanyl patch and initiation of a 50 mcg/hr patch, as well as increased Seroquel dosing, but no evidence of notification to the family or signed informed consent. The family member later discovered the changes after the resident experienced respiratory distress and appeared overly sedated, and staff interviews confirmed that the representative had not been notified, contrary to facility policies on resident rights, psychotropic medication use, and person-centered care planning.
A resident with dementia, bipolar disorder, anxiety disorder, epilepsy, chronic pain, and prior stroke had a PRN Seroquel 25 mg order for agitation related to anxiety that remained active well beyond the 14-day limit set by facility policy for PRN psychotropic medications. The MAR showed multiple PRN administrations, and observations later noted the resident in a wheelchair with eyes closed, chin on chest, and tongue hanging out. Nursing staff could not locate any documentation that the attending physician or a mental health provider had re-evaluated and documented the continued need for the PRN antipsychotic, and the MD was unsure about the 14-day documentation requirement. The pharmacist reported she had recommended discontinuation of the PRN Seroquel during a medication regimen review. This constituted a failure to prevent potential chemical restraint by not ensuring timely re-evaluation and documentation for continued PRN antipsychotic use.
A facility failed to investigate and report an alleged abuse incident involving a resident who reported physical abuse by a CNA, resulting in a hand discoloration. Despite the facility's policy requiring investigation and reporting, no documentation or investigation summary was provided to the State Department of Health, potentially delaying further investigation.
The facility failed to maintain the final rinse temperature of the dishwasher at the required 180 degrees Fahrenheit, compromising the sanitization of dinnerware and cooking utensils. Dietary staff confirmed the issue had been ongoing for several months, leading to the use of disposable plates and utensils as a temporary measure.
The facility failed to ensure hand hygiene for six residents before meals, did not conduct ongoing infection surveillance, and did not follow physician's orders for changing a resident's oxygen equipment weekly. Staff did not routinely offer hand hygiene, infection control documents were incomplete, and the resident's oxygen equipment was not labeled or changed as required.
The facility failed to consistently perform antibiotic stewardship, leading to potential inappropriate or unnecessary antibiotic treatment. The new Infection Preventionist (IP) had not seen previous documentation except for a folder on Antibiotic Stewardship, and the Director of Nursing (DON) stated that infection control documents could not be located. No antibiotic surveillance tracking was completed from August to December 2023, and the IP had not conducted in-services with staff on antibiotic stewardship.
A resident with dementia and dry eye syndrome had a large, bleeding growth on her nose that was not properly diagnosed or treated by the facility. Despite observations and interviews indicating the growth's consistent increase in size and bleeding, the facility only applied a band-aid and did not pursue further treatment or accurate monitoring. The resident's Responsible Person had declined further diagnosis based on age and perceived lack of pain, but had not seen the current state of the growth.
The facility failed to ensure that a resident received the RNA program as ordered by the physician, resulting in inconsistent delivery of prescribed exercises. Staffing shortages and reassignment of RNA staff to CNA duties contributed to this deficiency, which was confirmed by both the resident and staff.
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. Licensed staff reviewed meal tray cards and dietary orders but did not check the actual food consistency before serving it to residents. Unlicensed staff were observed delivering meal trays without the required checks when the responsible licensed staff member was on a break. Interviews revealed a lack of formal documentation or training on this task, and the DON was unaware of the issue.
The facility failed to ensure a safe and functional kitchen environment due to unrepaired cracks and missing tiles on the floor. Cracked tiles were observed in front of the dry good storage, by the washing sinks, the exit door, and another dry good storage entrance. The Certified Dietary Manager acknowledged the non-compliance.
The facility failed to perform annual performance reviews for two CNAs. The Director of Staff Development acknowledged the reviews were behind due to a three-day work schedule, with 2023 reviews not yet completed for all unlicensed staff. Human Resource files confirmed the absence of reviews for 2023 and 2024.
Failure to Follow FDA Fentanyl Patch Dosing Guidelines Resulting in Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to follow FDA Black Box Warnings and manufacturer dosing specifications for a fentanyl transdermal patch in an elderly resident with COPD and multiple comorbidities. The resident, in her late 70s, had diagnoses including dementia, chronic pain, vertebral compression fractures, bipolar disorder, anxiety disorder, COPD, and cerebral infarction. Prior to fentanyl initiation, the resident was receiving hydrocodone-acetaminophen (Norco) 5-325 mg on a scheduled basis, with a regimen that allowed for up to five tablets per day, but the MAR showed multiple instances where doses were refused or held due to sedation. Based on the consultant pharmacist’s review and morphine equivalent (ME) calculations, the resident’s actual opioid exposure at the time fentanyl was started was approximately 20–25 mg ME per day, below the FDA-defined threshold of at least 60 mg oral morphine daily for at least one week to qualify as opioid-tolerant. The record contained no documented justification for switching from Norco to a fentanyl patch or any risk assessment addressing the resident’s advanced age, COPD, and sub-threshold opioid exposure in relation to the FDA Black Box Warning and manufacturer guidance. On 11/26/25, an order was written for a fentanyl (Duragesic) 25 mcg/hr transdermal patch to be applied every 72 hours for chronic pain, and Norco was changed to PRN two days later. The consultant pharmacist later confirmed that, according to the Duragesic dosing guidelines, a 25 mcg/hr starting dose should only be used in patients already receiving at least 60 mg oral morphine equivalents daily for a minimum of seven days, which this resident did not meet. The facility’s own pain management policy stated that pain medications should be selected based on pertinent treatment guidelines, that the lowest possible effective opioid dose should be used with ongoing monitoring, and that combining opioids and benzodiazepines should be avoided or closely monitored for respiratory depression. Despite these standards and the resident’s COPD and geriatric status, the fentanyl patch was initiated without documentation that the resident was opioid-tolerant as defined by the FDA labeling, and without a documented risk assessment. Subsequently, the resident’s fentanyl dose was increased from 25 mcg/hr to 50 mcg/hr on 1/30/26, after a period in late January when the 25 mcg/hr patch had been removed and not replaced for several days due to unavailability. During January, the resident’s PRN Norco use ranged from one to three tablets per day, with nine days of no Norco administration, and pain scores varied from 0 to 9. On 1/29/26, nursing documentation showed the resident was restless and unable to be consoled, leading to a new order for lorazepam 0.5 mg for anxiety, which was administered at 5:20 p.m., following a Norco dose at 4:00 p.m. The next day, the fentanyl patch dose was doubled to 50 mcg/hr. The consultant pharmacist verified that, at the time of this dose increase, the resident was receiving only 5–15 mg of supplementary morphine equivalents per day, far below the 45 mg ME per day that the manufacturer’s titration guidelines associate with a 12.5 mcg/hr increase, and that lorazepam and Norco had been administered shortly before the fentanyl dose escalation, creating a potential for respiratory depression. On 2/1/26, nursing notes documented that the resident began screaming for help and reported, “I can’t breathe, I can’t talk, I can’t swallow.” The nurse applied supplemental oxygen, but the resident’s oxygen saturation dropped to 77%, and her temperature was 100.1°F. The medical director was notified and ordered transfer to the emergency department. ED triage documentation indicated shortness of breath, slow shallow respirations, pinpoint pupils, and a positive response to naloxone administered by EMS, with the fentanyl patch removed by EMS. The ED history and physical described somnolence presumed due to opioid overdose and shortness of breath, and the ED physician’s note characterized the event as an iatrogenic occurrence requiring re-evaluation of the resident’s pain management strategy. The ED diagnoses included accidental or unintentional opiate overdose and hypoxia. Throughout interviews, the consultant pharmacist confirmed that both the initial fentanyl dose and the subsequent dose increase did not meet FDA and manufacturer criteria for opioid tolerance and dose titration, while the medical director stated he believed he had followed fentanyl dosing guidelines but could not identify the cause of the resident’s respiratory distress.
Failure to Treat a Resident With Dignity and Respect During Behavioral Incident
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with kindness, respect, and dignity. A confidential witness (CW) reported that during an activities session in January 2026, a resident became upset during Bingo after observing another resident not covering a called number. According to a progress note dated 1/9/26 at 3:34 p.m., the resident stated that if someone did not know how to play, they should not be playing, and was informed by staff that assistance is provided to all residents. As the staff member removed the resident from the table, the resident threatened to slap another resident and threw two Bingo chips against the wall while being escorted down the hall, yelling loudly enough to draw the attention of the Administrator and the DON, who then took over the situation. The CW stated that later that afternoon, while at the nurses’ station, they observed the DON approach the nurses’ station in a very emotional and aggressive manner, saying that the resident was out of control and that something needed to be done, including that the resident needed to be sent out. This interaction occurred within earshot of the resident, who was only a few feet away in the lobby, and upon hearing the DON’s comments, the resident began sobbing. The CW described the DON’s behavior as physically and verbally aggressive and perceived it as bullying the resident. A subsequent progress note dated 1/9/26 at 5:20 p.m. documented that the resident had facial redness, shaking, shortness of breath, emotional distress, and crying, and was sent to the ED for further evaluation. The facility’s Resident Rights policy, last reviewed 3/31/26, states that employees shall treat all residents with kindness, respect, and dignity.
Failure to Inform Resident Representative of Pain and Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s family member of significant changes to the resident’s treatment plan for pain and behaviors, despite the resident lacking capacity to make healthcare decisions. The family member reported receiving a call that the resident was in respiratory distress after an increase in her fentanyl patch dose to 50 mcg/hr, and stated that he would not have agreed to this increase because the resident was already on multiple central nervous system depressants. He also reported that the resident’s Seroquel dose had been doubled in the hospital and continued upon her return to the facility without any discussion with him, even though the resident had delirium and was not at her baseline during the hospitalization. The family member described finding the resident slumped over in a chair and slurring her words, and later learned via text communication with the physician that there was also a PRN Seroquel order that he had not been informed about. Record review showed that the resident had multiple diagnoses including dementia with behavioral disturbance, epilepsy, chronic pain, traumatic brain injury, bipolar disorder, anxiety disorder, and cerebral infarction. The face sheet listed the resident as her own responsible party, but the medical director had previously informed surveyors that the resident did not have capacity to make healthcare decisions and confirmed that this had not changed and no county conservator had been arranged. Physician orders and MARs showed a fentanyl patch 25 mcg/hr ordered in November and discontinued in late January, with a new order for a fentanyl patch 50 mcg/hr dated 1/30 and administered on 1/30, as well as Seroquel 25 mg three times daily for agitation and later Seroquel 50 mg three times daily with an added PRN Seroquel 25 mg every six hours for agitation. Nursing progress notes documented discontinuation of the 25 mcg patch and initiation of the 50 mcg patch but contained no documentation that the family member was notified of this change. Interviews with facility staff confirmed the lack of family notification and informed consent. One licensed nurse stated that the family member was not informed of the decision to increase the fentanyl patch at the end of January. Another licensed nurse verified there was no informed consent signed for the increased Seroquel dose or the PRN Seroquel order and acknowledged that a new consent should have been obtained when the dose was increased and a PRN dose added in the hospital. The medical director confirmed that the resident still lacked decision-making capacity and stated that residents’ families have the right to participate in the plan of care and that he expected nursing staff to have informed the family member of the fentanyl dose increase. Facility policies on resident rights, psychotropic medication use, and comprehensive person-centered care planning required resident or representative participation in treatment decisions and care planning, informed consent for psychotropic medication changes, and documentation when resident or representative participation in care planning was not practicable, which did not occur in this case.
Failure to Re-Evaluate PRN Antipsychotic Order Within Required 14-Day Limit
Penalty
Summary
The deficiency involves the facility’s failure to comply with requirements for PRN antipsychotic medications, resulting in a chemical restraint concern for one resident. The resident, an older adult with dementia, epilepsy, chronic pain, bipolar disorder, anxiety disorder, and a history of cerebral infarction, had a physician order for Seroquel 25 mg to be given by mouth three times a day as needed for agitation related to anxiety disorder, starting on 2/3/26. The February MAR showed that the PRN Seroquel was administered on three occasions (2/11/26, 2/14/26, and 2/22/26). Observations on 3/12/26 documented the resident in a wheelchair in the lobby with eyes closed, chin resting on the chest, and later with the tongue hanging out of the mouth, while a musician performed nearby. Record review and staff interviews revealed that the PRN Seroquel order remained active from 2/3/26 through at least 3/26/26 without documented re-evaluation by the physician or a mental health provider, despite facility policy limiting PRN psychotropic orders to 14 days and requiring an evaluation and documentation to renew PRN antipsychotic orders. A nurse stated that the physician re-evaluated PRN antipsychotics during quarterly gradual dose reductions and monthly order recapitulations, but could not identify any documentation of a specific re-evaluation or rationale for continuing this PRN Seroquel order. The medical director could not recall if he documented a re-evaluation and appeared unaware that documentation every 14 days was required to continue a PRN antipsychotic. The facility’s pharmacist reported that, during a recent medication regimen review, she noted the PRN Seroquel order and recommended its discontinuation. This failure resulted in the resident having the potential to receive an antipsychotic dose beyond the 14-day limit without the required re-evaluation.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its abuse prevention policy and procedures when a resident reported an incident of alleged physical abuse by a certified nursing assistant (CNA). The resident claimed that the CNA pulled on her arms, resulting in a 2.5 cm x 2 cm discoloration on her left hand near the thumb. Despite this report, the facility did not conduct an investigation nor document any findings related to the incident. The resident's medical record contained a nurse's note documenting the alleged abuse, but there were no additional notes or interdisciplinary team (IDT) documentation addressing the incident. During interviews, facility staff confirmed the absence of documentation related to an in-house investigation or IDT notes regarding the incident. The facility's policy requires that all allegations of abuse be investigated and reported within the timeframes required by federal requirements. However, the facility did not provide a 5-day investigation summary to the State Department of Health, as required. This lack of action and documentation potentially delayed the Department's independent investigation of the incident.
Dishwasher Final Rinse Temperature Deficiency
Penalty
Summary
The facility failed to ensure the sanitization, safety, and functional environment in the kitchen when the temperature of the final rinse of the dishwasher was not maintained to adequately sanitize dinnerware and cooking utensils. During an observation and interview, it was noted that the final rinse temperature of the high-temperature dishwasher was only 150 degrees Fahrenheit, significantly below the required 180 degrees Fahrenheit. Dietary Aides E and F confirmed that the dishwasher frequently failed to reach the necessary temperature, and they had to run the dishwasher multiple times in an attempt to achieve the correct temperature. Despite these efforts, the dishwasher still did not consistently reach 180 degrees Fahrenheit, leading to the use of disposable plates and utensils as a temporary measure. A review of records revealed that the issue with the dishwasher's final rinse booster heater had been ongoing for several months. The monthly Consultant Dietitian Report Card indicated that the dishwasher was not holding temperature as early as January, with subsequent reports in February and March noting continued issues with the booster heater leaking and failing to maintain the required temperature. This prolonged failure to address the malfunctioning dishwasher compromised the facility's ability to properly sanitize dinnerware and cooking utensils, posing a risk of food contamination and potential foodborne illness among residents.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure hand hygiene was practiced by six of 15 sampled residents before meals. Observations revealed that staff did not offer or remind residents to wash or wipe their hands before eating. Interviews with staff confirmed that they did not routinely offer hand hygiene to residents, and moist wipes were not included on meal trays as previously done. The facility's policy on hand hygiene did not specify that staff should remind or offer hand hygiene to residents before meals, contributing to this oversight. The facility also failed to conduct ongoing analysis of infection surveillance. The newly appointed Infection Preventionist (IP) had not seen the infection prevention folders except for the one on Antibiotic Stewardship. Surveillance logs for the past 12 months were incomplete, and there was no documentation of data analysis or infection rate plotting. The Director of Nursing (DON) acknowledged that the infection control documents could not be located or had been misplaced, and the current IP had not started the process of overseeing infection surveillance. Additionally, the facility did not ensure that physician's orders were followed for one resident who was on oxygen therapy. The resident's nasal cannula and oxygen humidifier were not changed weekly as required, with the last documented change occurring nearly two months prior. Observations confirmed that the nasal cannula tubing and humidifier were not labeled with the date of the last change. Interviews with staff indicated that the responsibility for changing the equipment was not clearly assigned, and the DON admitted to not realizing the equipment had not been changed as scheduled.
Failure to Consistently Perform Antibiotic Stewardship
Penalty
Summary
The facility failed to consistently perform antibiotic stewardship, which had the potential to result in inappropriate or unnecessary antibiotic treatment. During an interview and records review, the Infection Preventionist (IP) stated she had only been working at the facility for three weeks and had not seen the previous IP's folders except for the one on Antibiotic Stewardship. The folder contained documentation on an antibiotic surveillance tracking form with residents' names who were treated with antibiotics from January to April 2024, but none for the past months. The Director of Nursing (DON) stated that infection control, surveillance, and monitoring documents could not be located or may have been misplaced after the previous IPs left. The DON had called the previous IP to help locate the folders. A review of the Infection Prevention and Control Line Listing Surveillance Logs indicated no antibiotic surveillance tracking was completed from August to December 2023, as there were no line listing surveillance logs for those months. The IP's job description indicated responsibility for the antibiotic stewardship program (ASP), including in-servicing, tracking, reporting, and educating families, employees, and physicians as needed. However, the IP stated she had not conducted in-services with staff on antibiotic stewardship. The facility's Antibiotic Stewardship policy, updated in January 2024, indicated that antibiotic usage and outcome data should be collected and documented using a facility-approved antibiotic surveillance tracking form. All clinical infections treated with antibiotics were supposed to undergo review by the IP or designee, but this was not consistently done, leading to the deficiency.
Failure to Diagnose and Treat Resident's Growth
Penalty
Summary
The facility failed to appropriately diagnose and treat a growth on the left side of Resident 29's nose. Resident 29, who has a history of dementia and dry eye syndrome, was observed with a large growth on her nose that had been bleeding. Unlicensed and licensed staff indicated that the growth had been consistently growing, and Resident 29 would scratch it, causing it to bleed. Despite these observations, the facility's staff only cleaned the area with saline solution and applied a band-aid, without pursuing further treatment or monitoring the growth's size and condition accurately. The Social Services Director (SSD) and various licensed staff members revealed that there had been a canceled plastic surgeon appointment and a dermatology appointment where Resident 29 became combative, preventing assessment. The Responsible Person (RP) for Resident 29 had decided against further diagnosis or treatment based on the resident's age and perceived lack of pain. However, the RP had not seen the current state of the growth, which had become larger and more prone to bleeding. The facility's weekly skin assessments failed to document the changing size and bleeding events of the growth accurately. The Director of Nursing (DON) was not aware of the growth's increase in size and its proximity to the lower eyelid. The facility's policies on charting, documentation, and skin and wound management were not followed accurately, leading to incomplete and inaccurate records. The lack of a comprehensive healthcare team approach and proper monitoring increased the risk of infection and discomfort for Resident 29.
Failure to Administer RNA Program as Ordered
Penalty
Summary
The facility failed to ensure that the Restorative Nursing Assistant (RNA) program was being administered according to physician orders for Resident 33. Resident 33, who was admitted with diagnoses including cerebral infarction, major depression disorder, and hemiplegia, had a care plan that included passive and active range of motion exercises to be performed 3 to 5 times per week. However, the records indicated that these exercises were not consistently provided, with significant gaps in the frequency of the sessions over multiple months. For example, in one six-week period, Resident 33 received the exercises only twice, whereas they should have been offered at least 12 times. Similar deficiencies were noted in subsequent periods, with the resident receiving the exercises far less frequently than ordered by the physician. This inconsistency in care delivery was corroborated by Resident 33, who expressed that promises to take him to the gym were not always kept and that he felt forgotten about. The Rehab Manager and the RNA staff confirmed that staffing shortages and the reassignment of RNA staff to CNA duties contributed to the failure to provide the ordered exercises. The facility's policies on restorative nursing services and resident mobility and range of motion were not adhered to, resulting in a failure to maintain or improve Resident 33's functional mobility and muscle strength as required by the care plan.
Failure to Ensure Appropriate Dietary Consistency in Resident Meals
Penalty
Summary
The facility failed to ensure that resident meals were served with the appropriate dietary consistency. During an observation, a licensed staff member was seen reviewing meal tray cards and dietary orders in the electronic medical record but did not check the actual food consistency before serving it to residents. The licensed staff member indicated that the meals were not uncovered to avoid touching the food. This process was common practice at the facility, and the staff member acknowledged the importance of checking meal trays to prevent residents from choking or aspirating on improperly prepared food. However, during another observation, unlicensed staff were seen delivering meal trays without the required checks, as the licensed staff member responsible was on a break and not available to perform the task. Interviews with various staff members, including the Director of Nursing (DON), revealed that there was no formal documentation or training on how to perform the task of checking meal trays for appropriate consistency. The DON was unaware that meals were not being checked by licensed staff before being served to residents and emphasized the importance of this safety measure to prevent aspiration. The facility's policy and procedure on tray line procedures indicated that assigned staff should deliver the cart to the nurses' station and announce its arrival, but it did not specify the need for checking meal consistency before serving.
Unrepaired Cracks and Missing Tiles in Kitchen
Penalty
Summary
The facility failed to ensure a safe and functional environment in the kitchen due to unrepaired cracks and missing tiles on the kitchen floor. During an initial tour of the kitchen, cracked tiles were observed in front of the entrance to the dry good storage. Further observations revealed more cracks and missing tiles by the washing sinks, the exit door to the back of the building, and the entrance to another dry good storage. The Certified Dietary Manager acknowledged the non-compliance when informed about the findings. The Food Code 2017 indicates that materials for indoor floor surfaces should be smooth, durable, and easily cleanable, which was not adhered to in this case.
Failure to Perform Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to perform annual performance reviews on two out of three sampled Certified Nursing Assistants (CNAs). During an interview, the Director of Staff Development (DSD) acknowledged that the annual performance reviews for Unlicensed Staff P and Unlicensed Staff Q were outstanding. The DSD indicated that the reviews were behind due to a three-day work schedule and that the facility was still working on completing the reviews for the current year of 2024, with 2023 reviews not yet completed for all unlicensed staff. A review of the Human Resource files for Unlicensed Staff Q and Unlicensed Staff P confirmed the absence of annual performance reviews for the year 2023 and, in the case of Unlicensed Staff P, also for 2024.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
