Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rancho Seco Care Center during CMS and state inspections, most recent first.
A cognitively intact resident with COPD was not protected from abuse by a co-resident with dementia and severe memory impairment. According to documentation and interviews, the resident with dementia accused the other of stealing a stuffed animal, then scratched her arm, swung the stuffed animal at her in a foyer area, and later kicked her leg in their shared room while cussing and repeatedly threatening to kill her. Staff reported hearing arguing, observing the stuffed animal being swung, and later hearing yelling and death threats from the room. An observed scabbed wound with redness on the victim’s arm was attributed to the aggressor’s fingernail. These incidents occurred despite a facility abuse prevention policy stating residents must be protected from verbal and physical abuse by anyone, including other residents.
Medication administration errors exceeded the allowed rate when a resident with DM and eye disease missed a scheduled metformin dose because it was unavailable, and an LPN gave timolol and artificial tears back-to-back instead of waiting between eye drops. The DON confirmed the metformin should have been given as ordered, and both the DON and CP stated different eye drops should be separated by five minutes.
Expired, discontinued, and improperly labeled medications were found in med cart C and the treatment cart at station 2. An LPN confirmed one expired medication and five discontinued medications were still stored in the med cart, while another LPN confirmed opened wound cleanser, povidone-iodine solution, and calmoseptine ointment were undated, and three packets of expired antibiotic ointment remained in the treatment cart. The DON stated expired and discontinued medications should not be stored in the carts and opened medications should have open and discard dates.
Failure to Follow Standardized Recipes for Vegetables and Fish: A dietary staff member did not follow standardized recipes when preparing seasoned carrots, seasoned peas, and oven crisp fish for a meal service. The carrots and peas were cooked longer than the recipe times, the peas were held on the stove until tray line, and the fish was prepared from frozen without parsley and with ranch dressing and crushed potato chips on only one side. The RD and DM stated the recipes were important for maintaining food flavor and nutritive value.
Food was not stored and served in a sanitary manner for a census of 95 residents. The facility missed refrigerator and freezer temperature monitoring on multiple p.m. shifts, had an expired cinnamon stick bottle available for use, and an employee used the same gloved hand to touch scoop handles, plates, and ready-to-eat fish during tray line. Facility policy required proper food storage, no use of expired items, and sanitary food handling.
An LN did not disinfect a BP monitor between resident uses, five opened sterile wound dressings were found stored in a treatment cart, and a housekeeper cleaning a resident’s room under EBP did not wear a gown while disinfecting high-touch surfaces. The resident on EBP had osteomyelitis and was ordered precautions due to wounds and a urinary catheter; the DON and staff confirmed the infection control lapses.
A resident with muscle weakness and dystonia, who was cognitively intact and able to make her own healthcare decisions, repeatedly requested to use her motorized wheelchair in the facility. Staff denied the request without documenting an evaluation of whether she could safely operate the device, and the DON confirmed no assessment was performed to support the restriction.
Failure to develop a hospice care plan for a resident receiving hospice services. A resident with hypertensive heart disease with heart failure was admitted to hospice for cerebral atherosclerosis, and the DON confirmed there was no care plan in place for the resident’s hospice care or related interventions, despite the facility policy requiring a comprehensive person-centered care plan for each resident.
Failure to provide effective language assistance for a resident with LEP. A resident admitted with DM spoke Spanish, but CNAs and an LN could not understand him and repeatedly had to search for someone who could translate. One CNA gave snacks when she could not understand the resident, and the resident’s question about medications was only clarified after an Activities Driver translated. The SSD said communication boards/binders were prepared and translation app posters were placed in staff areas, but the board for this resident and the poster could not be found, and the DSD said no 2025 in-service on language barriers had been provided.
The facility failed to act on the CP’s MRR recommendations for two residents receiving psychotropic medications. One resident’s trazodone GDR recommendation was not followed, and another resident’s lorazepam order lacked a frequency and was not clarified in the MRR record. The DON confirmed both issues during record review and interview, and the CP stated the facility was expected to notify the physician and update the MRR promptly.
A resident with anxiety disorder received a PRN lorazepam order that did not include a stop date. The MAR showed the medication was administered multiple times, and the DON confirmed the order should have been limited to 14 days per facility policy for PRN psychotropic meds.
Multiple residents engaged in physical altercations, including slapping and hitting each other on the arms, resulting in abrasions and bruising. Staff and a housekeeper intervened to separate the residents, but the incidents indicate a failure to prevent resident-to-resident abuse as required by facility policy.
Multiple residents and staff reported persistent cold temperatures throughout the facility, with room thermostats registering below required levels and no warm air from vents. Despite repeated complaints and visible resident discomfort, staff were unable to adjust thermostats or resolve the issue, and administration was initially unaware of the extent of the problem. The facility's boiler was found to be non-functional, and required temperatures were not maintained, contrary to facility policy.
Failure to protect a resident from physical abuse by another resident. A resident with intact cognition and diagnoses including COPD, inguinal hernia, and depression was slapped on the cheek and punched in the stomach by his roommate after a dispute over the TV. The roommate had dementia with moderate agitation and moderate cognitive impairment. LN, CNA, SSD, and DON interviews confirmed the incident, and the facility policy states residents have the right to be free from abuse by anyone, including other residents.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
A resident with severe cognitive impairment was repeatedly observed spitting on floors and having bowel movements on the facility patio, with staff confirming these behaviors and noting their impact on others. No care plan or interventions were in place to address these actions, despite facility policy requiring residents be treated with dignity and respect.
A resident with severe cognitive impairment sustained a bloody nose after being pushed in the face by another cognitively intact resident during an altercation on the patio. The incident occurred while the impaired resident was attempting to have a bowel movement outside, a behavior known to staff. The facility was aware of the ongoing issue but did not prevent the physical abuse, resulting in injury.
Two residents were involved in a physical altercation when one, who was alert and oriented, struck another resident with a wooden and metal reacher after the latter fell onto her bed. The incident resulted in minor injuries to both individuals and was witnessed by a CNA. The facility's abuse prevention policy was not effectively followed, as the reacher was accessible and prior similar incidents had not been reported.
A resident with cognitive impairment repeatedly hit another resident, who was cognitively intact and had a history of hemiplegia and epilepsy. The incident was witnessed by another resident and resulted in the victim experiencing fear and requiring medication to calm down. Staff confirmed the event and acknowledged the emotional impact on the victim.
Two residents experienced a persistent and strong urine odor in their shared room due to a soiled diaper left unaddressed on a potty chair. Both residents, who were alert and able to communicate, reported feeling undignified and uncomfortable. Staff, including a CNA and a nurse, confirmed the ongoing odor and the presence of the soiled brief, acknowledging that the situation was not dignified and did not meet facility policy standards.
A resident with moderate cognitive impairment and anxiety disorder was subjected to abuse when another cognitively intact resident deliberately ran over his foot twice with a wheelchair after being told to stop. Multiple staff, including a CNA and an LPN supervisor, witnessed the incident, and the affected resident expressed fear and distress following the event.
Surveyors found that the facility's main HVAC system, including all four air handlers, was inoperable, and portable AC units were being used throughout the building. Staff reported the cooling system had been down for over a year, affecting all residents and preventing the maintenance of required temperatures.
Surveyors observed multiple instances where portable air conditioning units and other devices were plugged into extension cords and power strips in corridors, resident rooms, and a medication storage closet. Staff interviews indicated that these items were brought in by residents or their families, resulting in non-compliance with electrical safety regulations throughout the facility.
The facility did not conduct fire drills at varied times and failed to provide required shift fire drills for multiple quarters, with staff confirming that overlapping drills led to missing required drills for individual shifts. This affected all residents in the facility.
Surveyors found multiple failures in food storage, kitchen sanitation, and equipment maintenance, including unsealed and undated dry goods, damaged and unclean kitchen surfaces, lack of backflow prevention at a produce sink, improper storage of wet kitchenware, and use of damaged utensils and equipment. These deficiencies were confirmed by the Registered Dietitian and maintenance staff, and were not in compliance with facility policy or FDA Food Code.
A resident with multiple medical conditions and moderate cognitive impairment, who required substantial assistance with ADLs, was not provided with necessary nail care despite repeated documentation and staff awareness of the issue. The resident's long fingernails and toenails caused discomfort and potential skin injury, and no interventions or referrals were made, contrary to facility policy and care plan requirements.
A resident with dementia, Alzheimer's, and major depressive disorder was not provided with activities meeting psychosocial needs for several weeks, despite a care plan outlining the importance of such engagement. Observations showed the resident unresponsive and without access to preferred activities, and staff confirmed the absence of appropriate activity programming during this period.
Surveyors found that two residents' discontinued controlled medications, specifically Ativan, were left in medication carts instead of being promptly removed and destroyed as required. Nurses and the DON confirmed that these medications should have been surrendered for destruction, but instead remained accessible in the carts for extended periods after completion or discontinuation.
Staff failed to follow recipes and used unmeasured amounts of water to thin pureed foods, resulting in diluted flavor and reduced nutritional value for several residents. The dietary cook did not use measuring tools or have recipes available, and the registered dietitian confirmed that these practices can negatively impact meal quality.
Staff failed to follow infection control protocols by not wearing required PPE during care of a resident on Enhanced Barrier Precautions, not disinfecting a blood pressure cuff between use on three residents, and returning used wound care supplies to a treatment cart, contrary to facility policy and training.
Two residents with dysphagia and orders for nectar-thick liquids were observed consuming unthickened beverages, contrary to their prescribed diets. Staff confirmed that no dysphagia care plans were documented in the electronic medical records, despite facility policy and federal requirements.
A resident with multiple health conditions did not consistently receive physician-ordered wound care for a right ankle wound, as documented in treatment records and confirmed by staff interviews. The missed treatments led to pain, increased bleeding, confusion, and ultimately a hospital transfer, where the wound was found to be infected with MRSA and Pseudomonas, requiring IV antibiotics.
A resident with a suprapubic catheter did not consistently receive catheter flushing and site cleansing as ordered by the physician, with multiple missed treatments documented over several months. Facility staff confirmed that care was not provided as required by policy and professional standards.
The facility did not change a resident's PICC line dressing within the required timeframe as per physician order and policy, and also failed to follow a physician's order for oxygen therapy for another resident with respiratory conditions.
A resident with chronic lung disease and hypoxia was observed receiving oxygen at a lower rate than prescribed by the physician. Staff confirmed the oxygen was set at three liters per minute instead of the ordered four liters, and there was no order to adjust the rate. The care plan and facility policy both required adherence to the physician's order, but this was not followed.
Two residents with dysphagia and physician orders for nectar-thick liquids were given regular fluids instead of thickened liquids. One resident drank regular water, and another coughed after drinking unthickened hot chocolate. Both incidents were confirmed by staff, who acknowledged the drinks should have been thickened according to the residents' dietary orders.
A resident with dementia, Alzheimer's, dysphagia, and major depressive disorder was not provided with the physician-ordered fortified diet, as meal trays lacked the required extra butter or fortification despite clear orders and care plan instructions. Staff confirmed the omission during meal observations, and the resident experienced significant weight loss over several months.
Two residents with severe cognitive impairment and high dependence on staff were found with their call light buttons on the floor, out of reach, preventing them from calling for assistance. Staff and facility leadership confirmed that call lights should be accessible, and facility policy required staff to ensure call lights are within reach.
Two medication carts were found unlocked and unattended, as confirmed by interviews with nursing staff and the DON, in violation of facility policy requiring all drugs and biologicals to be stored in locked compartments. Staff acknowledged that the carts should have been locked at all times to prevent unauthorized access.
Staff failed to follow infection control protocols during wound care for a resident with a diabetic foot ulcer. An LPN, another nurse, and a wound doctor entered an Enhanced Barrier Precaution room without wearing gowns, and the LPN did not perform hand hygiene before donning gloves. Facility policy required gowns and gloves to be available and used, and hand hygiene to be performed before glove use.
A resident with moderate memory impairment was assaulted by another resident with severe memory impairment during a smoke break, resulting in a fall and an elbow abrasion. The incident occurred despite supervision, and staff were aware of prior accusations made by the aggressor. The DON acknowledged the violation of the resident's right to be free from abuse.
A facility employed a CNA with a known criminal history of assault, leading to the sexual abuse of nine residents. Despite a background check revealing a misdemeanor charge, the ADM and DSD hired the CNA, who later assaulted residents. The facility's failure to adhere to its policy on screening potential employees for abuse history resulted in this deficiency.
A facility failed to protect residents from sexual abuse by a CNA, who assaulted nine residents. The CNA was hired despite a known criminal history of abuse, leading to incidents of unwanted sexual touching and exposure. Residents, with varying cognitive impairments and medical conditions, experienced fear, anxiety, and behavioral changes. The abuse was reported by staff, and the CNA admitted to the assaults. The facility's policies on abuse prevention and resident rights were not effectively implemented.
A facility failed to thoroughly investigate sexual abuse allegations involving a CNA and multiple residents, delaying necessary interventions. Initial reports identified three victims, but further investigation revealed nine. The facility's documentation was inconsistent, and interviews revealed that allegations were unsubstantiated due to lack of witnesses, despite a police report confirming the CNA's admission. The facility's abuse prevention policy was not adequately followed.
The facility failed to manage effectively by hiring a CNA with a known history of abuse, leading to the sexual abuse of nine residents. Despite being aware of the CNA's misdemeanor charge, the ADM and DSD did not verify previous employment references. This oversight violated the facility's policies on abuse prevention and hiring, which require thorough background checks and reference verification.
The facility failed to report three allegations of sexual abuse involving three residents to the Department within the required two-hour timeframe. A resident with severe cognitive impairment reported an incident involving a shirtless CNA, while another resident with intact cognition alleged sexual assault by the same CNA. A third resident with moderate cognitive impairment was involved in an incident where the CNA was found with his pants down near the resident's room. The Administrator confirmed the reports were sent late, contrary to the facility's policy requiring immediate reporting.
A resident was physically and verbally abused by another resident during an altercation in a shared bathroom. The aggressor used profanity and kicked the victim's shin, causing an abrasion. Both residents were cognitively intact and had histories of anxiety and depression. Staff noted the aggressor's tendency to instigate altercations. The facility's Administrator confirmed the incident as substantiated abuse, violating the facility's zero-tolerance policy for abuse.
A resident with a history of constipation did not receive prescribed bowel management treatments, leading to severe discomfort and distress. Despite having physician orders for various laxatives, the resident did not receive these medications, and the facility staff failed to notify the physician of the resident's condition. The resident experienced significant abdominal pain and was unable to eat or attend dialysis sessions due to the constipation.
A resident with severe cognitive impairment and dysphagia waited 38 minutes for feeding assistance during lunch, while other residents finished their meals and left. A CNA acknowledged the delay and the Director of Nursing confirmed that residents should not wait longer than 10-15 minutes to be fed, indicating a failure to maintain dignity and respect as per facility policy.
A facility failed to provide and document resident-centered activities for a resident with multiple sclerosis and depression. Despite the resident's care plan highlighting the importance of activities like reading and puzzles, the activities director did not conduct or document one-on-one visits for 21 days. The resident expressed feeling neglected, and the Activities Director admitted to lacking documentation. The Administrator confirmed the absence of records, which contradicted the facility's policy to support residents' well-being through activities.
Failure to Protect Resident From Physical and Verbal Abuse by Co-Resident
Penalty
Summary
The facility failed to protect a cognitively intact resident from physical and verbal abuse by a co-resident. Resident 1, admitted with COPD and documented as having intact cognition with a BIMS score of 15/15, reported that on the evening of 2/14/26 she was accused of stealing Resident 2’s stuffed animal. According to Resident 1 and an SBAR Communication Form dated 2/14/26, Resident 2 scratched and kicked Resident 1 during this altercation. An SBAR for Resident 2 on the same date documented that Resident 2 was involved in a physical and verbal altercation with Resident 1. On observation several days later, Resident 1 had a scabbed wound approximately 1/8 inch in length with surrounding redness on her right arm, which she stated resulted from Resident 2’s fingernail when Resident 2 grabbed her arm in the foyer while swinging the stuffed animal at her. Resident 2, who had dementia and a severely impaired BIMS score of 3/15, was observed and described by staff as engaging in both physical and verbal aggression toward Resident 1. An LPN (LN 2) reported that between 7:30 p.m. and 8 p.m. on 2/14/26, while charting at the nurse’s station near the foyer, he heard the two residents arguing and saw Resident 2 swing a stuffed animal at Resident 1 while cussing at her, with Resident 1 using her arm to block the blow. Resident 1 later stated that after they were separated, Resident 2 waited for her in their shared room, kicked her right leg, continued cussing, and threatened to kill her. Another nurse (LN 1) stated that around 9:30 p.m. that same night, she heard yelling from the room and heard Resident 2 threaten Resident 1, telling her to get out of the room and stating, “I want to kill you.” These events occurred despite the facility’s written Abuse Prevention Program policy, which states residents have the right to be free from verbal and physical abuse and that residents must be protected from abuse by anyone, including other residents.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5% for one of 23 sampled residents, Resident 10, when 3 of 34 medication opportunities were not carried out according to physician orders and professional standards of practice, resulting in an 8.82% medication error rate. Resident 10 was admitted with diagnoses including diabetes mellitus and peripheral corneal degeneration, and had an order for metformin 500 mg by mouth twice daily. During a concurrent observation and interview, a licensed nurse prepared the morning medications and stated the metformin would not be given because it was not available. Later, the same nurse confirmed the dose was missed because it was unavailable, and stated that a missed dose could cause high blood sugar. The DON stated the metformin should have been given as ordered. Resident 10 also had orders for timolol eye drops in the right eye twice daily and artificial tears in both eyes every two hours. During observation, the licensed nurse administered timolol and then immediately administered the artificial tears. The nurse confirmed the eye drops were given consecutively. The DON stated nurses were expected to wait five minutes between different eye drops to prevent reduced effectiveness and potential side effects, and the consultant pharmacist stated waiting five minutes between different eye drops was important. The facility policy titled Administering Medications stated medications are to be administered in a safe and timely manner, and as prescribed.
Expired, Discontinued, and Undated Medications Stored in Carts
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in the facility’s medication and treatment carts. During observation and interview with LN 2 in station 2, med cart C contained one medication with an expiration date of 11/2025 and five discontinued medications that belonged to a resident who had been discharged from the facility. LN 2 confirmed the expired and discontinued medications were still stored in the med cart and stated they should not have been kept there. During a separate observation and interview with LN 1 in station 2, the treatment cart contained one bottle of wound cleanser, one bottle of povidone-iodine solution, and one tube of calmoseptine ointment that were opened and undated. LN 1 also confirmed three packets of antibiotic ointment were expired with an expiration date of 11/2025 and were still stored in the treatment cart. The DON stated expired and discontinued medications should not be stored in the med cart or treatment cart, and that opened medications should be labeled with an open and discard date. Facility policy stated discontinued, outdated, or deteriorated drugs or biologicals are returned to the pharmacy or destroyed, drugs shall not be kept in stock after the expiration date, and the date opened is recorded on multi-dose containers.
Failure to Follow Standardized Recipes for Vegetables and Fish
Penalty
Summary
Food was not prepared in a manner to conserve nutritive value for a census of 95 residents when the facility did not follow standardized recipes for seasoned carrots, seasoned peas, and oven crisp fish. The lunch menu for 1/7/26 included oven crisp fish, tater tots, seasoned carrots, wheat roll, and apple hill cake. The facility’s recipe for seasoned peas called for a cooking time of 10-15 minutes, and the recipe for seasoned carrots called for a cooking time of 10-20 minutes. During observation, the carrots were placed in a pot of water at 10:45 a.m. and cooked until 11:20 a.m. before being placed on the steamer. The peas were kept on the stove until tray line at 12 p.m. The carrots were also prepared with one teaspoon of salt and two ounces of butter in each pot. During observation, the [NAME] opened frozen fillet fish, placed it on a pan, and spread one side with ranch dressing and crushed potato chips. The [NAME] confirmed parsley was not used. The facility’s recipe for oven crisp fish for 96 servings required two cups of parsley flakes, thawed fillet fish of choice, and coating both sides of the fish with ranch dressing. The RD stated it was important to follow the recipe regarding cooking time to maintain food flavor and nutritive value. The DM stated the carrots and peas should not have been cooked longer than 15-20 minutes because additional cooking could reduce nutritive flavor and make them too soft, and stated the fish should have been thawed, parsley added, and both sides coated with ranch dressing. Facility policies required standardized recipes to be used, vegetables to be served promptly, and meats to be properly thawed and seasoned appropriately.
Food Storage and Tray Line Sanitation Deficiencies
Penalty
Summary
Food was not stored and served in a sanitary manner for a census of 95 residents. The facility failed to monitor refrigerator and freezer temperatures on multiple p.m. shifts in October and November 2025 for the walk-in and reach-in refrigerators and freezers. During record review with the Dietary Manager, the missing temperature checks were confirmed, and the facility policy required refrigerator temperatures at 41 degrees Fahrenheit or lower and freezer temperatures at zero degrees Fahrenheit or lower. An expired cinnamon stick bottle with an expiration date of 11/30/25 was observed on the spices rack and confirmed by the Dietary Manager as available for use. During tray line observation, the [NAME] used gloved hands to touch scoop handles and plates, then used the same gloved hand to crush ready-to-eat fish into smaller pieces. The Registered Dietician expected the [NAME] not to use the same gloved hands after touching multiple surfaces to touch ready-to-eat food, and the facility policy stated food would be prepared and served in a sanitary manner and utensils should be used as much as possible.
Infection Control Lapses With Equipment, Sterile Supplies, and EBP PPE
Penalty
Summary
Proper infection prevention and control measures were not implemented when an LN did not disinfect a BP monitor between resident uses. During observation, the LN checked one resident’s BP and placed the monitor on the medication cart without disinfecting it, then used the same monitor to check another resident’s BP in the hallway without disinfecting it first. The LN later confirmed the monitor was not disinfected between uses, and the DON stated BP monitors were expected to be disinfected in between resident use. The facility policy stated reusable items are cleaned and disinfected or sterilized between residents. The facility also had five sterile wound dressings opened and stored in the treatment cart at station 2. During observation, LN 4 confirmed the dressings were opened and stored in the cart, and stated they should not be kept there once opened because sterility would not be maintained. The DON stated that if a sterile wound dressing was opened, even if unused, it should be discarded and not stored in the treatment cart. In addition, a housekeeper cleaning a resident’s room under EBP did not wear a gown while disinfecting high-touch surfaces such as the bedside table and bed rail. The resident had been admitted with osteomyelitis of the vertebra and sacral region and was ordered on EBP due to wounds and a urinary catheter. The housekeeper stated she did not understand the EBP sign, and the DON stated staff should know the proper procedure before entering a room under precautions.
Failure to Evaluate Resident’s Request to Use Motorized Wheelchair
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of one resident when she was not evaluated after requesting to use her motorized wheelchair in the facility. The resident was admitted with diagnoses including muscle weakness and dystonia, was responsible for herself, and could make her own healthcare decisions. Her MDS indicated she was independent with bed mobility, required only set-up assistance for transfers, and had intact cognition with a BIMS score of 15 out of 15. During observation and interview, the resident stated her motorized wheelchair was parked next to her bed but she was not permitted to use it, and she said she was not assessed to determine whether she could drive it safely and was only told of the restriction without a clear explanation. Social services notes showed she repeatedly asked for permission to use the wheelchair, but the request was denied. The DOR stated an evaluation was not initiated because permission had been denied by prior administration, and the DON confirmed there was no documentation that an evaluation had been conducted to support the decision to deny use of the motorized wheelchair. The RC also confirmed that no evaluation was performed for the resident's request.
Failure to Care Plan for Hospice Services
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 13 that addressed hospice care and related interventions. Resident 13 was admitted to the facility in June 2024 with diagnoses including hypertensive heart disease with heart failure. She was later admitted to hospice care in November 2025 with a diagnosis of cerebral atherosclerosis, and a significant change in status MDS assessment was completed on 11/26/25 following the hospice admission. During a concurrent interview and record review on 1/8/26, the DON reviewed Resident 13’s admission order and care plans and stated that Resident 13 had been receiving hospice care since November 2025. The DON confirmed there was no care plan in place for Resident 13’s hospice care and stated that a care plan should have been developed by nursing staff to ensure care was centered according to the patient’s wishes and that necessary hospice care interventions were implemented effectively. The facility’s undated policy titled Comprehensive Care Plans stated that the facility is to develop and implement a comprehensive person-centered care plan for each resident, including all services identified in the resident’s comprehensive assessment and meeting professional standards of quality.
Failure to Provide Effective Language Assistance
Penalty
Summary
The facility failed to provide necessary care and services for one of 23 sampled residents, Resident 48, when staff did not implement an appropriate communication system for a resident who spoke Spanish. Resident 48 was admitted in October 2025 with a diagnosis of diabetes mellitus. During an observation, Resident 48 asked a question in Spanish and a CNA responded in English that she would look for a staff member who spoke the same language. The CNA returned and said no Spanish-speaking staff were available and asked the resident to wait longer. During another observation, Resident 48 was talking in Spanish and appeared anxious while an LN stated he could not understand the resident and left to find someone who could translate. After several minutes, the LN returned with the Activities Driver, who explained that Resident 48 was asking about his medications. A CNA later stated she could not understand what Resident 48 was saying and gave him snacks, saying maybe he was hungry. The SSD stated communication boards/binders had been prepared for residents and posters with the translation app phone number were placed in staff areas, but the SSD could not find a communication board/binder for Resident 48 and could not find the translation app poster in the staff break room. The DON also could not find the poster, and the DSD stated no in-service training had been provided in 2025 on how to address language barriers. The facility policy stated it would ensure individuals with limited English proficiency had access to language assistance services and that staff would be trained in effective communication techniques, including use of an interpreter.
Pharmacist Medication Review Recommendations Not Followed for Psychotropic Medications
Penalty
Summary
The facility failed to review and act on the consultant pharmacist’s medication regimen review recommendations for psychotropic medications for two residents. One resident was admitted with diagnoses including depression and anxiety and had an order for trazodone 25 mg by mouth at bedtime every Monday through Saturday for inability to sleep. The consultant pharmacist’s medication regimen review recommended a gradual dose reduction of trazodone to every other night, but the record did not show a physician or prescriber response with rationale, signature, or date. During interview and record review, the DON confirmed the recommendation was not followed and stated it might affect the resident’s mental status. A second resident was admitted with a diagnosis of depression and had an order for lorazepam 0.5 mg by mouth as needed for anxiety for 14 days. The consultant pharmacist’s medication regimen review requested clarification because the lorazepam order did not include a frequency, and there was no follow-up note documentation in the record. During interview and record review, the DON confirmed the order had no frequency and stated that without a frequency, the nurse could have given an overdose. The CP stated the facility was expected to notify the physician and clarify the monthly medication regimen review, and that all orders should have a frequency and the review should have been updated as soon as possible.
PRN Lorazepam Ordered Without Required Stop Date
Penalty
Summary
The facility failed to ensure that one of 23 sampled residents, Resident 53, was free from unnecessary medications when lorazepam was prescribed without a stop date. Resident 53 was admitted in October 2025 with a diagnosis of anxiety disorder. The Order Summary Report dated 12/13/25 showed an order for lorazepam 0.5 mg every eight hours as needed for anxiety with agitation, but no stop date was listed. The Medication Administration Record showed Resident 53 received lorazepam 13 times in 12/25 and twice in 1/26. During a concurrent interview and record review on 1/8/26, the DON confirmed the PRN lorazepam order did not include a stop date and stated it should have been ordered for a limited duration of 14 days per facility policy. The facility policy stated PRN psychotropic medication orders shall be limited to no more than 14 days.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect three residents from abuse when multiple incidents of physical altercations occurred between them. On two separate occasions, residents were observed slapping and hitting each other on the arms. In the first incident, two residents engaged in a physical altercation after an argument about seating, resulting in both slapping each other on the arms. In the second incident, two residents began hitting each other after one resident grabbed the other's belongings while sitting at the same table in the dining room. These altercations were witnessed by staff and a housekeeper, who intervened to separate the residents. As a result of these incidents, two residents sustained abrasions with bleeding, and one resident displayed bruising on her forearm. The involved residents had varying cognitive statuses, with one resident having severe memory impairment and others being cognitively intact. The facility's policy required the prevention and prohibition of all types of abuse, neglect, and exploitation, but these measures were not effectively implemented to prevent the physical altercations and resulting injuries.
Failure to Maintain Safe and Comfortable Temperatures Due to Inoperable Heating System
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for its residents, as evidenced by multiple complaints of cold temperatures and room temperatures consistently below regulatory requirements. Observations and interviews revealed that residents were dressed in multiple layers, using extra blankets, and still experiencing discomfort and difficulty sleeping due to the cold. Thermostats in several rooms registered temperatures as low as 61 to 65 degrees Fahrenheit, with no warm air coming from the vents, and staff were unable to adjust the thermostats or provide effective relief. Residents repeatedly reported their discomfort to staff, but the only response was the provision of additional blankets, and no effective action was taken to resolve the underlying issue. Staff interviews confirmed that the facility had been cold for at least a week, particularly at night, and that the heating system was not functioning properly. Staff members acknowledged their inability to adjust thermostats or confirm whether the heating system was operational. Maintenance staff and facility administration were aware of the heating issue, specifically a non-functioning boiler, but failed to act in a timely manner to restore adequate heating. The Director of Nursing and Administrator initially denied awareness of the problem, despite direct observations and multiple resident complaints. A review of facility policies indicated that immediate action was required when heating systems were inoperable, with a mandate to maintain temperatures between 71 and 81 degrees Fahrenheit. However, the facility did not follow these policies, as evidenced by the lack of timely repairs and inadequate interim measures to ensure resident comfort. Temperature logs provided by maintenance were inconsistent with observed room temperatures, and staff could not explain the discrepancies. The failure to maintain appropriate temperatures resulted in ongoing resident discomfort and a failure to provide a safe, homelike environment as required by facility policy.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to ensure one of four sampled residents was free from physical abuse when another resident slapped him on the right cheek and punched him in the stomach. Resident 1 was admitted in winter 2024 with diagnoses including COPD, inguinal hernia, and depression, and his records indicated he was capable of understanding rights, responsibilities, and informed consent. His MDS dated 9/11/25 showed a BIMS score of 15 out of 15, indicating intact cognition. Resident 1’s progress note documented that his roommate suddenly came to him and hit him on the face and stomach. Resident 2 was admitted in October 2025 with diagnoses including vascular dementia with moderate agitation, delirium, and Alzheimer’s disease, and his MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Resident 1 stated that Resident 2 wanted the television turned off, unplugged it, and then slapped him on the right cheek and punched him in the stomach after he plugged the TV back in. LN 1 stated that CNA 1 witnessed the incident, and the SSD stated the CNA was in the hallway outside the room when the incident occurred and separated the residents after seeing something. The DON stated that CNA 1 witnessed and confirmed that Resident 2 slapped Resident 1 on the face and punched him in the stomach, and the facility policy stated residents have the right to be free from abuse, including physical abuse by other residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Promote Dignity and Address Inappropriate Resident Behaviors
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15 and a diagnosis of dementia, was observed engaging in behaviors that did not promote dignity and respect. The resident was seen spitting on the hallway floors and was reported by staff to have frequent bowel movements on the facility's outside patio. These behaviors were witnessed by multiple staff members, including a CNA and two licensed nurses, who confirmed the incidents and noted that the actions could be distressing to other residents. Additionally, there was an altercation between this resident and another after the latter observed the resident with his pants down on the patio. A review of the resident's clinical record revealed that there were no care plans or interventions in place to address the resident's behaviors of spitting and having bowel movements outside. The Director of Nursing confirmed the absence of such interventions and acknowledged the altercation resulting from the resident's actions. The facility's policy on resident rights and dignity requires that all residents be treated with kindness, respect, and dignity, but this was not upheld in the care provided to this resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia was physically abused by another resident who was cognitively intact. The incident took place in the patio area, where the cognitively intact resident pushed the other resident in the face with his forearm, resulting in a bloody nose. The aggressor stated that he acted to block the other resident, who had his pants down and was attempting to have a bowel movement on the patio. Staff interviews and clinical record reviews confirmed the incident and the resulting injury. The facility was aware that the resident with dementia had a pattern of having bowel movements on the patio, but this behavior was not effectively managed or prevented. Staff, including a CNA and the DON, acknowledged knowledge of the ongoing issue. The facility's policy on abuse and neglect defines abuse as the willful infliction of injury with resulting physical harm, which was consistent with the events described. The failure to prevent the altercation led to physical harm to a vulnerable resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident struck another with a wooden and metal reacher during an altercation. One resident, who had severe memory impairment and multiple diagnoses including dementia, was involved in an incident with her roommate, who was alert and oriented. According to nurse's notes and staff interviews, the altercation began when the resident with dementia lost her balance and fell across her roommate's bed, prompting the roommate to hit her in the face with a stick. The roommate admitted to striking her with the reacher, and both residents sustained minor injuries during the incident. Observations and interviews confirmed that the reacher was accessible to the resident who used it as a weapon, and both residents recalled aspects of the altercation, with one stating that similar incidents had occurred before but were not reported. Staff responded to the commotion and witnessed the physical altercation, noting that both residents were upset. The facility's abuse prevention policy states that residents have the right to be free from abuse, including abuse by other residents, but this policy was not effectively implemented in this case.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident repeatedly hit her on the arm. The resident who was hit had a history of flaccid hemiplegia, epilepsy, and muscle weakness, and was cognitively intact. The aggressor resident had severe cognitive impairment. The incident was witnessed by another resident, who confirmed that the aggressor hit the victim on the arm, causing the victim to yell. The victim reported feeling scared and stated that she did not like being touched due to past trauma. She required medication to calm down after the incident. Staff interviews confirmed awareness of the incident, with a licensed nurse and the Director of Nursing both acknowledging that the resident was upset and required medication for nervousness. The facility's policy defined abuse as the willful infliction of injury or intimidation resulting in physical harm, pain, or mental anguish, and stated that all residents, regardless of mental or physical condition, are protected from such abuse. The report of suspected abuse was documented, and the incident was corroborated by both the victim and a witness.
Failure to Maintain Resident Dignity Due to Persistent Urine Odor
Penalty
Summary
The facility failed to promote dignity for two residents sharing a room, as evidenced by a persistent and strong urine odor in their shared bedroom. Observations revealed a soiled diaper left on top of a potty chair since the morning, which had not been cleaned or removed by staff. Both residents were alert and able to communicate, with one resident expressing that the constant urine smell made her feel undignified and that staff did not care about maintaining a clean environment. The other resident reported feeling uncomfortable and likened the experience to being inside a bathroom, stating that there was no dignity in the situation. Staff interviews confirmed the presence of the strong urine odor and the soiled brief, with a CNA acknowledging that the room often smelled this way and a licensed nurse describing the situation as undignified. The Social Service Director and Director of Nursing both agreed that the environment was not dignified and that the room should be kept clean to promote residents' dignity and quality of life. The facility's own policies require care that enhances residents' well-being and prohibits practices that compromise dignity, but these standards were not upheld in this instance.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when one resident intentionally ran over another resident's foot with a wheelchair on two separate occasions during the same incident. The first resident, who was cognitively intact according to a recent BIMS assessment, was observed by staff and other residents to be yelling and screaming at staff before backing his wheelchair over the second resident's foot. When notified by staff that he had run over the other resident's foot, the first resident responded, "I don't care," and proceeded to run over the foot again. Multiple staff members, including a CNA and a Licensed Nurse Supervisor, witnessed the incident and confirmed the sequence of events. The second resident, who had moderate cognitive impairment and a history of anxiety disorder, expressed fear and distress following the incident and stated he did not want to be hit again. The incident was documented in progress notes and corroborated by interviews with both residents, staff witnesses, and the Social Services Director. The facility's policy defines abuse as the willful infliction of injury, and the actions of the first resident were described as deliberate. The second resident reported the incident to staff and indicated a desire to press charges. The administrator acknowledged that abuse is not tolerated at the facility.
Failure to Maintain HVAC System Resulting in Inoperable Cooling
Penalty
Summary
The facility failed to maintain its Heating, Ventilation, and Air Conditioning (HVAC) system as required by federal regulations and the National Fire Protection Association (NFPA) Life Safety Code. During a facility tour and staff interviews, surveyors observed that the chiller system, which includes four air handlers serving each wing, was completely inoperable. As a result, the facility was using six portable air conditioning units distributed throughout the corridors and dining room. Staff confirmed that the main cooling system had been nonfunctional for over a year, and the facility was in the process of obtaining a new system while relying on portable units in the interim. This deficiency affected all 95 residents across all four compartments of the facility, resulting in the inability to maintain required temperatures.
Plan Of Correction
HVAC How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Facility completed contract to have chiller replaced on 04/05/2024. Chiller install date is May of 2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-service was conducted by the facility Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring the facility maintains functional HVAC system to maintain facility temperatures. d) Maintenance Director and/or designee will conduct weekly facility inspections focusing on functioning HVAC system and maintaining facility temperature. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Administrator. Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI committee for further evaluation and/or recommendations.
Improper Use of Extension Cords and Power Strips for Electrical Equipment
Penalty
Summary
The facility failed to maintain electrical equipment in accordance with NFPA 101 and related standards, as evidenced by the use of extension cords and power strips in multiple areas. During a facility tour, surveyors observed several instances where portable air conditioning units were plugged into orange extension cords in corridors near resident rooms 9, 23, 36, and 50. Additionally, an extension cord was found in use by bed A in resident room 20, and another was observed in the medication storage closet in nurses station 2, where it was connected to an air conditioning unit placed on a cabinet. In each case, staff interviews revealed that either residents or their families had brought the extension cords or power strips into the facility. These observations indicate that extension cords and power strips were being used as a substitute for fixed wiring, which is not permitted under the cited regulations. The use of such equipment was not limited to personal electronics in resident rooms without patient-care-related electrical equipment, but extended to areas where it is explicitly prohibited. The deficiency affected all 95 residents and all four smoke compartments of the facility, as the improper use of electrical equipment was widespread throughout the building.
Plan Of Correction
and for all three shifts. Issues identified will be immediately addressed and corrected by the Maintenance Director and/or designee and will be validated by the Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained: e) Maintenance Director and/or designee will bring monthly to the department manager morning meeting the fire drill binder to validate that fire drills are being conducted as required and for all three shifts. Issues identified will be immediately addressed and corrected by the Maintenance Director and/or designee and will be validated by the Administrator. Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025 K920 Electrical Equipment - Power Cords and Extens How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: (a) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 23 on 04/16/2025. (b) The Maintenance Director immediately removed the extension cord plugged into the resident room 20 on 04/16/2025. (c) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 50 on 04/16/2025. (d) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 36 on 04/16/2025. (e) The Maintenance Director immediately removed the extension cord plugged into the air conditioning in the medication storage closet 04/16/2025. (f) The Maintenance Director immediately removed the orange extension cord plugged into the portable air conditioning found in the corridor near resident room 9 on 04/16/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: g) All areas have the potential to be affected by this deficient practice. No other areas were identified as being affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: h) In-Service was conducted by Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring that the facility is following the proper procedures and regulations as it pertains to the use of extension cords within the facility. i) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility use of extension cords. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Administrator. How the facility plans to monitor its performance to make sure that solutions are sustained: j) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility use of extension cords. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Maintenance Director and/or designee and will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025
Failure to Conduct Timely and Varied Fire Drills
Penalty
Summary
The facility failed to properly maintain fire drill procedures as required by NFPA 101. Fire drill records showed that drills were conducted at the same time on multiple occasions, specifically with PM shift fire drills occurring at 3:30 p.m. on two separate dates. Additionally, the facility did not provide evidence of conducting required shift fire drills for several quarters, including the first, second, and fourth quarters of the specified years. Staff interviews confirmed that drills were sometimes scheduled to overlap shifts in an attempt to involve more staff, but this resulted in missing required drills for individual shifts. These deficiencies affected all 95 residents across four smoke compartments.
Plan Of Correction
How the facility plans to monitor its performance to make sure that solutions are sustained: e) Maintenance Director and/or designee will conduct weekly facility inspections focusing on the facility maintaining a functional HVAC system to ensure proper facility temperatures. Issues identified will be corrected immediately by the Maintenance Director and/or designee and will be validated by the Maintenance Director and/or designee. The Maintenance Director and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Completion Date: 04/17/2025 K712 Fire Drills: How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) A fire drill was conducted for PM shift on 01/31/2025, for NOC shift on 02/27/2025, and for AM shift on 03/25/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) All areas have the potential to be affected by this deficient practice. No other areas were identified as being affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by the Administrator to the Maintenance Director on 04/17/2025 regarding the importance of ensuring that the facility is following the proper procedures and regulations as it pertains to fire drills for all three shifts (AM, PM, and NOC). d) Maintenance Director and/or designee will bring monthly to the department manager morning meeting the fire drill binder to validate that fire drills are being conducted as required.
Deficient Food Storage, Sanitation, and Equipment Maintenance in Kitchen
Penalty
Summary
The facility failed to maintain food storage, preparation, and kitchen equipment in accordance with professional standards for food service safety. During a kitchen tour, an open bag of grits was found unsealed and undated in dry storage, contrary to facility policy requiring opened dry food items to be tightly closed, labeled, and dated. The Registered Dietitian (RD) confirmed the lack of proper sealing and dating, acknowledging the risk of contamination. Additionally, several kitchen environment issues were observed, including a worn and damaged walk-in refrigerator floor, walls and ceilings with missing paint, texture, and signs of water damage, and a fruit and vegetable sink lacking an air gap for backflow prevention. The Maintenance Supervisor stated that maintenance needs should be logged by kitchen staff, but no requests for repairs had been made according to the facility's work history report. Further deficiencies included improper storage of kitchenware, with five metal bowls and nine steam table pans stacked and stored while still wet, which the RD confirmed was not compliant with air-drying requirements. Damaged small wares were not discarded as required by policy; a fry pan with extensive markings and scratches, a discolored and deeply scored cutting board, beverage pitcher lids with cracks and chips, and a can opener with missing metal were all found in use or storage. The RD and facility policies confirmed these items should have been discarded or replaced due to their condition, which could harbor bacteria or introduce foreign objects into food. Additionally, a large mixer was found with hardened, crusted build-up and rust-colored debris behind the mixing bowl, indicating inadequate cleaning. The RD confirmed the mixer was dirty and needed cleaning. These findings, based on direct observation, interviews, and record review, demonstrated a failure to adhere to both facility policies and FDA Food Code requirements for food safety, sanitation, and equipment maintenance. The deficiencies had the potential to cause foodborne illness for the 91 residents consuming facility-prepared meals.
Plan Of Correction
04/07/2025. b) The rough textured scratch was repaired by Maintenance Supervisor on 05/07/2025. c) The walk-in refrigerator floor was repaired by Maintenance Supervisor on 05/07/2025. d) The fruit and vegetable cleaning sink was repaired by Maintenance Supervisor on 05/07/2025. e) The ceiling cracks above the food service area were repaired by Maintenance Supervisor on 04/11/2025. f) The fruit and vegetable cleaning sink was repaired to have an airgap by Maintenance Supervisor on 05/07/2025. g) The wet metal bowls and steam table pans were removed, washed and left to air dry on 04/07/2025. h) The discolored fry pan and cutting board were removed and thrown away on 04/07/2025. i) The can opener was removed and thrown away on 04/07/2025. j) The discolored and cracked beverage lids pan and cutting board were removed and thrown away on 04/07/2025. k) The large mixer was removed and cleaned on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: I) All residents have the potential to be affected by this deficient practice. No other areas were identified as having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: m) In-Service was provided by the Registered Dietician to the dietary staff on 04/11/2025 through 04/15/2025 regarding the importance of labeling and dating food items, ensuring that staff are monitoring properly air drying items before placing them for storage. In-Service was provided by the Administrator to the Maintenance Department staff on 05/07/2025 regarding the importance of making rounds in all of the necessary areas in the kitchen and that there is no buildup on equipment that items needing repair are reported immediately in an effort to avoid foods becoming affected. n) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. o) Dietary Manager and/or designee to conduct random audits of the kitchen to look for food that may be unlabeled or undated and checks that equipment is stored properly, clean and not discolored along with items requiring to be reported for repair/replacement. Any issues identified will be reviewed, validated and immediately corrected. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations until negative trends resolve. F 812 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice:
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living (ADLs) was not provided with necessary nail care. The resident, who had diagnoses including metabolic encephalopathy, diabetes, gait abnormalities, and depression, required substantial to maximal assistance with personal hygiene, including nail care, as documented in her care plan. Despite this, observations revealed that the resident had long fingernails and toenails, with some toenails curved and causing discomfort by poking her other toes. The resident reported that she had requested nail trimming from staff over a month prior, but the care had not been provided. Certified Nurse Assistant (CNA) staff confirmed awareness of the resident's long nails, noting that they had observed the issue during showers and reported it to nursing staff approximately two weeks earlier. Facility documentation, including multiple "Skin Monitoring: Comprehensive CNA Shower Review" sheets, consistently indicated that the resident needed her toenails cut, with both CNA and nurse signatures, but no interventions were documented in response. The facility's process required nurses to perform nail care for diabetic residents and to refer residents needing special tools to a podiatrist, but the resident was not included on the podiatry referral list, and no action was taken to address her nail care needs. Interviews with facility leadership, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that nail care should be assessed and performed regularly, particularly for residents with diabetes, and that failure to provide this care could result in skin injury or infection. The facility's policy required provision of necessary services for residents unable to perform ADLs, including grooming and personal hygiene, but this was not followed in the resident's case.
Plan Of Correction
F677 ADL Care Provided for Dependent Residents How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #70 had their fingernails trimmed and toes trimmed on 04/10/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of all residents was completed on 04/09/2025 by MDS LVN/designee to ensure that residents had cleaned, well-trimmed fingernails and toenails. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON / DSD to LN and CNA staff from 04/10/2025 through 04/17/2025 regarding the importance of ensuring that all residents have cleaned, well-trimmed fingernails and toenails. d) LN supervisor / designee review shower sheets and check resident nails the following day to ensure that nails and toenails are being kept cleaned, and well-trimmed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained: e) LN Supervisor / designee review shower sheets and check resident nails the following day to ensure that nails and toenails are being kept cleaned, and well-trimmed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. Administrator and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Provide Ongoing Activities Meeting Psychosocial Needs
Penalty
Summary
A deficiency was identified when a resident with dementia, Alzheimer's disease, and major depressive disorder was not provided with an ongoing activity program that met her psychosocial needs for multiple periods. The resident's care plan specified the importance of activities such as reading, listening to music, being around animals, staying updated with the news, participating in group activities, going outdoors, and engaging in religious practices. The care plan also included goals for both in-room and out-of-room activities, with interventions to invite, encourage, and assist the resident in participating as tolerated. Observations over several days showed the resident lying in bed, unresponsive to greetings, with no music playing and the television turned off. There was no evidence of activities being provided in the resident's room during these times. The Activities Director confirmed that the resident did not receive any activities that met her psychosocial needs during two specific periods, and acknowledged that this lack of engagement would not maintain the resident's activity level as intended by the care plan. Interviews with facility staff, including the Activities Director and the DON, revealed that residents unable to attend group activities should be provided with bedside activities to keep them engaged. The DON stated that it was unacceptable for a resident to go without activities meeting psychosocial needs for several weeks, as this could lead to a decline in activity level and self-isolation. Review of the facility's policy confirmed the requirement to provide individualized, ongoing activity programs based on resident assessments and preferences, including special considerations for residents with dementia.
Plan Of Correction
Activities Meet Interest/Needs Each Resident How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 plan of care was updated to include alternate activities on 04/11/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Activities Director completed an audit on 04/17/2025 to ensure that residents have activities offered. All residents in the facility have the potential to be affected by this deficient practice. No other residents were identified. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was initiated by facility Administrator on 04/11/2025 to Activities Director regarding the importance of offering residents activities. e) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: f) DON and/or designee will conduct weekly random audits of residents' activities charting to ensure that residents are offered activities. Issues identified during these audits will be brought forth to the five-day a week clinical department manager meeting for review, validation, and immediate correction. All non-compliance issues identified will be corrected immediately and reported to the Administrator for review, validation, and resolution. DON will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Remove and Destroy Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure that completed or discontinued controlled medications were promptly removed from medication carts and properly destroyed, as required by federal regulations and facility policy. During observations and interviews, surveyors found that controlled medications, specifically Ativan 0.5 mg tablets, remained in the medication carts for two residents after the medications had been discontinued or completed. In one instance, a nurse confirmed that a bubble pack containing forty Ativan tablets for a resident with a history of radiculopathy, convulsions, and muscle spasm was still present in the cart, despite the medication order having ended weeks prior. The nurse acknowledged that the medication should have been surrendered to the DON for destruction. A similar situation was observed with another resident diagnosed with dementia, psychotic disturbance, and pain. Two bubble packs of Ativan, containing a total of thirty tablets, were found in the medication cart, even though the medications had been completed the previous year. The nurse responsible for the cart confirmed that the medications should have been removed and given to the DON for destruction, and acknowledged that keeping discontinued controlled medications in the cart was unsafe. Interviews with the DON and the pharmacy consultant confirmed that the facility's policy requires discontinued or completed controlled medications to be immediately removed from medication carts, documented, and stored securely until destruction. Record reviews corroborated that the medications in question had not been administered for several months, yet remained accessible in the carts. The facility's failure to follow its own procedures and federal requirements resulted in the presence of unused controlled substances in medication carts, as directly observed by surveyors.
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #8 and Resident #59 discontinued medications were removed from the cart immediately on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) An audit of all medication carts was completed on 05/01/2025 by Nurse Supervisor to ensure all discontinued medications were removed from the cart and logged for destruction. All residents have the potential to be affected by this deficient practice. No other residents were identified to have this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all resident's discontinued medications were removed from the medication cart. d) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. This plan of correction is integrated into the quality assurance system: e) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/01/2025
Improper Preparation of Pureed Foods Reduces Nutritional Value and Palatability
Penalty
Summary
The facility failed to prepare pureed foods for ten residents according to established recipes and methods that conserve nutritive value, flavor, and appearance. During meal preparation, the dietary cook did not use measuring tools and added unmeasured amounts of water to various foods, including pasta, meatballs, and spinach, to achieve a pureed consistency. The cook also did not have pureed diet recipes available at the workstation during food preparation. Observations revealed that water was used as the primary thinning agent for pureed foods, rather than recommended liquids such as low sodium broth or gravy. For example, the cook added unmeasured water to pasta and spinach, and used cooking juice and water for the meatballs, resulting in a watery consistency. The cook expressed dissatisfaction with the texture of the pureed spinach and continued to add more water to adjust it. These practices were inconsistent with the facility's documented recipes and guidelines, which specifically state that water should not be used as it dilutes flavors and results in a poorly accepted product. The registered dietitian confirmed that adding water to pureed foods can dilute taste and alter the nutrient content of meals. Review of facility documents and recipes further supported that water should not be used in pureed foods, and that warm liquid such as broth or gravy should be added gradually to achieve the desired consistency. The failure to follow these procedures affected the quality and nutritional value of meals provided to the residents on pureed diets.
Plan Of Correction
Nutritive Value/Appear, Palatable/Prefer Temp How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Dietary Cook 1 disposed of the pureed that was made with water on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the recipe for pureed food to ensure that residents are provided the correct nutritional content. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking at preparation of pureed food to ensure it was prepared according to the recipe to maintain nutritional value. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025 F 804
Infection Control Lapses in PPE Use, Equipment Disinfection, and Supply Handling
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols in several instances. Two CNAs did not wear the required gowns, only gloves, while providing care to a resident on Enhanced Barrier Precautions (EBP) for an arteriovenous shunt used in dialysis. The EBP signage and facility policy clearly indicated that both gown and gloves were required for high-contact activities such as dressing and transferring, and both CNAs acknowledged awareness of these requirements. The Infection Preventionist and Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves during such care, and records showed both CNAs had received recent in-service training on EBP prior to the incident. A licensed nurse failed to disinfect a blood pressure cuff between uses on three different residents during medication administration. The nurse used the same cuff on each resident consecutively without cleaning it, and later acknowledged this lapse. Facility policy required that multi-resident use equipment be cleaned and disinfected after each use, but this was not followed in these instances. During a wound care procedure, a nurse placed excess treatment supplies, including opened packs of gauze and silicone foam dressings, back into the treatment cart after use in a resident's room. Both the nurse and the Infection Preventionist confirmed that this practice could lead to cross-contamination, and facility policy specified that supplies removed from the cart and exposed during treatment should not be returned unless sanitized. The Director of Nursing also stated that returning such supplies to the cart was not appropriate due to the risk of spreading infection.
Plan Of Correction
a) On 04/09/2025 CNA 1 and CNA 2 immediately put on PPE required for Resident 73's Enhanced Barrier Precaution. b) On 04/08/2025 Licensed Nurse 9 immediately cleaned and disinfected the blood pressure cuff. c) On 04/08/2025 Licensed Nurse 1 removed and disposed of the excess treatment supplies from the treatment cart. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: d) Infection Prevention Nurse Consultant completed an audit on 04/09/2025 of staff to ensure no other staff were identified with having the same deficient practice of not wearing enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. e) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were identified with having the same deficient practice of not cleaning and disinfecting the blood pressure cuff between residents. No other areas were identified with having the same deficient practice. f) Infection Prevention Nurse / designee completed an audit on 04/09/2025 of staff to ensure no other licensed nurses were placing excessive treatment supplies back into the treatment cart. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: g) DON in-served Licensed Nurses on 04/17/2025 regarding the importance of wearing enhanced barrier precaution PPE, cleaning and disinfecting resident equipment between uses, and not putting excess treatment supplies back into the treatment cart. h) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: i) Infection Preventionist and/or designee will conduct random audits of staff to ensure that enhanced barrier precaution PPE is worn, disinfecting of resident equipment between uses, and excess treatment supplies are not placed back into the treatment cart. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Infection Preventionist will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation/s. 04/17/2025
Failure to Develop and Implement Dysphagia Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with dysphagia, as required by federal regulations. Both residents had documented diagnoses including acute respiratory failure with hypoxia and orders for nectar-thick liquids to address their swallowing difficulties. Despite these orders, one resident was observed drinking regular water and another was observed drinking unthickened hot chocolate, both contrary to their prescribed diet orders. The Activity Director and Director of Nursing confirmed that the drinks should have been thickened according to the residents' meal tickets to prevent choking or aspiration. Further review of the electronic medical records for both residents revealed no documented evidence of a dysphagia care plan. This was confirmed by both a licensed nurse and the Director of Nursing, who acknowledged that a care plan should have been in place as a means of communication for nursing staff. The facility's own policy requires the development and implementation of a comprehensive, person-centered care plan for each resident, including all services identified in the comprehensive assessment.
Plan Of Correction
Either by the governmental agencies or third party. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the federal rules of evidence and California evidence code section 1151 and should be inadmissible in any proceeding on that basis. F656 Develop/Implement Comprehensive Care Plan How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/09/25 Resident 49 and Resident 79 care plans were updated to include dysphagia diagnosis. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Clinical Resource Nurse completed an audit on 05/01/2025 to ensure all current residents with a dysphagia diagnosis/diets had a completed care plan to reflect their dysphagia diagnosis. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DON on 04/11/2025 to LN staff regarding the importance of completing dysphagia care plans for residents with a dysphagia diagnosis. d) Medical Records / designee will pull the report of new admissions each morning and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) Medical Records / designee will pull the report of new admissions and bring to the clinical meeting 5 days per week to ensure dysphagia care plans have been completed. Any issues identified during the audit will be brought forth to the IDT members and physician for review and resolution. All non-compliance issues identified will be brought forth immediately and reported to the IDT members for review, validation and resolution. DON / designee will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations. F 656
Failure to Consistently Provide Physician-Ordered Wound Care
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including multiple sclerosis, malnutrition, depression, and anxiety disorder, did not consistently receive prescribed wound care for a right ankle wound. The resident was cognitively intact and reported that staff were not cleaning the wound as frequently as ordered by the physician. The care plan required monitoring and documentation of the wound, as well as reporting abnormalities to the physician. Physician orders specified daily evening wound care, with changes as needed if soiled or dislodged, and later included specific wound care products. However, treatment administration records showed that wound care was missed on several specific dates. Interviews with facility staff, including the Nurse Supervisor, Director of Staff Development, and Director of Nursing, confirmed that the wound care was not performed as ordered. Staff acknowledged that failure to follow wound care orders could result in infection, delayed healing, or worsening of the wound. The facility's policies required wound treatments to be provided according to physician orders and professional standards of practice. As a result of the missed wound care, the resident experienced right ankle pain, increased bleeding, confusion, elevated heart rate, and temperature, which led to a hospital transfer. Hospital records indicated the presence of an infected wound with MRSA and Pseudomonas, requiring intravenous antibiotics. The failure to provide consistent wound care as ordered by the physician and outlined in facility policy directly contributed to the resident's condition and subsequent hospitalization.
Plan Of Correction
**Quality of Care** How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 right ankle wound care was completed on 04/08/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with wounds was completed on 04/11/2025 by Medical Records Director to ensure that residents had their treatments completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents treatments are done consistently. d) LN Supervisor will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) LN Supervisor and/or designee will review treatment administration records to ensure treatments are being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/17/2025
Failure to Consistently Provide Suprapubic Catheter Care per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not consistently receive care and treatment in accordance with professional standards of practice, facility policy and procedure, and physician's orders. The resident, who had multiple diagnoses including multiple sclerosis, malnutrition, neuromuscular dysfunction of the bladder, depression, and anxiety disorder, was cognitively intact and able to report her care. She stated that staff would miss days of catheter care and treatment. Review of the resident's care plan and physician's orders showed that the suprapubic catheter was to be flushed with 60 cc saline every shift to prevent sedimentation and clogging, and the insertion site was to be cleansed every evening shift. However, treatment administration records revealed multiple missed shifts for both catheter flushing and site cleansing across several months. These omissions were confirmed by the nurse supervisor, who acknowledged that the care and treatment were not done consistently as ordered. Interviews with facility staff, including the nurse supervisor, director of staff development, and DON, confirmed that the expected standard was to follow the physician's orders for catheter care and treatment. The facility's policies also required that care be provided in accordance with physician orders and professional standards. The lack of consistent documentation and performance of the required catheter care constituted the deficiency.
Plan Of Correction
Bowel/Bladder Incontinence, Catheter, UTI How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 suprapubic catheter care was completed on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. The facility will identify other residents having the potential to be affected by the same deficient practice and take action: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. Measures to prevent recurrence: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Monitoring and evaluation: e) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Date of review: 04/17/2025
Failure to Change PICC Line Dressing and Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to change the peripherally inserted central catheter (PICC) line dressing for a resident diagnosed with osteomyelitis. During an observation and interview, it was noted that the PICC line dressing was dated ten days prior, and the resident was unsure when it was last changed. The DON confirmed that PICC line dressings should be changed weekly, and the physician's order as well as facility policy required weekly dressing changes. The dressing had not been changed within the required timeframe. Additionally, the facility failed to follow a physician's order for oxygen therapy for another resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. During observation and interview, the resident's oxygen was set at three liters per minute, but the report does not specify if this matched the physician's order. The resident was able to understand and communicate but was unaware of the details of their oxygen therapy.
Plan Of Correction
Parenteral/IV Fluids How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 3 PICC line was changed on 04/30/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with PICC lines was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had their PICC lines changed completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents PICC lines are changed. d) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) DON and/or designee will review treatment administration records to ensure PICC lines are changed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. --- Respiratory/Tracheostomy Care and Suctioning How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident # 49 oxygen order was changed on 04/26/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure that the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for oxygen therapy for a resident with chronic obstructive pulmonary disease and respiratory failure with hypoxia. The resident was observed receiving oxygen at three liters per minute, while the physician's order specified four liters per minute. The resident was not aware of the prescribed oxygen setting, stating that the nurses handled it. A licensed nurse confirmed the oxygen was set incorrectly and verified the physician's order for four liters per minute. The care plan also directed staff to administer oxygen as ordered by the physician. Further review and interviews with the respiratory therapist and the Director of Nursing confirmed that there was no order to titrate the oxygen and that the expectation was to follow the physician's order exactly. Facility policy required oxygen to be administered under a physician's order. The failure to administer oxygen at the prescribed rate constituted a deviation from both the physician's order and facility policy.
Plan Of Correction
b) Audit of current residents with oxygen orders was completed on 05/02/2025 by Clinical Resource Nurse to ensure that residents had the correct liters flow per their MD order. All residents have the potential to be affected by this deficient practice. No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents oxygen orders are followed. d) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. e) LN Supervisor and/or designee will review oxygen orders to ensure the liters are being followed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025
Failure to Provide Thickened Liquids as Ordered for Residents with Dysphagia
Penalty
Summary
The facility failed to follow physician-ordered diet instructions regarding fluid consistency for two residents with dysphagia. One resident, with a history of acute respiratory failure with hypoxia and gastro-esophageal reflux, was observed drinking regular water despite an order for nectar-thick liquids. The resident's meal ticket also indicated the need for thickened liquids, and this was confirmed by the Activity Director, who acknowledged that the water should have been thickened as per the order. Another resident, also diagnosed with acute respiratory failure with hypoxia and pneumonia, was observed coughing after drinking hot chocolate that was not thickened, despite an order for nectar-thick liquids. The Director of Nursing confirmed that the drink should have been thickened according to the resident's meal ticket and physician's order. The facility's policy on nutritional management of thickened liquids emphasizes the importance of following thickened liquid orders to prevent aspiration in residents with dysphagia.
Plan Of Correction
Drinks Available to Meet Needs/Preferences/Hydration How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #49 and Resident #79 were provided with thickened beverages according to their diet orders on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct beverages according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025
Failure to Provide Physician-Ordered Fortified Diet
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, Alzheimer's disease, dysphagia, and major depressive disorder, was not provided with food in accordance with the physician's prescribed fortified diet. The resident's care plan and physician's order specified a dysphagia Level 1 puree texture with thin consistency and a fortified diet to increase caloric intake. However, during multiple observations, staff assisting the resident with meals confirmed that the meal trays did not contain extra butter or other means of fortification, despite the meal ticket indicating a fortified diet was required. Interviews with certified nurse assistants and the facility cook revealed that the standard practice for a fortified diet was to include a packet of extra butter on the meal tray, but this was not done for the resident in question. The registered dietitian confirmed that the fortified diet was intended to add extra calories and expected diet orders to be followed. The director of nursing also stated that diet orders should be followed and acknowledged the risk of nutritional problems if residents do not receive enough calories. A review of the resident's weight records showed a consistent decline in weight over several months, with the resident losing 23 pounds from September to April. The facility's policy required that therapeutic diets be provided as prescribed by a physician, with dietary and nursing staff responsible for ensuring the appropriate nutritive content. Despite these policies and clear orders, the resident did not receive the prescribed fortified diet during the observed meals.
Plan Of Correction
Therapeutic Diet Prescribed by Physician How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #30 was provided a fortified meal on 04/07/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. b) Registered Dietician / designee completed an audit of residents with fortified diet orders on 04/11/2025 to ensure those residents had the appropriate fortified meal provided. All residents have the potential to be affected by this deficient practice. No other residents were affected. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: d) In-Service was completed by the Registered Dietician / designee to Dietary Staff on 04/11/2025 through 04/15/2025 regarding the importance of following the meal tray diet order to ensure that residents are provided the correct meal according to their diet. d) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. f) Registered Dietician / designee completed an audit of resident meals on 05/02/2025 looking to ensure the correct beverage consistency is provided to the residents. All issues identified will be brought forth to the DON and/or designee for immediate review and resolution. Issues identified will be reported to the Administrator and/or DON for immediate resolution. Dietary Manager and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/02/2025 F 808 F812 Food Procurement, Store/Prepare/Serve - Sanitary How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Opened and undated food items removed and thrown away on
Deficiency: Inaccessible Resident Call Light System
Penalty
Summary
Surveyors identified a deficiency related to the accessibility of the resident call light system for two residents. Both residents were observed lying in bed with their call light buttons on the floor, out of their reach. Interviews with the residents revealed that they were unaware of the location of their call light buttons and could not access them when needed. Certified Nurse Assistant (CNA) 3 confirmed during interviews that the call light buttons were not within reach and acknowledged that they should have been accessible to the residents. Resident 85 had a history of dementia with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This resident was dependent on staff for most activities of daily living, including transfers and hygiene. Resident 39 also had severely impaired cognition, with diagnoses including metabolic encephalopathy, schizophrenia, and depression. This resident was similarly dependent on staff for toileting, bathing, dressing, and mobility. Both residents' care plans and the facility's policy required that call lights be within reach and accessible at all times. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the expectation that call light buttons should be placed within reach of residents. The facility's policy also stated that staff are responsible for ensuring the call light is accessible to residents while in bed or other sleeping accommodations. The failure to ensure the call light system was within reach for these two residents constituted a deficiency under federal regulations.
Plan Of Correction
F919 Resident Call System How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/07/2025 CNA 3 moved Resident #85 and Resident #39's call light within reach. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) On 04/08/2025 DSD and/or designee completed an audit ensuring that no further residents had call light out of reach. There were no other areas identified with the same deficient practice. All other rooms were observed to have call lights within reach. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DSD on 04/10/2025 to licensed nurses and CNAs regarding the importance of keeping the call light within resident's reach. d) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. Administrator and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/10/2025
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two medication carts, labeled as cart A and cart B, were left unlocked and unattended in the facility. These observations occurred in the facility's lobby and were confirmed by interviews with two licensed nurses, both of whom acknowledged that the carts should have been locked at all times. The Director of Nursing also confirmed that medication carts are required to be locked to prevent drug diversion. A review of the facility's own policy on medication storage, dated 2024, indicated that all drugs and biologicals must be stored in locked compartments. The failure to keep the medication carts locked and attended was identified during a survey for a facility with a census of 93 residents. The unlocked carts contained medications, and the staff interviewed recognized that leaving them unsecured could allow unauthorized access. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based on the direct observation of the unlocked and unattended medication carts.
Plan Of Correction
Civil, criminal action or proceedings against the provider or its employees, agents, officers, directors, or shareholders. The provider reserves the right to challenge the cited findings if at any time the provider determines that the disputed findings are relied upon in a manner adverse to the interest of the provider either by the governmental agencies or third parties. Any changes to provider policy or procedures should be considered to be subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and California Evidence Code Section 1151 and should be inadmissible in any proceeding on that basis. F761 Label/Store Drugs and Biologics How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 04/03/2025, upon discovery of medication cart being unlocked, Licensed Nurse 1 and Licensed Nurse 2 immediately locked both carts. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B) DON / designee completed an audit on 04/03/2025 of medication carts to ensure all were locked. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C) An in-service was initiated by facility DSD / DON on 04/03/2025 and will continue until completion of 100% of Licensed Nurses regarding the importance of locking medication carts. D) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. How the facility plans to monitor its performance to make sure that solutions are sustained: E) DON / designee will conduct random audits of medication carts during their rounds to ensure that the facility process for securing medications is being adhered to. Any issues identified during the audit rounds will be brought forth to the Department Managers five days a week during the morning meeting for review and immediate resolution. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. The Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow infection prevention and control practices during wound care for a resident with a diabetic foot ulcer. Specifically, a licensed nurse entered an Enhanced Barrier Precaution (EBP) room without wearing a gown, donned gloves without performing hand hygiene, and proceeded to open the resident's wound dressing. The nurse acknowledged that both a gown and hand hygiene should have been used prior to the procedure to prevent infection. Further observations revealed that a wound doctor and another licensed nurse also entered the same EBP room to assess the resident's wound without wearing gowns. The wound doctor admitted that the required personal protective equipment (PPE), including a gown and gloves, should have been used in the EBP room. The second nurse confirmed that there were no gowns available by the door or in the medication cart and stated that the use of gown and gloves is necessary to prevent the spread of infection. The facility's infection preventionist confirmed that staff are expected to wash hands or use hand sanitizer before donning gloves and that gowns and gloves are required PPE for EBP rooms. Facility policy indicated that gowns and gloves should be made available immediately near or outside the resident's room and that hand hygiene must be performed prior to donning gloves. These lapses in infection control practices were observed during care for a resident admitted with a diabetic foot ulcer.
Plan Of Correction
04/03/2025 F880 Infection Prevention & Control How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A.) On 04/01/2025 Licensed Nurse 2 immediately performed hand hygiene. On 04/01/2025 Licensed Nurse 2, Licensed Nurse 3, and Wound Doctor donned enhanced barrier precaution PPE. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: B.) Infection Preventionist completed an audit of staff to ensure no other staff were identified with having the same deficient practice of not performing hand hygiene and donning enhanced barrier precaution PPE. No other areas were identified with having the same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: C.) Staff have been in serviced 04/01/2025 through 04/04/2025 by Infection Preventionist regarding the importance of hand hygiene and ensuring that enhanced barrier precaution PPE is donned. D.) Infection Preventionist and/or designee will conduct random audits of staff to ensure that hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025 Integrated into the quality assurance system: E.) Infection Preventionist and/or designee will conduct random audits of staff to ensure hand hygiene is performed and enhanced barrier precaution PPE is donned. All non-compliance issues identified during these audits will be brought forth to the department managers five days a week morning meeting for review, validation, and immediate correction. Administrator will do a trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendation(s). Include dates when corrective action will be completed. The corrective action completion date must be acceptable to the State: 04/04/2025
Resident Assaulted by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when another resident physically assaulted him. Resident 1, who has moderate memory impairment and was admitted with pancytopenia, was punched in the head by Resident 2 during a smoke break. This incident resulted in Resident 1 falling from his wheelchair and sustaining an abrasion to his left elbow. The altercation occurred despite the presence of a Restorative Nursing Assistant (RNA) who was supervising through a window but was unable to intervene in time. Resident 2, who has severe memory impairment and was admitted with unspecified dementia and anxiety, was identified as the aggressor. Prior to the incident, Resident 2 had been accusing Resident 1 of stealing money, a situation that staff were aware of. The Director of Nursing (DON) acknowledged that the altercation violated Resident 1's right to be free from abuse, as outlined in the facility's Abuse Prevention and Prohibition Program policy. This policy emphasizes that each resident has the right to be free from mistreatment, neglect, and abuse.
Plan Of Correction
F600 Free from Abuse and Neglect How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A) On 03/14/2025 Resident #1 was moved to a different hallway of the facility. B) Resident #1 monitored elbow abrasion and for delayed injury doctor will be notified of any changes. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: C) DON completed an audit on 03/26/2025 of residents who pose a risk for altercation. All residents have the potential to be affected by this deficient practice. No other areas were identified with having this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: D) An in-service was initiated by facility DSD on 03/26/2025 to licensed staff regarding the importance of preventing abuse and reporting abuse. E) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. How the facility plans to monitor its performance to make sure that solutions are sustained: F) Nursing staff to monitor resident #1's abrasion and for delayed injury for the next 7 days and report any changes to the doctor. G) IDT team will review COC the following day during the five day a week clinical morning meeting to ensure abuse prevention efforts were made ensure reoccurrence does not. All non-compliance issues identified will be brought forth to the daily morning manager meeting and corrected immediately and reported to the Administrator for review, validation, and resolution. Administrator will do trending/analysis and will report quarterly to the QAPI Committee for further evaluation and/or recommendations.
Failure to Protect Residents from Sexual Abuse by Employing CNA with Criminal History
Penalty
Summary
The facility failed to protect nine residents from sexual abuse by employing a Certified Nursing Assistant (CNA 1) with a known criminal misdemeanor history. The CNA was hired despite a background screening report indicating a charge of knowingly touching with the intention to injure, insult, or provoke a person. The Administrator (ADM) and Director of Staff Development (DSD) were aware of this history prior to hiring CNA 1, who explained the charge as a domestic incident with his husband. The deficiency was identified when allegations of sexual abuse toward a resident were reported by another CNA. The ADM confirmed that CNA 1 was suspended and removed from the facility following these allegations. Despite the facility's policy to screen potential employees for a history of abuse, the ADM and DSD failed to adequately verify CNA 1's background and references, leading to the employment of an individual with a history of assault. The facility's policy and procedure on abuse, neglect, and exploitation clearly state the need for background checks to prevent abuse. However, the ADM and DSD did not adhere to these procedures, resulting in the employment of CNA 1, who subsequently sexually assaulted multiple residents. This failure to follow established protocols directly contributed to the deficiency and placed all residents at risk of harm.
Removal Plan
- Immediate suspension of CNA 1
- Audit of all current employee files to review background investigations
- In-serviced ADM to not hire employees with background/history of abuse.
- ADM and/or designee to review applicant backgrounds
- Director of Staff Development (DSD) and/or designee will contact listed references for new hires.
Failure to Protect Residents from Sexual Abuse by Staff
Penalty
Summary
The facility failed to protect the residents' right to be free from sexual abuse by a staff member, specifically a Certified Nursing Assistant (CNA 1), who sexually assaulted nine residents. The incidents involved various forms of sexual misconduct, including unwanted sexual touching and exposure, which were confirmed through interviews, observations, and record reviews. The facility's Administrator was aware of CNA 1's criminal history of abuse prior to hiring him, yet proceeded with the employment, which led to the abuse of multiple residents. The residents affected by the abuse had varying degrees of cognitive impairment and medical conditions, such as muscle weakness, encephalopathy, cerebral infarction, and depression. Some residents were incapable of making health care decisions, while others had intact cognition. The abuse caused significant distress among the residents, with reports of fear, anxiety, and changes in behavior following the incidents. Several residents expressed feelings of shame and embarrassment, and some were unable to sleep due to fear of further abuse. The incidents were reported by other staff members who witnessed suspicious behavior by CNA 1, such as being in residents' rooms with the curtains closed and without a shirt. The police were involved, and CNA 1 admitted to the sexual assaults during interviews. The facility's policies on abuse prevention and resident rights were not effectively implemented, as evidenced by the hiring of CNA 1 despite his known criminal history and the subsequent abuse of residents.
Removal Plan
- Immediate suspension of CNA 1
- Physician visits to residents subjected to abuse
- Activity Director visits to residents subjected to abuse
- Psychosocial assessments, and trauma assessment completed for all victims
- Every shift monitoring of victims by nursing staff, reviewed by ADM or designee
- Audit of all current employee files for history of abuse, adverse actions on background
- In-service on preventing abuse and reporting abuse
- Physical assessment and interview of all victims
Failure to Investigate Sexual Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse involving a Certified Nursing Assistant (CNA 1) and multiple residents. Initial reports identified three residents as victims, but further investigation revealed additional victims, totaling nine residents. The facility's initial investigation did not identify all victims promptly, delaying necessary interventions such as counseling and monitoring for emotional trauma. The report details the clinical backgrounds of the affected residents, who were admitted with various diagnoses including muscle weakness, encephalopathy, cerebral infarction, depression, dementia, and other cognitive impairments. These conditions rendered some residents incapable of providing consent, making them particularly vulnerable to abuse. The facility's documentation of suspected abuse was inconsistent, with reports being faxed to the Department at different times, and some incidents not being reported until days later. Interviews with the Administrator and Director of Nursing revealed that the facility unsubstantiated the allegations in their five-day follow-up reports, citing a lack of witnesses. This decision was made despite a police report confirming the CNA's admission to the assaults. The facility's policy on abuse prevention and investigation was not adequately followed, as the investigation did not immediately identify all involved persons or determine the full extent of the abuse.
Failure to Prevent Hiring of CNA with Abuse History
Penalty
Summary
The facility failed to ensure effective management by the Administrator (ADM) and Director of Staff Development (DSD) when they hired a Certified Nursing Assistant (CNA1) with a known history of abuse. Despite being aware of CNA1's background screening report, which indicated a misdemeanor charge for knowingly touching with the intention to injure, insult, or provoke a person, the ADM and DSD proceeded with the hiring. The ADM confirmed awareness of the background check results and stated that CNA1 explained the charge as a fight with his husband. The DSD did not verify CNA1's previous employment references, as calls to the previous employer were not returned. The facility's policies and procedures on abuse prevention and hiring were not adhered to, as they require thorough background checks and reference verification for potential employees. The failure to follow these protocols resulted in CNA1 being employed at the facility, which subsequently led to the sexual abuse of nine residents. The facility's policy mandates the designation of an Abuse Prevention Coordinator and ongoing staff supervision to prevent abuse, which was not effectively implemented in this case.
Delayed Reporting of Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to report three allegations of sexual abuse involving three residents to the Department within the required two-hour timeframe. Resident 1, who was admitted in early 2022 and had a severe cognitive impairment, reported an incident involving a shirtless Certified Nursing Assistant (CNA 1) in his room. The report for this incident was faxed to the Department over four hours after the alleged abuse occurred. Resident 2, admitted in late 2023 with intact cognition, alleged sexual assault by CNA 1, and this report was also delayed beyond the two-hour requirement. Resident 5, admitted in early 2023 with moderate cognitive impairment, was involved in an incident where CNA 1 was found with his pants down near Resident 5's room. This report was sent to the Department more than seven hours after the incident was discovered. During an interview, the Administrator confirmed that the reports were sent late and acknowledged that they should have been reported within two hours to ensure resident safety and compliance with abuse reporting requirements. The facility's policy on abuse, neglect, and exploitation mandates immediate reporting, but not later than two hours after an allegation is made if it involves abuse or results in serious bodily injury. The delay in reporting these incidents decreased the facility's potential to protect vulnerable residents and provide a safe environment.
Failure to Protect Resident from Abuse in Shared Bathroom
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident during an altercation in a shared bathroom. Resident 1, who was admitted with anxiety and depression and was cognitively intact, was involved in a physical and verbal altercation with Resident 2. During the incident, Resident 2 opened the bathroom door from his side, used profanity, and kicked Resident 1's left shin, resulting in an abrasion. This incident left Resident 1 feeling afraid to leave his room due to fear of encountering Resident 2. Resident 2, also admitted with anxiety and depression and cognitively intact, acknowledged the altercation and admitted to using derogatory language and kicking Resident 1. Staff interviews revealed that Resident 2 had a history of being argumentative and instigating altercations with peers. The facility's Administrator confirmed that the incident was substantiated as abuse, as Resident 2's actions caused injury to Resident 1. The facility's 'Abuse Prevention and Prohibition Program' emphasizes a zero-tolerance policy for abuse, highlighting the failure to protect residents from mistreatment.
Failure to Administer Bowel Management as Ordered
Penalty
Summary
The facility failed to provide appropriate bowel management for a resident with a known history of constipation, resulting in significant discomfort and distress. The resident, who was admitted with multiple diagnoses including diabetes, kidney disease, and a below-knee amputation, had physician orders for various laxatives and bowel care interventions. Despite these orders, the resident did not receive the prescribed treatments, and the facility staff failed to notify the physician when the resident had no bowel movement for six days. Observations and interviews revealed that the resident was in visible distress, experiencing abdominal pain and discomfort due to constipation. The resident repeatedly requested an enema, which was part of the physician's orders, but was told by the nursing staff that there was no order for it. The resident's care plan, which included monitoring bowel movements and administering medications as ordered, was not followed, leading to the resident's condition worsening over several days. The Director of Nursing acknowledged the oversight and confirmed that the resident had not received any 'as needed' laxatives, nor was the physician informed of the resident's condition. The facility's policy on bowel management was not adhered to, resulting in the resident experiencing severe discomfort and being unable to eat or attend dialysis sessions due to the pain and bloating caused by constipation.
Resident Waited 38 Minutes for Feeding Assistance
Penalty
Summary
The facility failed to promote and maintain dignity and respect for a resident who waited 38 minutes to be assisted with feeding. The resident, who was admitted in 2023 with diagnoses including dysphagia and Huntington's disease, was observed in the dining room during lunch. Despite being dependent on staff for all activities of daily living due to severe cognitive impairment, the resident's lunch tray remained untouched while other residents finished their meals and left the dining room. A Certified Nursing Assistant (CNA) acknowledged the delay, stating that lunch was served around 11:20 a.m., and the resident was not assisted with feeding until 11:58 a.m. The CNA admitted that the resident should have been assisted at the same time as others and recognized it was inappropriate for the resident to watch others eat without being fed. The Director of Nursing confirmed that residents should not wait longer than 10-15 minutes to be fed, highlighting the failure to adhere to the facility's policy on maintaining resident dignity during mealtimes.
Failure to Implement Resident-Centered Activities
Penalty
Summary
The facility failed to implement resident-centered activities for a resident diagnosed with multiple sclerosis and depression, who had intact cognition. The resident's care plan emphasized the importance of engaging in recreational activities such as playing cards, reading, and doing word search puzzles. However, the facility did not conduct or document one-on-one visits for the resident, as confirmed by the resident and a Certified Nursing Assistant (CNA). The resident expressed dissatisfaction, noting that the activities director had not visited for 21 days, leaving the resident without the necessary materials for preferred activities. The Activities Director admitted to not having documentation of the room visits and was in the process of organizing it. The facility's policy and procedure emphasized the importance of providing activities that support residents' physical, mental, and psychosocial well-being, and the need to document these activities. The Administrator confirmed the lack of documentation for the resident's activity participation tasks, acknowledging that what is not documented is considered not to have happened. This oversight decreased the facility's potential to support and enhance the resident's well-being.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Galt
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lodi Creek Post Acute | 7.3 mi | ★★★★★ | 22 | 0 |
| Vienna Nursing And Rehabilitation Center | 8.4 mi | ★★★★★ | 27 | 0 |
| Fairmont Rehabilitation Hospital | 8.8 mi | ★★★★★ | 2 | 0 |
| Arbor Rehabilitation & Nursing Center | 8.8 mi | ★★★★★ | 22 | 0 |
| Lodi Nursing & Rehabilitation | 9.2 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.