Rancho Mesa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alta Loma, California.
- Location
- 9333 La Mesa Dr, Alta Loma, California 91701
- CMS Provider Number
- 555521
- Inspections on file
- 27
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Rancho Mesa Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia and moderate cognitive impairment experienced a delay in receiving a requested diaper change due to a lack of communication between CNAs during shift change. The facility did not follow its policy for providing timely ADL assistance, resulting in a three-hour delay.
The facility did not adhere to the prescribed menu for residents on CCHO and regular diets, serving incorrect portions of mashed potatoes and meatloaf. The cook used a larger scoop than specified for mashed potatoes, and the facility lacked a scale to verify meatloaf portions. These actions potentially impacted the nutritional intake of 45 residents.
The facility failed to maintain sanitary conditions in its food storage and preparation areas, with crumbs and dust found under the coffee maker, a build-up of food crumbs and a liquid spill in the dry storage room, and old food and dust under refrigerators in the staff lounge. Additionally, the ice machine had black and yellow discoloration where ice is formed. These conditions were not in line with the facility's sanitation policy or the FDA Federal Food Code, posing a risk of contamination and pest attraction.
The facility failed to provide 26 residents on a mechanical soft diet with the appropriate form of meatloaf, serving them regular diet meatloaf instead of the required mashable and moist version with gravy. This was observed during a kitchen inspection, and both the Dietetic Services Supervisor and Registered Dietitian confirmed the need to follow the prescribed menu to prevent choking and aspiration risks.
A facility failed to complete and transmit an MDS Discharge Assessment for a resident discharged with home health services. The resident's last assessment was an Admission Assessment, and the oversight was confirmed by the LVN/MDS Nurse. The DON acknowledged the failure to adhere to facility policy and federal guidelines.
A resident with cerebral infarction and dysphagia did not receive tube feeding as ordered, leading to potential nutritional deficiencies. The feeding was stopped prematurely, and the required amount was not administered, as confirmed by the LVN and DON. The resident's Nutrition Assessment indicated malnutrition and a BMI of 19, underscoring the need for consistent nutritional support.
A resident with cerebral infarction, aphasia, and dysphagia did not receive the full prescribed dose of enteral tube feeding due to nursing staff's lack of competency in calculating the amount administered. The LVN/MDS was unable to determine the feeding amount from the previous shift, resulting in the resident receiving only 940 ml instead of the prescribed 1200 ml. The DON confirmed the oversight and noted the absence of competency evaluations for such calculations, while the RD highlighted the nurses' responsibility to ensure full dosage and timely bottle changes.
A resident with GERD was given Omeprazole after breakfast instead of before, as per physician's orders. The DON confirmed the error, noting the medication's reduced effectiveness when not administered as directed. Facility policy requires adherence to physician's orders, which was not followed in this instance.
The facility failed to store vaccines under proper temperature control, as two vaccine solutions were found in a medication cart instead of the refrigerator. An LVN admitted to storing an unopened vial of Covid Spikevax 23-24 and an unopened syringe of Afluria Quad 2023-2024 in the cart since the start of his shift. The DON confirmed the improper storage and acknowledged the facility's failure to follow its medication storage policy.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to adhere to its policy and procedure for activities of daily living (ADL) by not providing timely care and services to a resident who was unable to perform ADLs independently. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis, had a moderate cognitive impairment and was completely dependent on staff for toileting hygiene. On one occasion, the resident requested a diaper change from a certified nursing assistant (CNA 1), who stated she only performed diaper changes once per shift. As a result, the resident's request was delayed for approximately three hours. The delay occurred because CNA 1 did not communicate the resident's request to the incoming CNA (CNA 2) at the end of her shift. CNA 2, who was unaware of the situation, changed the resident's diaper twice during her shift, but not until several hours after the initial request. The Director of Nursing (DON) acknowledged that the facility's policy, which mandates appropriate care and services for residents unable to carry out ADLs independently, was not followed in this instance.
Failure to Follow Prescribed Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a carbohydrate-controlled diet (CCHO) and regular diets during lunch on August 5, 2024. Specifically, the cook served 1/2 cup of mashed potatoes instead of the 1/3 cup indicated on the menu for residents on the CCHO diet. This discrepancy was observed during a meal preparation and tray line observation, where the cook used a #8 scoop (4 oz) instead of the #12 scoop (3.25 oz) specified in the Cooks Spreadsheet. The Dietetic Services Supervisor (DSS) and the Registered Dietitian (RD) both confirmed that the menu should be followed as planned. Additionally, the facility did not have a method to ensure that the correct portion size of 4 oz of meat was served to residents on both CCHO and regular diets. During the same observation, the DSS was unable to verify the weight of the meatloaf portion due to the absence of an ounce scale. The RD emphasized the importance of following the menu to ensure correct portion sizes, as indicated in the facility's policy and procedure titled "Menu Planning." These failures potentially affected the nutritional intake and weight maintenance of 45 out of 52 residents.
Sanitation Deficiencies in Food Storage and Preparation Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during a survey. Crumbs and dust were found on the shelf under the coffee maker, which could attract pests and promote microorganism growth. Additionally, the floor under the shelves in the dry storage room had a build-up of food crumbs and a liquid spill, further increasing the risk of pest attraction and microorganism growth. These conditions were not in line with the facility's sanitation policy or the FDA Federal Food Code, which require nonfood contact surfaces to be free of dust, dirt, and food residue. In the staff lounge, old food and dust were found under the refrigerators, which the Dietetic Services Supervisor acknowledged. The Registered Dietitian stated that the area should be kept clean to the same standards as the main kitchen. This failure to maintain cleanliness could potentially contaminate food and attract pests, posing a risk to the residents who consume food prepared in the facility. The ice machine in the facility was also found to have black and yellow discoloration in the area where ice is formed. This was acknowledged by the Maintenance staff and the Registered Dietitian, who stated that the ice machine should be clean and free of discoloration. The facility's policy requires the ice machine to be cleaned and sanitized monthly, but the observed condition indicated a failure to adhere to this policy, potentially leading to contamination of the ice used by residents.
Failure to Serve Appropriate Diet to Residents on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents on a mechanical soft diet. Specifically, 26 residents who required a mechanically soft diet due to difficulties with chewing and swallowing were served regular diet meatloaf instead of the mashable and moist meatloaf with gravy as prescribed. This oversight was observed during a kitchen inspection, where a cook served a resident the incorrect form of meatloaf. The facility's documentation, including the Cooks Spreadsheet - Summer Menus, indicated that the meatloaf for mechanical soft diets should be mashable and moist with gravy. Interviews with the Dietetic Services Supervisor and the Registered Dietitian confirmed that the cook should have followed the menu to prevent risks such as choking and aspiration. The facility's policy on Menu Planning also emphasized the importance of adhering to menus that meet the nutritional needs of residents according to physician orders.
Failure to Complete and Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) Discharge Assessment for a resident, identified as Resident 53, in accordance with federal guidelines. Resident 53 was admitted with diagnoses including hyperlipidemia and major depressive disorder. The resident was discharged home with home health services on March 28, 2024, but the discharge assessment was not completed or transmitted. The last MDS assessment for Resident 53 was the Admission Assessment completed on February 15, 2024. This oversight was confirmed by the LVN/MDS Nurse during a review of the resident's clinical record. The Director of Nurses (DON) acknowledged that the discharge assessment should have been completed on the discharge date, March 28, 2024, and confirmed that the facility did not adhere to its policy. The facility's policy, revised in March 2022, mandates that comprehensive assessments be conducted at intervals designated by OBRA and PPS requirements. The DON reviewed the CMS RAI manual, which outlines the federally mandated assessments, including the Discharge Assessment, and confirmed that the facility failed to follow these guidelines.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident 58, who was dependent on tube feeding due to conditions such as cerebral infarction, aphasia, dysphagia, and debility. On August 6, 2024, it was observed that Resident 58's tube feeding was not connected, and the machine was off, contrary to the physician's order which specified that the feeding should be administered at 60 ml/hr for 20 hours daily. The Licensed Vocational Nurse/Minimum Data Set (LVN/MDS) confirmed that the tube feeding was stopped at 9:40 AM, and the feeding bottle was discarded without calculating the total amount administered. The Director of Nurses (DON) confirmed that the tube feeding should have been on from 2:00 PM to 10:00 AM, and a new bag should have been hung at 6:00 AM to ensure the resident received the full 1200 ml as ordered. The Registered Dietitian (RD) noted that without the tube feeding running, the resident was not receiving necessary nutrition, increasing the risk of weight loss. Resident 58's Nutrition Assessment indicated malnutrition related to dysphagia, severe muscle wasting, and a BMI of 19, with a goal weight range of 160-170 pounds, highlighting the critical need for consistent nutritional support.
Inadequate Tube Feeding Administration Due to Staff Competency Issues
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies to provide adequate tube feeding to a resident, identified as Resident 58. The resident, who was admitted with diagnoses including cerebral infarction, aphasia, and dysphagia, was prescribed 1200 ml of Osmolite 1.5 enteral tube feeding formula per day. However, the resident only received 940 ml due to the tube feeding being stopped prematurely. The Licensed Vocational Nurse/Minimum Data Set (LVN/MDS) was unable to calculate the total amount of feeding administered during the previous shift, leading to an incomplete dose. The Director of Nurses (DON) confirmed that the tube feeding was not administered as per the physician's orders, and a new bag should have been hung at 6:00 AM. The DON acknowledged that there was no competency evaluation for licensed nursing staff on calculating the amount of feeding administered per shift. The Registered Dietitian (RD) emphasized that licensed nurses are responsible for ensuring the full dose is given and knowing when to change the feeding bottle. The facility's policy indicated that inservice training on monitoring enteral solutions should be provided, but this was not effectively implemented.
Medication Administration Error for GERD Treatment
Penalty
Summary
The facility failed to administer medication according to the physician's orders for a resident diagnosed with hepatic encephalopathy, morbid obesity, and phantom limb syndrome. The resident was prescribed Omeprazole, a delayed-release medication intended to manage gastroesophageal reflux disease (GERD), to be taken before breakfast. However, during an observation, a Licensed Vocational Nurse (LVN) administered the medication after the resident had already eaten breakfast, contrary to the physician's instructions. The Director of Nurses (DON) confirmed that the medication should have been given before breakfast to ensure its effectiveness. The facility's policy and procedure manual also stipulates that medications must be administered in accordance with the attending physician's written orders. The failure to follow these orders and the facility's policy was acknowledged by the DON, who noted that the medication would not have the same effect if given after a meal.
Improper Storage of Vaccines in Medication Cart
Penalty
Summary
The facility failed to store medications under proper temperature control, as specified by the manufacturer, when two vaccine solutions were found inside the medication cart instead of the refrigerator. During an observation and interview, a Licensed Vocational Nurse (LVN) was found to have stored an unopened vial of Covid Spikevax 23-24 and an unopened syringe of Afluria Quad 2023-2024 in the medication cart since the start of his shift. Both vaccines were labeled to be kept in the refrigerator, and the LVN acknowledged that they should not have been in the medication cart. The Director of Nurses (DON) confirmed the improper storage of the vaccines and acknowledged that the facility did not follow its policy on medication storage. The facility's policy, effective since November 2020, requires medications and biologicals to be stored safely and properly, following the manufacturer's recommendations. The manufacturer's guidelines for Spikevax and the CDC's guidelines for influenza vaccines both specify that these vaccines should be refrigerated between 2°C and 8°C. The failure to adhere to these guidelines had the potential to decrease the efficacy of the vaccines administered to residents.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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