Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ridgecrest Regional Transitional Care And Rehabili during CMS and state inspections, most recent first.
Infection control practices were not followed when the facility lacked a WMP for its own water system and the IP and MS stated the hospital plan did not include the LTC facility. The MS could not describe risk areas, monitoring measures, control limits, or system documentation. In addition, wet linens and mop heads were left in washers unattended after EVS staff left for the day; the items were damp and warm, and the IP and EVS Supervisor confirmed laundry was not to be left overnight.
The facility failed to send a discharge notice to the Ombudsman for one resident who was discharged home. During record review and interview, the MDSC confirmed the resident’s discharge and stated the Ombudsman was not notified, despite the facility policy requiring the notice be sent at the same time as the resident and representative receive it.
A resident with a positive PASRR Level I screen for SMI did not have the required Level II evaluation completed. The NAE showed the evaluation could not be completed because facility staff were unresponsive to repeated communication attempts within 48 hours of the Level I screen, and the MDSC confirmed the PASRR Level II was not completed.
A resident with decreased urine output and a suprapubic catheter had an unsuccessful catheter flush attempt, after which an LPN called the physician and received a VO to send the resident to the ER. The DON could not provide documentation of the physician notification or the VO in the EMR, and the LPN stated he forgot to chart it after the transfer.
A resident did not receive two ordered a.m. meds when an RN administered the rest of the medications but stated lisinopril and fluoxetine were not available. The RN said pharmacy was not notified, and the MAR showed no documentation that the meds were given. The facility policy required meds to be administered safely, timely, and in accordance with prescriber orders.
Surveyors identified multiple deficiencies in foodservice sanitation and food handling, including a resident found with unrefrigerated milk at unsafe temperatures, improper storage of raw eggs below raw beef, unsanitary kitchen conditions such as dirty drains and vents, a cracked light fixture cover, and failure to properly sanitize three ice machines according to manufacturer guidelines.
Essential equipment, including a food preparation sink and two ice machines, were not maintained in safe operating condition due to improper plumbing without required air gaps and floor sink drains, as well as environmental issues such as peeling paint, cracks, and dirty floors near one ice machine. These deficiencies were confirmed through observation, interviews, and review of regulatory requirements and facility policy.
Surveyors found that call lights were not within reach for four residents, including one with limited mobility, one whose call light was out of reach over the headboard, one who could not locate her call light while in a wheelchair, and one whose call light was on the floor. Staff confirmed in each case that the call lights should have been accessible, in accordance with facility policy.
Three residents were not informed about the process to file a grievance, as required by facility policy. Interviews revealed that two cognitively intact residents and one with moderate cognitive impairment did not know how to file a grievance or could not recall being informed, despite policies mandating staff to provide this information.
The facility did not maintain the required minimum CNA direct care hours per patient day on multiple occasions, as confirmed by staff interviews and record reviews. Staff reported frequent short staffing, and the facility was unable to provide complete staffing documentation for the requested period. The deficiency was related to the facility's failure to follow its own policy on sufficient and competent nursing staffing.
The QAPI committee did not identify or address multiple infection prevention and control deficiencies, including improper cleaning of glucometers, lack of staff education, failure to implement enhanced barrier precautions, and insufficient surveillance by the Infection Preventionist. These issues were not discussed or documented in the most recent QAPI meeting.
Multiple infection control deficiencies were observed, including improper storage of distilled water for a CPAP machine on a commode, a nurse returning a dropped medical device kit to the treatment cart, lack of comprehensive infection surveillance and documentation by the IP, failure to implement Enhanced Barrier Precautions for residents with wounds or indwelling devices, and repeated use of glucometers on different residents without cleaning or disinfection between uses.
The facility did not ensure that mandatory infection control training was provided and documented for several LVNs and RNs, as required by its own policy. Interviews and record reviews revealed that staff could not recall receiving recent infection control training, and the Infection Preventionist was unable to provide documentation or details of the training content.
A resident's bathroom had a persistent strong urine odor, as reported by the resident, a family member, a CNA, a housekeeping aide, and the environmental services supervisor. Despite daily cleaning, the odor remained, affecting the comfort and home-like environment for the resident and visitors.
The facility did not develop or implement care plans for two residents with active infections—one receiving IV antibiotics for a UTI and another with chronic wound cellulitis—despite changes in their conditions and facility policy requiring ongoing assessment and care plan updates.
A resident's preference for a lacto-vegetarian diet, which includes dairy but excludes eggs, was not clearly specified or communicated in the diet order. The term 'vegetarian' was used broadly in the care plan and medical record, and the order was not clarified with the physician as required by facility policy and professional standards, resulting in a deficiency in meeting professional standards of quality.
Two residents were placed at risk due to inadequate safety measures and supervision. One resident's bathroom grab bar was slippery and lacked secure grip tape, leading to a fall and ongoing safety concerns. Another resident was left unsupervised on the patio with a non-functioning phone, preventing her from calling for assistance. Staff interviews revealed inconsistent supervision practices, and the resident's care plan indicated a need for staff support due to moderate cognitive impairment.
Two residents with orders for opioid pain medications reported uncontrolled pain, and review of their MARs showed that while pain medications were administered for high pain scores, staff did not document follow-up assessments of medication effectiveness as required by facility policy. The DON confirmed that such monitoring and documentation should have occurred.
A resident's insulin vial was not labeled with their name, as only the outer box contained identifying information. During medication administration, an LVN confirmed that this was standard practice, and the DON stated that vials were not labeled to avoid covering medication details. The consultant pharmacist and facility policy both indicated that insulin vials should be labeled with the resident's name to prevent medication errors.
The facility did not follow planned menus or honor dietary needs and preferences for several residents, including serving incorrect portions on a renal diet, failing to provide a registered dietitian-developed lacto-vegetarian menu for a resident requiring a mechanical soft diet, and serving a disliked food item despite clear documentation. These actions resulted in residents not receiving meals consistent with their individualized nutritional requirements and preferences.
The Infection Preventionist did not follow facility policy for infection control surveillance, failing to collect, analyze, and report data or implement Enhanced Barrier Precautions (EBP) for residents with wounds, indwelling devices, or infections. Multiple residents with ulcers, cellulitis, and Foley catheters did not have EBP signage or PPE available, and staff were unfamiliar with EBP procedures, resulting in a lack of infection control measures.
A resident in an LTC facility missed doses of Insulin Glargine and Potassium due to the facility running out of these medications. The resident, diagnosed with diabetes mellitus, was not given her morning dose of Insulin Glargine and missed several doses of Potassium. The responsibility for medication availability was on the floor nurses, who failed to reorder the medications in time, contrary to the facility's policy on timely administration.
A resident with Type 2 diabetes filed grievances about not receiving a dinner tray and a loud kitchen door, but the facility failed to investigate or resolve these issues within the required timeframe. The resident was not informed of any findings or corrective actions, and staff interviews revealed disorganization in handling grievances.
A resident with Type 2 diabetes did not receive her insulin medications on time, as per the facility's policy. The resident experienced anxiety and physical symptoms due to the late administration of both short-acting and long-acting insulin. The DON and LVNs confirmed the delays and the lack of timely documentation on the MAR.
The facility failed to accommodate the needs of two residents, leading to delays in care. One resident reported call lights taking 20 minutes to be answered, while another waited two hours in a wet brief due to staff shortages. CNAs were often assigned 11 to 17 residents, making it difficult to provide timely care. Facility policies required calls to be answered within five minutes, but this standard was not met.
A resident did not receive medications as ordered, including missed doses of insulin and delayed administration of Ozempic. The facility's medication records confirmed these discrepancies, and the Quality Assurance Nurse acknowledged a data entry error and lack of proper documentation.
A resident's mail was opened without permission by an Administrative Service Manager in Training (ASM), violating the facility's policy on mail privacy. The ASM assumed the letter was related to a medication issue the resident mentioned and opened it without consent. The facility's policy requires mail to be delivered unopened unless the resident requests assistance, which must be documented.
A resident's grievances were not resolved by the facility, as evidenced by incomplete grievance reports and lack of communication. The facility's policy requires prompt resolution and communication of findings, which was not adhered to in this case.
The facility failed to maintain adequate supplies, causing discomfort for two residents due to shortages of chux, wipes, and briefs. Staff interviews revealed issues in the supply ordering process, with the Unit Secretary lacking training to prevent shortages and new admissions not being considered. The facility's policy indicated that incontinence care supplies should be provided to meet residents' needs.
The facility failed to implement a care plan for a resident who made a threat to kill an LVN. The care plan required hourly monitoring, but documentation was missing for multiple hours on two consecutive days. The DON acknowledged the missing documentation, which was against the facility's policy on comprehensive, person-centered care plans.
A resident with severe cognitive impairment and high fall risk fell and sustained a major injury because the bed alarm was not activated. Multiple staff members confirmed the alarm was not turned on, despite the care plan requiring it. The facility's policy on fall risk management was not followed, leading to the incident.
A resident with a history of inappropriate behavior was not adequately supervised, leading to an incident where he engaged in sexual misconduct with another resident who had severe cognitive impairment. Despite previous warnings and documented behaviors, the facility failed to implement effective monitoring and interventions, resulting in the abuse of a vulnerable resident.
Infection Control Failures in Water Management and Laundry Handling
Penalty
Summary
Infection control practices were not followed for 33 of 33 sampled residents because the facility did not have a Water Management Program (WMP) developed and implemented for its own water system. During interview, the Infection Preventionist stated the WMP was overseen by the maintenance department and the hospital, and that he did not participate in identifying or preventing potential waterborne pathogens at the facility. The Maintenance Supervisor stated the policy reviewed was for the hospital and did not include the long-term care facility, that the facility did not have a WMP policy and procedure, and that he had no WMP training. He was unable to describe areas at risk for bacterial growth, measures used to monitor or mitigate risk, control limits, or documentation such as a diagram of the facility water system with areas of concern. The facility also left linens and mop heads wet and unattended in washing machines after the EVS staff work shift ended. During observation, two washing machines contained white linens and blue mop heads, and no staff were present in the laundry area. The Infection Preventionist stated laundry staff left at 3 p.m. and there was no staff in laundry at night. When the machines were opened, the linens and mop heads were damp and warm. The Infection Preventionist and Environmental Services Supervisor confirmed the items were not to be left in the washing machines overnight, and the Infection Preventionist stated there were concerns for mold and bacterial growth. The facility policy titled Safety - Laundry stated to turn off all equipment and leave washer and dryer doors slightly ajar when closing the laundry at the end of the day and not to leave laundry unattended.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a discharge notice was sent to the Office of the State Long-Term Care Ombudsman for one sampled resident, Resident 88, when the resident was discharged home. During a concurrent interview and record review, the Minimum Data Set Coordinator reviewed Resident 88’s admission record, which indicated the resident was discharged to home. The MDS Coordinator stated that Resident 88 was discharged home and that the Ombudsman was not notified. Review of the facility’s policy and procedure for Transfer or Discharge Notices stated that a copy of the notice is to be sent to the Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.
PASRR Level II Evaluation Not Completed for Resident with Positive SMI Screen
Penalty
Summary
The facility failed to accurately complete the annual PASRR for Resident 12. The resident’s PASRR Level I screening, dated 9/24/25, indicated a positive screen for serious mental illness (SMI). During a concurrent interview and record review on 2/26/26 with the MDS Coordinator, the resident’s Notice of Attempted Evaluation, dated 9/28/25, was reviewed and showed that the Level II evaluation could not be completed for SMI because facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening. The MDS Coordinator stated that the PASRR Level II was not completed for Resident 12. The facility’s policy titled Admission Criteria, dated 2019, stated that all new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders through the Medicaid PASARR process. The policy further stated that if the Level I screen indicates the individual may meet criteria for a mental disorder, intellectual disability, or related disorder, the person is referred to the state PASARR representative for the Level II evaluation and determination screening process. The report documented that this process was not completed for Resident 12.
Missing Documentation of Physician Notification and Verbal Order
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate when a physician's verbal order and documentation of physician notification for a change in condition were not entered into the EMR for one resident. Resident 82 was admitted to the facility and, during the reviewed period, had decreased urine output and a suprapubic catheter that RN 9 attempted to flush unsuccessfully. LVN 8 stated he was the nurse for Resident 82 at the time and telephoned the physician to report the resident's change in condition. According to LVN 8, the physician gave a verbal order to send Resident 82 to the hospital emergency room, but the verbal order and the physician notification were not documented in the EMR. The DON also stated she was unable to provide documentation of the physician order or notice of the change in condition for the resident's transfer to the emergency room. Facility policies required verbal orders and changes in condition to be documented in the resident's medical record.
Medication Administration Errors for Ordered Morning Medications
Penalty
Summary
Medication administration errors occurred for one sampled resident when two prescribed morning medications were not given. During observation, RN 1 administered the resident’s a.m. medications but told the resident that lisinopril and fluoxetine were not available. In an interview immediately afterward, RN 1 stated she did not administer the lisinopril or fluoxetine because they were not available and that the pharmacy should have been notified about the unavailability, but this was not done. A review of the resident’s February 2026 MAR showed lisinopril 10 mg daily for hypertension and fluoxetine 20 mg daily for depression were ordered for 8:00 a.m. on 2/25/26, and no check marks were documented to show they were administered. The facility’s policy stated medications are to be administered in a safe and timely manner, in accordance with prescriber orders and within one hour of the prescribed time unless otherwise specified.
Multiple Foodservice Sanitation and Food Handling Deficiencies Identified
Penalty
Summary
The facility failed to maintain sanitary conditions and safe food handling practices in several areas of its foodservice operation. One resident, who was cognitively intact, was found with three unopened cartons of milk left unrefrigerated in her room, with two cartons present since the morning and one from the previous night. The milk was measured at temperatures above 72°F, well above the safe holding temperature, and the facility's policy identified milk as a potentially hazardous food that should not be kept in the danger zone for more than four hours. In the kitchen, raw pasteurized shell eggs were stored below a pan of covered raw beef in the walk-in refrigerator, contrary to the facility's posted policy and standard food safety practices. The Dietary Manager was unaware of the correct storage order, and both the Dietary Manager and Registered Dietitian acknowledged that the facility's policy was not followed. Additionally, multiple unsanitary conditions were observed in the kitchen, including extensive buildup of debris and discoloration in floor drains, accumulation of dust on ceiling vents above exposed food, cracked and chipped flooring around drains, and areas of pooled water. Cleaning schedules did not include floor sink drains, and these areas were not being cleaned or reported for maintenance as required by facility policy. Further deficiencies included a cracked cover on a light fixture in the dish machine room, which had not been identified or reported for repair, posing a risk of foreign object contamination. Three ice machines were not sanitized according to the manufacturer's guidelines; the Maintenance Supervisor used a cleaner that was not an approved sanitizer and missed the required sanitizing step. The facility's policies required ice machines to be cleaned and sanitized per manufacturer instructions, but this was not being followed.
Deficient Plumbing and Environmental Conditions for Food Prep Sink and Ice Machines
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically regarding the plumbing and installation of a food preparation sink and two ice machines. In the kitchen, the food preparation sink was observed to have a pipe directly plumbed into the wall, lacking the required air gap and floor sink drain as specified by the Food and Drug Administration Food Code (FDAFC) and California Health and Safety Code. The Maintenance Supervisor confirmed that the sink's plumbing did not include an air gap and was unaware of this requirement. An external compliance officer also confirmed that the sink's discharge setup was not compliant and would require a project record for correction. Additionally, two ice machines located near separate nursing stations were found to be non-compliant with both manufacturer guidelines and FDAFC requirements. One ice machine lacked a visible air gap or drain, while the other had a pipe inserted into a plastic pipe, preventing the necessary one-inch air gap. The compliance officer noted that the air gap installation was incorrect and that the drain piping should be copper with proper fittings. These deficiencies were confirmed through direct observation and interviews with the Maintenance Supervisor. Further observations revealed that the area surrounding one of the ice machines had environmental deficiencies, including cracks and crevices in the wall, peeling paint, and a dirty floor with cracked tiles. These conditions were contrary to FDAFC requirements for smooth, cleanable surfaces and the facility's own policy, which mandates that walls and ceilings be free of chipped or peeling paint and that such areas be repaired promptly. The presence of these conditions could provide harborage for pests and hinder effective cleaning.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as observed during multiple room visits. In one instance, a resident with limited mobility was found lying on her side and appeared restless, with her sensitive call light tied to the right upper side rail, which she could activate. A licensed vocational nurse confirmed that the call light should be within the resident's reach. Another resident's call light was observed hanging over the headboard, out of reach, and a certified nursing assistant acknowledged that the resident should be able to access it. Additionally, a resident sitting in a wheelchair next to her bed did not have a call light within reach and was unaware of its location, stating it was likely mixed up in the bed linens. The certified nursing assistant present confirmed that the call light should have been accessible. In a separate observation, another resident's call light was found on the floor, and the attending certified nursing assistant stated it should be in the resident's hand or within reach. The facility's policy requires that residents be provided with a means to call staff for assistance and that calls for help are answered promptly.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that three of seven sampled residents were informed of the process to file a grievance. During interviews, one resident stated he did not know how to file a grievance, and another resident reported not remembering if the facility had informed her about the grievance process, instead choosing to address issues directly with staff. A third resident also stated she did not know how to file a grievance and had not been informed by the facility about the process or whom to contact. Record reviews showed that two of these residents were cognitively intact, while one had moderate cognitive impairment, as indicated by their BIMS scores. A review of the facility's policies and procedures confirmed that staff are required to inform residents or their representatives about where to obtain grievance forms and how to file a grievance or complaint. Despite these policies, the sampled residents interviewed were either unaware of the process or could not recall being informed, indicating a failure by the facility to communicate this information as required.
Failure to Maintain Minimum CNA Staffing Levels and Documentation
Penalty
Summary
The facility failed to follow its policy and procedure regarding sufficient and competent nursing staffing for all 73 residents when Certified Nursing Assistant (CNA) direct care service hours per patient day (DHPPD) fell below the minimum standard of 2.4 on multiple occasions. On 3/1/25, the actual CNA DHPPD was 2.31, and on 3/2/25, it was 2.24, as confirmed by the Director of Nursing (DON) during a record review. Staff interviews revealed that when staff called off work, the remaining staff had to divide up the tasks, resulting in frequent short staffing. Both a Licensed Vocational Nurse (LVN) and a CNA confirmed that working short staffed was a common occurrence. The facility was unable to provide complete DHPPD documentation for the requested six-month period, only supplying records for select dates. The facility's policy, dated August 2022, states that minimum staffing requirements imposed by the state are adhered to but are not necessarily considered sufficient for competent staffing. The lack of adequate CNA staffing and incomplete documentation had the potential for residents' care needs not to be met by staff.
QAPI Committee Failed to Address Infection Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement action plans to address infection prevention and control deficiencies. During a review of the most recent QAPI meeting minutes, it was found that the committee only documented infection rates for urinary tract infections, respiratory infections, and skin infections, without addressing other infection control concerns. The QAPI meeting did not include discussion or documentation of infection prevention and control issues identified by the survey team. Surveyors identified several infection control deficiencies that were not recognized or addressed by the facility, including failure to clean and disinfect glucometers between resident use, lack of infection prevention and control education for staff, failure to implement enhanced barrier precautions, and inadequate surveillance activities by the Infection Preventionist. The Administrator confirmed that these issues were not identified or discussed in the QAPI meeting, despite being present in the facility.
Infection Control Failures in Multiple Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. In one case, a resident with obstructive sleep apnea who used a CPAP machine stored three opened gallons of distilled water on top of a commode, which the resident occasionally used. The Infection Preventionist (IP) confirmed that this storage method was unsanitary. Additionally, a Treatment Nurse (TN) was observed dropping a packaged medical device kit from the treatment cart onto the floor, then placing it back into the cart next to an opened package of gauze, acknowledging that this was improper practice. The IP did not follow the facility's policy and procedure for monitoring compliance with infection control. The IP only monitored hand hygiene and PPE use, excluding other critical areas such as glucometer use and cleaning. Documentation of staff noncompliance and corrective actions was lacking, and infection surveillance data was not reported to the QAPI committee as required by policy. Furthermore, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds or indwelling medical devices, and staff, including the IP, LVN, CNA, ADON, DSD, and DON, demonstrated a lack of knowledge regarding EBP requirements, signage, and PPE use. The facility also failed to clean and disinfect glucometers between resident use according to manufacturer instructions. Two LVNs were observed using the same glucometer on multiple residents without cleaning or disinfecting the device between uses. The IP confirmed that glucometers should be disinfected after each use with appropriate wipes and contact time, and the facility's policy and the device manual both required cleaning and disinfection between uses. These failures were observed during direct care activities and interviews with staff.
Failure to Provide and Document Mandatory Infection Control Training
Penalty
Summary
The facility failed to follow its own policy and procedure regarding employee training on infection control for a significant number of its licensed nursing staff, including 11 Licensed Vocational Nurses and 4 Registered Nurses. During interviews and record reviews, it was found that the Infection Preventionist could not recall the content of the training provided and was unable to produce documentation of the training. Additionally, at least one nurse could not remember the last infection control training attended. The facility's policy required all staff to complete orientation and training on preventing the transmission of healthcare-associated infections, but records and staff interviews indicated this was not consistently done. As a result, licensed nursing staff were unaware of standard infection prevention precautions.
Persistent Urine Odor in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident's bathroom had a persistent and strong odor of urine, which was noted by the resident, a family member, a CNA, a housekeeping aide, and the environmental services supervisor. The family member reported that the odor was present whenever the bathroom door was left open and had been noticeable during daily visits over a three-week period. The resident, who was assessed as cognitively intact, also confirmed the unpleasant smell. The CNA and housekeeping aide both acknowledged the ongoing urine odor, particularly in the mornings, despite daily cleaning efforts. The environmental services supervisor confirmed that the odor persisted during their assessment. Review of the facility's infection prevention and control policy indicated that the facility is required to maintain a safe, sanitary, and comfortable environment. However, the continued presence of the urine odor in the resident's bathroom demonstrated a failure to provide a home-like and comfortable environment as required by policy. This deficiency was based on direct observations, interviews with staff and family, and review of facility records.
Failure to Develop and Implement Care Plans for Residents with Infections
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with active infections, as required by its own policy and procedure. One resident was observed with an intravenous (IV) catheter and receiving IV antibiotics for a urinary tract infection (UTI) after oral antibiotics were found to be ineffective. Despite the presence of an active infection and a change in treatment, there was no care plan addressing the UTI documented in the resident's electronic medical record. The Minimum Data Set Coordinator confirmed that a care plan should have been in place for this condition but was not found. Another resident had a diagnosis of cellulitis of the left lower limb, as indicated in the Client Diagnosis Report. Upon review of the medical record, the Minimum Data Set Coordinator was unable to provide a care plan for the resident's chronic wound cellulitis. The facility's policy states that assessments and care plans should be ongoing and revised as residents' conditions change, but this was not followed for these two residents with infections.
Failure to Clarify and Communicate Resident's Lacto-Vegetarian Diet Order
Penalty
Summary
The facility failed to ensure that a resident's diet order was clarified to reflect the individual's specific preference for a lacto-vegetarian diet, which includes dairy products but excludes eggs. The Nutrition Risk Assessment documented the resident's preference for a vegetarian diet with dairy but no eggs, and the Plan of Care noted that vegetarian alternatives would be offered. However, there was no documentation specifying the exact nature of the vegetarian preference, nor was the diet order updated to include the lacto-vegetarian specification. The registered dietitians acknowledged that the term 'vegetarian' is broad and should be resident-specific, and that it is standard practice to clarify such preferences with the physician responsible for the resident's care. Record review and interviews revealed that the diet order in the medical record only indicated a mechanical soft ground diet without specifying the lacto-vegetarian requirement. The facility's policy and procedures, as well as the Academy of Nutrition and Dietetics guidelines, require that diet names and orders be consistent and clearly defined across all documentation and communication tools. The facility's own diet manual also specifies the need to clarify the correct category of vegetarian diet. The lack of clarification and communication regarding the resident's specific dietary needs resulted in a deficiency related to ensuring services meet professional standards of quality.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for two residents, resulting in accident hazards and lack of appropriate assistance. For one resident, the grab bar in the bathroom was slippery due to the use of silicone cream, and the grip tape intended to provide a non-slip surface was not properly secured. The resident demonstrated that his hands slipped on the grab bar and reported a previous fall when attempting to use the bar. Despite staff being aware of the fall and the resident's concerns about safety, the grab bar remained inadequately adapted, with blue tape that did not provide a secure grip. Another resident was left unsupervised on the patio without a reliable means to call for assistance. The resident was given a phone to use, but it did not function properly, leaving her unable to request help when needed. Staff interviews revealed inconsistent practices regarding supervision and checking on residents outside, with some staff stating checks should occur every 20 to 30 minutes, while others indicated more frequent checks for residents with cognitive impairment. The resident's care plan indicated dependence on staff for activities and social interaction, and her cognitive assessment showed moderate impairment, yet she was left without adequate supervision or a functioning call device.
Failure to Monitor and Document Pain Medication Effectiveness
Penalty
Summary
The facility failed to monitor and document the effectiveness of pain medications for two residents who reported experiencing uncontrolled pain. Resident 35 had an order for Dilaudid 2 mg every 6 hours as needed for pain, and Resident 55 had an order for Norco 5/325 mg every 6 hours for pain. Both residents reported ongoing, uncontrolled pain during interviews. Review of their Medication Administration Records (MARs) showed that pain medications were administered in response to high pain scores, but there was no documentation of follow-up to assess or record the effectiveness of the medications after administration. The Director of Nursing (DON) confirmed during interviews and record reviews that nurses are expected to check and document the effectiveness of pain medications after each administration, as outlined in the facility's policy and procedure for pain assessment and management. Despite this policy, there was no evidence in the MARs that the effectiveness of the administered opioids was monitored or documented for either resident during the reviewed period.
Insulin Vials Not Labeled with Resident Name
Penalty
Summary
Insulin vials used for a resident were not labeled with the resident's name or other identifying information. During a medication pass, an LVN prepared to administer insulin by removing a box from the medication cart that was labeled with the resident's name, but the insulin vial inside the box was only labeled with the medication name and not the resident's name. The LVN confirmed that each resident had a dedicated insulin vial, but the labeling was only on the outside box, not on the vial itself. The Director of Nursing stated that insulin vials were not labeled with resident names and that the label was only placed on the box to avoid covering the medication name on the vial. The facility's consultant pharmacist indicated that best practice is to label both the insulin vial and the box with the resident's name to prevent mix-ups. A review of a National Library of Medicine document and the facility's own policy confirmed that insulin vials should be labeled with the patient's name, consistent with professional standards and facility policy.
Failure to Follow Menus and Honor Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and met the individualized nutritional needs of residents, as evidenced by three separate incidents involving different residents. In one case, a resident on a therapeutic renal diet was served 2 oz. of gravy instead of the 1 oz. specified in the planned menu. The food service assistant used a 2 oz. ladle, and neither the staff member plating the tray nor the staff member checking trays for accuracy identified the error. The resident's meal tray card and the planned therapeutic menu both indicated the correct portion, but the menu was not followed. Another incident involved a resident with a lacto-vegetarian preference and a mechanical soft (M/S) ground consistency diet due to being nearly edentulous. The resident was served whole blueberries, which are not allowed on a mechanical soft diet, and there was no pre-planned lacto-vegetarian menu developed by a registered dietitian (RD) to guide staff. The RD confirmed that the facility did not have vegetarian, lacto-vegetarian, or vegan pre-planned menus and that the staff member responsible for plating the meal had not received specific instructions for the resident's dietary needs. The lack of a planned menu resulted in inappropriate food items being served and a lack of variety for the resident. A third deficiency was identified when a resident was served lasagna despite it being listed as a food dislike on the resident's meal tray card. The staff member responsible for checking the tray did not catch the error, and the facility's policies required that food preferences be adhered to and that tray cards accurately reflect resident dislikes and preferences. These failures demonstrate that the facility did not consistently follow its own policies and procedures for ensuring that residents' dietary needs and preferences were met.
Infection Preventionist Failed to Implement Surveillance and Enhanced Barrier Precautions
Penalty
Summary
The Infection Preventionist (IP) failed to demonstrate competency in managing the facility's Infection Prevention and Control Program. The IP did not adhere to the facility's policy and procedure for monitoring compliance with infection control, specifically in surveillance activities, data collection, analysis, tracking, and trending. The IP only monitored hand hygiene and PPE use, excluding other critical areas such as glucometer use and cleaning. Documentation of adherence rates and corrective actions for non-compliance was lacking, and the IP did not provide tracking, trending reports, or analysis of surveillance data to the QAPI committee as required by policy. Enhanced Barrier Precautions (EBP) were not implemented in the facility, despite the presence of residents with wounds, indwelling medical devices, and infections such as ulcers and cellulitis. Observations revealed that residents with these conditions did not have EBP signage or PPE supplies in or outside their rooms. Staff interviews indicated a lack of knowledge and training regarding EBP, with the IP, LVN, CNA, ADON, DSD, and DON all expressing unfamiliarity with EBP criteria, required PPE, and related procedures. The facility's policies required EBP for residents with wounds or indwelling devices, but these were not followed in practice. Multiple residents were identified with conditions that met the criteria for EBP, including open wounds, ulcers, cellulitis, and Foley catheters. Despite this, there was no evidence of EBP implementation, signage, or PPE availability. The facility's policies and job descriptions outlined the IP's responsibility for infection prevention, surveillance, data analysis, and staff education, but these duties were not fulfilled, resulting in the facility's failure to monitor, identify, and control the spread of infections.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident 1, by not administering prescribed doses of Insulin Glargine and Potassium. Resident 1, who was admitted with a diagnosis of diabetes mellitus, missed her morning dose of Insulin Glargine on January 29, 2025, and two doses of Potassium on January 27, 2025, as well as another Potassium dose earlier in the month. The missed doses were due to the facility running out of these medications, as confirmed by the Medication Administration Record and interviews with the resident and staff. Interviews with the Licensed Nurse (LN) and the Director of Nursing (DON) revealed that the responsibility for ensuring medication availability lies with the floor nurses, who are expected to reorder medications before they run out. The facility's policy on administering medication, revised in April 2019, states that medications should be administered safely, timely, and as prescribed. However, the failure to reorder medications in a timely manner led to the resident missing critical doses, as documented in the Medication Administration Record and Order History.
Failure to Resolve and Communicate Grievances
Penalty
Summary
The facility failed to adhere to its policy and procedure for recording and investigating grievances for a resident who had filed multiple grievances. The resident, who has Type 2 diabetes mellitus, reported not receiving a dinner tray on one occasion, which led her to purchase food out of concern for her blood sugar levels. Despite filing a grievance about this incident, the resident was not informed of the findings or any corrective actions taken by the facility. Additionally, another grievance regarding a loud kitchen door was also not resolved or communicated to the resident. Interviews with facility staff, including the Social Services Designee and the Administrator, revealed that the grievances were not investigated or resolved within the required timeframe. The Social Services Designee admitted to being disorganized with handling grievances, and the Dietary Supervisor was unaware of any grievances related to the kitchen. The facility's policy requires that grievances be investigated and resolved within 14 working days, with findings communicated to the resident, but this process was not followed in these instances.
Failure to Administer Insulin Timely
Penalty
Summary
The facility failed to adhere to its policy and procedure on administering medications, specifically insulin, for a resident diagnosed with Type 2 diabetes mellitus. The resident reported receiving her insulin more than an hour too late or too early, which caused her to feel anxious, nervous, experience shortness of breath, and shakiness. A review of the Medication Administration Record (MAR) revealed multiple instances where the resident's insulin was not administered at the scheduled times. For example, Insulin Human Regular, a short-acting insulin, was administered hours after the scheduled time on several occasions, and Insulin Glargine, a long-acting insulin, was also given late on different dates. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) confirmed the late administration of insulin and the lack of timely documentation on the MAR. The facility's policy, dated April 2019, mandates that medications be administered safely, timely, and as prescribed, with documentation on the MAR immediately after administration. The DON acknowledged the expectation for timely administration and documentation, while the LVNs confirmed that more than an hour's delay from the scheduled time is considered late.
Failure to Provide Timely Resident Care
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents, leading to potential delays in care. Resident 2 reported that call lights sometimes took 20 minutes to be answered, which was not acceptable and raised concerns about emergency situations. Resident 2's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15, showing cognitive intactness. Resident 1 experienced a significant delay in care, having to wait two hours in a wet brief due to staff shortages, which made her feel dehumanized. Her MDS showed a BIMS score of 14, indicating cognitive intactness. Interviews with Certified Nursing Assistants (CNAs) revealed that they were often assigned 11 to 17 residents per shift, making it difficult to provide timely care. CNA 1 reported having 17 residents on a recent shift, which made it challenging to answer call lights and provide showers, resulting in longer wait times for residents. CNA 2 also reported feeling rushed and unable to take breaks due to being assigned 14 residents frequently. The facility's policies on staffing and call systems were reviewed, indicating that calls for assistance should be answered within five minutes, but this standard was not met, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for a resident, which had the potential to lead to adverse outcomes. During an interview, the resident reported being sent to an out-of-town appointment with an insulin pen but no needle, resulting in missed insulin administration before lunch. Additionally, the resident stated that their Ozempic medication, which should be administered weekly on Fridays, was delayed until Saturday. The medication records for September and October 2024 confirmed these discrepancies, showing missed doses and lack of documentation by licensed staff. The Quality Assurance Nurse (QAN) confirmed the findings, noting that the Ozempic was held due to a data entry error and was not administered as ordered. The facility's policy and procedure for administering medications, revised in April 2019, stipulates that medications should be administered safely, timely, and as prescribed, within one hour of the scheduled time unless specified otherwise. However, the records showed instances where medications were either missed or held without proper documentation or explanation, indicating a failure to adhere to these guidelines.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure the privacy of a resident's mail, resulting in a violation of the resident's rights. During an interview, the resident reported that an Administrative Service Manager in Training (ASM) handed her a letter from her insurance company that was already opened. The letter was addressed to the resident, and she did not give permission for it to be opened. The resident questioned the ASM about who opened her mail, but did not receive a response. A review of the resident's Interdisciplinary Progress Note (IDTPN) indicated that the ASM had the letter in the office and opened it, assuming it was related to a medication issue the resident had mentioned. The ASM confirmed in an interview that he opened the letter without the resident's permission, as he assumed it was the document the resident was referring to. The facility's policy and procedure on mail and electronic communication, revised in May 2017, clearly states that mail should be delivered unopened unless the resident requests assistance, which should be documented in the resident's plan of care.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances filed by one of the three sampled residents, identified as Resident 1. During an interview, Resident 1 stated that she had filed grievances, but the facility did not resolve them. A review of the Resident/Family Concern/Grievance Report (RFCGR) for Resident 1, dated 4/22/24, 5/1/24, and 5/4/24, revealed that the grievances were not completed. There was no follow-up, no resolution, and the forms were not signed off by the administration. Additionally, Resident 1 did not sign the forms to indicate that the grievances had been resolved. The facility's policy and procedure on grievances, revised in April 2017, requires that the administrator and staff make prompt efforts to resolve grievances to the satisfaction of the resident. The policy states that upon receipt of a grievance, the grievance officer should review and investigate the allegations and submit a written report to the administrator within five working days. The resident should be informed verbally and in writing of the findings and actions to be taken. However, the facility did not adhere to these procedures, as evidenced by the incomplete grievance reports and lack of communication with Resident 1 regarding the resolution of her grievances.
Supply Shortages Lead to Resident Discomfort
Penalty
Summary
The facility failed to ensure adequate supplies were available for two residents, leading to unmet care needs and discomfort. Resident 1 reported that the facility frequently runs out of chux (underpads) and wipes, particularly at night. Resident 2 also experienced shortages of large briefs and chux, occurring about twice a month. When supplies ran out, staff resorted to using briefs that were either too large or too small, causing leaks or discomfort for Resident 2. Interviews with facility staff revealed issues in the supply ordering process. The Unit Secretary, responsible for placing supply orders, indicated she was trained on how to place orders but not on preventing shortages. A Certified Nursing Assistant noted that the facility's new admissions were not considered when ordering supplies, contributing to the shortages. The facility's policy and procedure document, revised in April 2021, stated that routine personal hygiene items, including incontinence care supplies, should be provided to meet residents' needs during covered Medicare/Medicaid stays.
Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure that a care plan was implemented for one of the sampled residents when the behaviors were not monitored hourly. Specifically, Resident 1 had made a threat to kill an LVN, and the care plan required hourly rounding to monitor the resident's location, behavior, and activity. However, the documentation of this monitoring was missing for multiple hours on two consecutive days, as evidenced by the absence of entries in the Administration Order Text for those dates and times. During an interview, the Director of Nursing acknowledged the missing documentation. The facility's policy and procedure on comprehensive, person-centered care plans, which includes measurable objectives and timetables to meet the resident's needs, was not followed. This lapse in monitoring and documentation had the potential to result in unmonitored behaviors and delayed psychosocial interventions for Resident 1.
Failure to Monitor Bed Alarm Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to monitor the efficacy of a bed alarm for a resident, resulting in an unwitnessed fall and a major injury. The resident, who had severe cognitive impairment and was at high risk for falls, was found on the floor with a transverse fracture of the right patella. The bed alarm, which was supposed to be activated as per the resident's care plan, was not turned on at the time of the fall. Multiple staff members, including LVNs and CNAs, confirmed that the bed alarm was not activated. The resident's care plan indicated the need for a bed alarm due to the high risk of falls, but staff failed to ensure it was functioning. The Director of Nursing and other staff members acknowledged that the bed alarm was not turned on and that it should have been. The facility's policy on fall risk management stated that position-change alarms should not be the sole intervention but should assist staff in identifying patterns and routines. However, the staff did not verify the bed alarm's functionality, leading to the resident's fall and subsequent injury. The facility's investigation confirmed that the bed alarm was not activated by the staff, and there was no system in place to ensure its proper functioning.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident, who had a history of inappropriate behavior, was not adequately supervised. Resident 2, who was cognitively intact and independent with mobility, engaged in inappropriate sexual behavior with Resident 1, who had severe cognitive impairment and was not ambulatory. On the day of the incident, Resident 2 was found in Resident 1's room with the door closed, and Resident 1's brief was down to her ankles. Resident 2 admitted to touching Resident 1's breasts and perineal area. Resident 2 had a documented history of inappropriate behavior, including making sexually explicit comments to staff and crossing boundaries with other residents. Despite these behaviors, the facility's interventions, such as close monitoring and setting healthy boundaries, were not effectively implemented. Staff interviews revealed that Resident 2 had been in Resident 1's room multiple times before the incident, and there was a lack of consistent monitoring to prevent such occurrences. The facility's policy on abuse prevention emphasized protecting residents from abuse by anyone, including other residents. However, the facility did not adequately identify and investigate the potential for abuse, nor did it protect Resident 1 from further harm. The failure to supervise Resident 2 appropriately and the lack of effective interventions contributed to the incident of abuse against Resident 1.
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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.
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