Shields Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cerrito, California.
- Location
- 3230 Carlson Boulevard, El Cerrito, California 94530
- CMS Provider Number
- 555364
- Inspections on file
- 20
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shields Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple health issues continued to receive routine acetaminophen for pain management without reevaluation, despite ongoing assessments showing no pain. Physician-ordered lab tests were not completed, and required monitoring of fluid intake and output was not performed, even though the resident's intake was often below the recommended level. When a STAT urinalysis was ordered due to a change in condition, the nurse failed to notify the physician after unsuccessful attempts to obtain a specimen and did not document the actions taken, resulting in delayed care.
A resident's medical record was not accurately documented when an LVN failed to record a physician's STAT order for urinalysis and straight catheterization, including the date and time received. The LVN did not notify the physician of unsuccessful attempts to obtain a urine specimen or the resident's ongoing pain, and the order was not properly documented or communicated between shifts. The DON was unaware of the order's status, and the progress notes lacked critical timing information.
The facility did not report two residents who tested positive for COVID-19 to the health department, despite facility policy requiring such reporting. Interviews with the DON, Admin, and IP confirmed knowledge of the cases and the lack of reporting, with the IP later receiving instructions from public health to report all positive cases.
A resident council meeting was held in an empty resident room that could not accommodate all interested participants, with several residents in wheelchairs present. A resident reported discomfort with meetings being held in her room and noted that space was insufficient for group participation. The AD and Admin confirmed that meetings were held in empty rooms due to lack of a designated space, limiting resident involvement. Facility policy required provision of space and privacy for such meetings, which was not met.
The facility did not ensure that discussions about advance directives were documented in the medical records for several residents, including those with cognitive impairment and those who were cognitively intact. Review of records and staff interviews confirmed that required documentation and follow-up regarding advance directives were missing, contrary to facility policy.
The Consultant Pharmacist did not provide comprehensive onsite pharmacy services, as evidenced by loose pills found in a med cart, tube feeding formula stored under a hand washing sink, and a cabinet full of discontinued narcotics that had not been destroyed in a timely manner. The CP had not been physically present for medication reviews, drug destruction, or QA meetings, contrary to facility and pharmacy policy.
Surveyors found expired sour cream, a bag of soggy salad, and a dirty utensil holder in the kitchen, all of which were acknowledged by the Dietary Supervisor as not meeting facility policy and posing risks such as stomach upset and cross-contamination for residents receiving food from the kitchen.
A resident was unable to store perishable food brought by family due to the facility's lack of a refrigerator, despite facility policy requiring such storage. Both the ADON and DON confirmed that the refrigerator previously available for resident use had not been replaced after it broke, and families were told to only bring food for immediate consumption.
Two residents with a diagnosis of schizophrenia were not referred for a required PASRR Level II evaluation. Review of admission records and PASRR Level I screenings revealed that the necessary referrals were not made, and the DON and MDS coordinator were unaware of the requirement.
A resident receiving hospice care did not have a coordinated plan of care developed with participation from hospice representatives, the resident, or their representatives, as required by facility policy. Interviews with the SSD and DON confirmed that no care plan conference was scheduled and no collaboration occurred with hospice staff, resulting in the resident's hospice care plan lacking required input.
A resident with morbid obesity, hemiplegia, and hemiparesis, who required two-person assistance for bed mobility, was turned by a CNA without help, resulting in the resident falling from bed and sustaining a left femur fracture. Staff interviews confirmed the resident's need for extensive assistance, and the incident occurred when the bed was in a high position.
A resident's legal representative did not receive requested medical records within the required timeframe, as the facility delayed processing and mailing the documents for over forty days despite receiving a hand-delivered authorization request. The delay was due to miscommunication and lack of timely action by staff, in violation of facility policy.
A resident with dementia and a high risk for pressure ulcers developed a stage 3 sacral wound, but staff failed to consistently assess and document the wound as required. Facility records showed missing or incomplete weekly wound assessments, and interviews with the DON and an LVN confirmed that expected documentation practices were not always followed.
A facility failed to complete a comprehensive MDS assessment for a resident within the required timeframe. The MDSC acknowledged the delay was due to workload, and the assessment was still in progress at the time of the survey. Facility policy mandates timely assessments, which was not followed.
A facility failed to provide a resident with a 30-day notice of discharge and did not send a copy to the State Long-Term Care Ombudsman. The resident, with severe cognitive impairment and multiple diagnoses, was discharged home without proper notification and documentation procedures being followed.
A resident with severe cognitive impairment and multiple medical conditions was discharged without proper consideration of their needs, leading to re-admission to the hospital. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. The facility's policy and procedure for discharge planning were not followed, resulting in the resident falling multiple times and being sent back to the hospital.
Failure to Reevaluate Pain Medication, Complete Lab Orders, and Monitor Fluid Status
Penalty
Summary
The facility failed to provide necessary treatment and care services for a resident with severe cognitive impairment and multiple medical diagnoses, including non-Alzheimer's dementia and malnutrition. The resident was routinely administered acetaminophen twice daily for pain management, despite documentation over several months indicating no complaints of pain and regular pain assessments showing no pain. The care plan required reassessment of the need for pain medication, but this was not done, and the medication regimen continued without reevaluation, contrary to facility policy and professional standards. Additionally, the facility did not carry out physician-ordered diagnostic laboratory tests, including blood work, for the resident. The Director of Nursing confirmed that the laboratory tests ordered by the physician were not performed. The resident's care plan also required monitoring and documentation of fluid intake and output due to a risk for fluid deficit related to chronic urinary tract infection. However, daily fluid intake was not consistently tallied, output was not recorded, and the resident's intake was frequently below the minimum required amount, with no documentation to show that intake and output were monitored as required by the care plan and facility policy. When the resident experienced a change in condition, including abdominal pain and other symptoms, a STAT order for a urinalysis via straight catheterization was received. The nurse attempted to obtain the specimen twice without success but did not notify the physician of the failed attempts or document the order and actions taken. The STAT order was endorsed to the next shift without timely follow-up, and the Director of Nursing was unaware of the delay. The facility's policies required prompt communication with the physician and documentation of such events, which did not occur in this case.
Failure to Accurately Document and Communicate STAT Lab Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurately documented and systematically organized according to accepted professional standards. Specifically, a Licensed Vocational Nurse (LVN) did not document a physician's order for a STAT urinalysis (UA) and straight catheterization, including the date and time the order was received. The LVN attempted to obtain a urine specimen by straight catheterization twice without success and endorsed the STAT order to the night shift nurse but did not notify the physician of the failed attempts or the resident's continued complaints of pain. The LVN also did not document the order for straight catheterization in the resident's medical record. Upon review of the resident's progress notes and laboratory reports, it was found that the documentation did not reflect the time the physician's order for STAT labs was received, and the Director of Nursing (DON) was unaware that the STAT lab order had been endorsed from shift to shift or that it was received a day before the resident was transferred to the hospital. The lack of proper documentation and communication regarding the physician's orders and the resident's condition contributed to the deficiency identified during the survey.
Failure to Report COVID-19 Outbreak to Health Department
Penalty
Summary
The facility failed to implement its policy and procedure for reporting an outbreak of communicable disease, specifically COVID-19. Two residents tested positive for COVID-19 in July 2025, with one resident being transferred to the hospital for shortness of breath and subsequently testing positive for COVID-19, and another resident's laboratory test confirming a positive result. Despite these cases, the facility did not report the outbreak to the local or state health department as required by their policy. Interviews with the Director of Nursing, Administrator, and Infection Preventionist confirmed awareness of the two positive cases but revealed that no report was made to the health department. The facility's policy, dated September 2022, defines an outbreak as even a single case of a highly communicable disease and assigns responsibility for reporting to the Administrator. The Infection Preventionist stated that the facility later received instructions from the county public health nurse to report all positive COVID-19 cases, but the initial cases were not reported as required.
Inadequate Space Provided for Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate space for resident council meetings, as evidenced by observations and interviews. During a resident council meeting, six residents in wheelchairs were seated in an empty resident room, which was reported to be insufficient to accommodate all interested participants. One resident, who was cognitively intact and able to express her needs, stated that meetings were sometimes held in her room or other empty resident rooms, but these spaces were not large enough for all residents wishing to attend. She also expressed discomfort with having meetings in her personal room. The Activity Director confirmed that space was limited and that more residents would participate if a larger area were available. As a result, some meetings were conducted one-on-one in residents' rooms instead of as group sessions. The Administrator acknowledged that there was no specific room assigned for resident council meetings and that meetings typically took place in empty resident rooms. Review of the facility's policy indicated that the resident council should be provided with space, privacy, and support to conduct meetings, which was not being met at the time of the survey.
Failure to Document Advance Directive Discussions in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with residents and/or their responsible parties. Specifically, for four out of fifteen sampled residents, there was no evidence in the medical records that advance directives were addressed as required. These residents included individuals with varying cognitive abilities, such as those who were cognitively intact and those with severe cognitive impairment due to conditions like dementia and Alzheimer's disease. In each case, reviews of admission records, Minimum Data Set (MDS) assessments, and Physician Orders for Life-Sustaining Treatment (POLST) forms showed either the absence of an advance directive or a lack of documentation regarding any discussion about advance directives. Interviews with facility staff, including the Social Service Director (SSD) and the Director of Nursing (DON), confirmed that there was no documentation of advance directive discussions or follow-up with the residents or their responsible parties. The facility's policy required that information about advance directives be provided and documented upon or prior to admission, and that the existence of such directives be prominently displayed in the medical record. However, this process was not followed for the identified residents, resulting in incomplete records regarding their wishes for medical treatment.
Consultant Pharmacist Failed to Provide Comprehensive Onsite Pharmacy Services
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) provided comprehensive consultation on all aspects of pharmacy services. During observations, loose pills were found in the medication cart, and multiple bottles of tube feeding formula were stored in a cabinet underneath a hand washing sink. The Registered Nurse (RN) present was unaware of the improper storage of both the loose pills and the formula. The Director of Nursing (DON) confirmed the improper storage and stated that there was a designated container for loose pills, expecting licensed nurses to dispose of medications properly. Additionally, a cabinet in the medication room was found to be full of discontinued narcotic medications, with the last destruction of these drugs by the CP occurring several months prior. The DON stated that the CP had been conducting medication reviews remotely and had not visited the facility to assist with the destruction of discontinued medications. The Administrator reported that the CP had been inconsistent with facility visits, continued remote reviews since the COVID-19 period, and had not attended quarterly Quality Assurance (QA) Committee meetings since 2022. The CP's Director of Clinical Operation was unaware of the lack of physical presence and stated that pharmacy policy required in-person visits for drug destruction and QA attendance.
Improper Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
During an initial kitchen tour, surveyors observed two expired containers of sour cream stored in the kitchen refrigerator, one of which was opened and nearly empty. The Dietary Supervisor (DS) confirmed that the expired sour cream should have been disposed of and acknowledged the risk of stomach upset for residents if consumed. Additionally, an opened plastic bag of soggy salad was found in the refrigerator, which the DS also stated should have been discarded due to similar risks. Review of the facility's policy indicated that all perishable food items are to be stored properly, with open dates and use-by dates per manufacturer guidelines. Further observation revealed that the utensil holder used for storing kitchen utensils was not clean, with visible brownish stains and scattered brownish particles. The DS acknowledged the utensil holder was dirty and recognized the risk of cross-contamination from storing utensils in such a condition. Facility policy requires all kitchen equipment and surfaces that come in contact with food to be cleaned and sanitized after each use. The 2022 Federal Food Code also mandates that food-contact surfaces be clean to sight and touch, and free of food residue and debris.
Failure to Provide Refrigerator for Resident Food Storage
Penalty
Summary
The facility failed to provide a means for residents to store food brought in by family members, as evidenced by the experience of one resident who was unable to refrigerate food brought from home. During a resident council meeting, the resident reported that she had to consume the food immediately and share it with her caregiver because there was no refrigerator available for resident use. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed in interviews that the facility previously had a refrigerator for this purpose, but it had broken and was not replaced. Instead, families were instructed to only bring enough food for immediate consumption and to take any leftovers home. A review of the facility's policy and procedure on food brought by family or visitors indicated that perishable foods should be stored in resealable containers with tight-fitting lids in a refrigerator, labeled with the resident's name, item, and use-by date. However, the facility was not following this policy due to the lack of a refrigerator, resulting in the resident being unable to store perishable food items as intended. The resident involved was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS).
Failure to Refer Residents with Schizophrenia for PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that two residents with a diagnosis of schizophrenia were properly screened and referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation, as required for individuals with mental disorders or intellectual disabilities. Record reviews showed that both residents had a documented diagnosis of schizophrenia at the time of admission, but their PASRR Level I screenings did not result in a referral for Level II evaluation. During interviews, the Director of Nursing and the MDS coordinator confirmed they were not aware of the need to refer these residents for further PASRR assessment.
Failure to Collaborate with Hospice for Resident's Plan of Care
Penalty
Summary
The facility failed to follow its hospice policy and procedure by not collaborating, developing, and implementing a coordinated plan of care (POC) with hospice representatives for a resident who was admitted into the hospice program. The resident, who had a principal diagnosis of a disorder of the brain, was admitted to the facility and started on hospice services. However, the resident's hospice POC did not reflect the participation of hospice representatives, the resident, or the resident's representatives, as required by facility policy and applicable regulations. Interviews with the Social Services Designee (SSD) and the Director of Nursing (DON) confirmed that no care plan conference had been scheduled with the hospice provider, and there was no collaboration with hospice representatives in developing the resident's hospice care plan. The SSD acknowledged awareness of the requirement but stated that the care conference had not been scheduled. The DON confirmed that the facility had not met to collaborate with hospice representatives on the resident's POC, attributing the failure to an oversight. Review of the facility's policy indicated that such collaboration and coordination were required for residents receiving hospice services.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
Resident 14, who had diagnoses including morbid obesity, hemiplegia, and hemiparesis, required extensive assistance by two staff members for bed mobility and repositioning, as documented in the resident's care plan and Minimum Data Set (MDS). Despite these documented needs, a Certified Nursing Assistant (CNA) attempted to turn and reposition the resident alone, without requesting the required assistance. During this unsupervised care, the resident was rolled out of bed and fell to the floor, resulting in a left femur fracture. The resident's bed was also noted to be in a high position at the time of the fall. Interviews and record reviews confirmed that the CNA was aware of the need for a second person to assist but did not seek help. The resident was subsequently found screaming in pain and was transferred to the hospital, where the fracture was confirmed. Staff interviews further corroborated that the resident consistently required two to three persons for safe repositioning due to her condition, and the Director of Rehabilitation stated the fall was avoidable if proper assistance had been used.
Failure to Timely Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's representative with copies of the resident's medical records within the required forty-eight-hour timeframe after receiving a written request. The representative hand-delivered an authorization request for the records, which was received by facility staff. Despite this, the medical records staff did not promptly process the request, stating uncertainty about when the request was received and indicating that the request may have been left in the administrator's office. The medical records staff later confirmed to the representative that the request was still being processed several weeks after the initial submission. Ultimately, the requested documents were not mailed until forty-two days after the initial request, as confirmed by a USPS receipt. The facility's own policy required that such requests be fulfilled within forty-eight hours, excluding weekends and holidays. The delay in providing the records was due to a lack of timely communication and follow-through by both the medical records staff and the administrator, resulting in the representative not receiving the necessary documents within the mandated period.
Failure to Consistently Assess and Document Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and document a coccyx pressure ulcer for one resident with a history of dementia and a urinary tract infection. The resident was admitted with a low pain score and later developed a stage 3 pressure ulcer in the sacral region. Review of facility records showed inconsistent and incomplete documentation of weekly wound assessments and skin evaluations, with several dates missing required wound descriptions and skin section entries. The Braden Scale assessment indicated the resident was at very high risk for pressure ulcers, yet the documentation did not consistently reflect thorough wound monitoring. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that weekly wound assessments, including staging and detailed wound descriptions, were expected but not always completed or documented as required. Facility policy specified that all wound assessment data should be recorded in the resident's medical record, but this was not consistently done. The lack of regular and complete wound assessment documentation had the potential to delay identification of infection or changes in the wound's condition.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the regulatory specified timeframes. The resident was admitted to the facility, and the Admission MDS was not completed within 14 calendar days as required. The MDS Coordinator (MDSC) acknowledged that the Admission Assessment should have been completed by the specified date but was delayed due to the MDSC's workload. During an interview and record review, the MDSC confirmed that the Admission MDS was still in progress and not yet completed at the time of the survey. The facility's policy requires that the Assessment Coordinator ensures timely resident assessments, which was not adhered to in this case.
Failure to Provide Timely Discharge Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident with a notice of proposed discharge within the required timeframe of at least 30 days prior to the actual discharge date. Additionally, the facility did not send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman as required. The resident, who was admitted with multiple diagnoses including cerebral palsy, dysphagia, repeated falls, rhabdomyolysis, syncope, and dorsalgia, had a BIMS score indicating severe cognitive impairment. Despite this, the resident was discharged home without the proper notification and documentation procedures being followed. The Notice of Proposed Transfer/Discharge was signed by the caregiver on the same day as the discharge, which was only five days after the notification date, far short of the required 30-day notice period. During interviews, the Physical Therapist indicated that the resident still needed 24-hour care at the time of discharge, and the Administrator admitted to not knowing if the discharge notice was sent to the Ombudsman office. Furthermore, the facility lacked a policy and procedure addressing discharge notices, and no proof was provided that the notice was sent to the Ombudsman office.
Failure to Implement Effective Discharge Planning
Penalty
Summary
The facility failed to implement effective discharge planning for a resident who required 24-hour care. The resident, who had severe cognitive impairment and multiple medical conditions including cerebral palsy, dysphagia, and repeated falls, was discharged without proper consideration of their needs. The discharge plan did not account for the availability and capability of caregiver support, nor did it ensure the resident's diet requirements were met. This oversight led to the resident being re-admitted to the hospital shortly after discharge due to severe pain and repeated falls. Interviews and record reviews revealed that the resident's family had agreed to take the resident home only when they could use the bathroom independently. However, the resident still required significant assistance with activities of daily living (ADLs) and needed 24-hour care at the time of discharge. The Director of Nursing (DON) was unaware of the resident's need for 24-hour care, which would have altered the discharge plan to keep the resident in the facility for long-term care. Additionally, the caregiver did not attend training sessions, and the resident's discharge plan was not thoroughly reviewed by the interdisciplinary team. The facility's policy and procedure for discharge planning were not followed, as the discharge plan did not include a description of the resident's discharge goals, the degree of caregiver support, or factors that could make the resident vulnerable to readmission. The caregiver reported being unable to provide the necessary 24-hour care and stated that the resident fell multiple times after being discharged. The resident was eventually sent back to the hospital due to severe pain and repeated falls, highlighting the facility's failure to ensure a safe and effective discharge plan.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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