Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Solano Post Acute during CMS and state inspections, most recent first.
The facility failed to follow its abuse prohibition policy when two roommates were not separated after an LPN found one resident kneeling by the other’s bed, holding the resident’s arms, and the resident was noted to have a new eye injury and facial abrasion with severe pain. One resident had a history of dementia with behavioral dysregulation and documented episodes of confusion, restlessness, and attempts to hit staff and other residents, while the other had diabetes, depression, and mild cognitive impairment. Despite these events and care plans noting risk for behavioral dysregulation and injury related to exposure to another resident, the residents continued to share a room, and the DON confirmed there was no documentation of continuous monitoring in the room after the incident, contrary to the facility’s policy requiring removal of a resident who has threatened or attacked another from the situation during investigation.
The facility failed to timely report a suspected abuse incident when an LN found two roommates in bed with one resident kneeling over the other and holding his arms, and the resident in bed had a new left eye injury with bleeding and severe pain that required ED evaluation. One resident had DM, depression, and mild cognitive impairment, while the other had dementia, disorientation, and anxiety with a care plan noting behavioral dysregulation and risk for unintended physical contact. Documentation showed escalating aggressive behavior by the cognitively impaired resident toward his roommate and staff. Although the event and resulting eye and facial injuries were documented and later incorporated into both residents’ care plans, the administrator confirmed the incident was not reported to authorities until two days after it occurred, contrary to facility policy requiring reporting of abuse-related allegations within two hours.
The facility failed to ensure adequate and accessible fluids for three residents, including one with severe cognitive impairment and documented risk for dehydration who was observed over several hours with very dry lips and tongue, an empty cup at bedside, and no staff offering fluids. Another resident with ESRD and muscle weakness reported thirst while his water pitcher was placed out of reach on an overbed table behind him. A third resident with DM and chronic kidney disease repeatedly called out for water while an empty water pitcher remained on the overbed table and was not refilled in a timely manner. These situations occurred despite facility policies requiring staff to provide, position, and encourage routine fluid intake at bedside and during daily care.
Surveyors found that call light buttons were not kept within reach for three dependent residents with cognitive impairment, mobility limitations, and identified fall risk. One resident reported not having a call light while it was tied to the bed rail in a way that was not readily usable. Another resident’s call light was observed on the floor by the bedside table, and a third resident, who could not locate the call light despite needing assistance for most ADLs, had the device placed on top of the bedside table and it remained there without staff repositioning it. Facility policy required call lights to be accessible from the bed, toilet, shower or bathing area, and from the floor, but this was not followed in these cases.
Two residents who were dependent on staff for turning, repositioning, and toilet hygiene did not receive the required assistance with ADLs. One resident with diabetes, generalized weakness, and morbid obesity had a care plan calling for turning at least every 2–4 hours, yet was observed lying on her back for several hours with no repositioning or incontinence care until a CNA provided care in the early afternoon, after which she remained in the same position. The resident reported her last change and repositioning had been during the night. Another resident with severe cognitive impairment and total dependence for toilet hygiene and repositioning had no person-centered care plan addressing these needs and was repeatedly observed lying flat on her back with no incontinence care or repositioning provided. Staff interviews confirmed the expectation for turning and incontinence care every few hours, and facility policies required comprehensive care planning and turning to prevent skin issues.
The facility failed to maintain a safe, clean, and pest-free environment when multiple flies were observed in several resident rooms, including a shared room occupied by three residents with dementia, depression, muscle weakness, and communication difficulties. Surveyors observed flies on privacy curtains, walls, bedding, a pillowcase, a resident’s gown, a sandwich and its wrapper, a phone, a drinking cup, and in the air around residents, along with a thick dried yellow substance on one resident’s sheets, bedframe, and pooled on the floor. One resident reported that bugs were "everywhere" and another was seen waving flies away from his face, stating they had been present for a while and that they bothered him. A CNA, the housekeeping manager, the ADM, the IP, and the ADON all confirmed the presence of flies and acknowledged that the conditions did not meet expectations for a safe, clean, and dignified environment, contrary to the facility’s infection control, pest control, homelike environment, and resident rights policies.
Medication storage and labeling were deficient when surveyors found loose pills, non-medication items, bisacodyl suppositories, triamcinolone cream, and residue in medication carts, along with expired OTC meds in a medication room. Surveyors also found two unlabeled medications at a resident’s bedside without an order for bedside self-administration; the resident had acute and chronic respiratory failure with hypoxia, and the LN confirmed the meds were left there without proper authorization.
Improper storage of frozen food items was identified in kitchen Freezer #1. Surveyors found ice cream containers with no open or use-by date, unsealed donut holes and flour tortillas, and a lemon cake with dates that showed it was expired. The DM confirmed the findings and stated that expired food should be discarded and food should be properly sealed.
Residents were not given advance notice about roof construction and the loud banging that disrupted sleep, rest, and resident council communication. A resident with respiratory failure, another with respiratory failure, a resident with DM2, and a resident with severe cognitive impairment reported anxiety, restlessness, and poor sleep from the noise. In a separate incident, food brought in by family or a resident was labeled and placed in the refrigerator, then discarded the next morning before the required holding period, which the DON, ADON, and Administrator confirmed affected resident dignity.
A facility failed to maintain infection prevention practices for several residents with respiratory equipment and Foley catheters. Staff observed a nebulizer mask left unbagged and undated, Foley bags and catheter tubing on the floor, open distilled water for CPAP stored on the floor without a date, unlabeled oxygen tubing, and oxygen tubing wrapped around a side rail instead of being secured in a storage bag. The IP and DON stated these items should have been stored and labeled appropriately.
Ineffective pest control program with gnats and flies observed in resident rooms and hallways. Staff and residents reported gnats were everywhere in the building, including in rooms, hallways, and near food and water. A CNA confirmed gnats were flying above a resident's bed, and the MS stated pest control treatment had only been done in one hallway while the IP said the issue had been ongoing for months.
Failure to provide and document restorative nursing services: A resident with right-sided hemiplegia had a care plan for AROM to the RUE three times weekly, but the RNA confirmed the service was not provided that week and there was no documentation that the intervention was offered or completed over the reviewed period. The ADON and DON confirmed the lack of documentation, and the DON stated care plan interventions were expected to be followed and documented.
A resident with aphasia, right-sided upper-limb monoplegia, generalized weakness, and severe cognitive impairment had two beds placed side by side and put together in the room. An LN confirmed the arrangement, the DON stated the family had not signed consent for the beds to be together and confirmed the bed was not locked, and the RC acknowledged the resident could be at risk of entrapment with the current bed setup.
Medication services were not maintained when an LPN failed to sign the narcotic count record immediately after giving hydrocodone acetaminophen to a resident, leaving the controlled drug count inaccurate. In a separate event, an LPN prepared an IV ceftriaxone dose incorrectly for a resident with endocarditis and severe sepsis by using the wrong vial strength and improper reconstitution, and the DON and pharmacy vendor pharmacist confirmed the dose was not prepared accurately.
A resident with hemiplegia and dysarthria reported inappropriate touching by another resident and a staff member, but the facility did not report the alleged abuse to the state agency within the required two-hour timeframe. Staff interviews and documentation confirmed the delay, and the resident expressed feeling ignored and disappointed by the lack of urgency.
A resident with paralysis and speech difficulties reported being inappropriately touched by another resident and a staff member. The facility did not complete or report the required abuse investigations within the five-day timeframe outlined in policy, resulting in delayed action and the resident feeling ignored and distressed. Staff interviews confirmed the delay and awareness of reporting protocols.
A resident with schizophrenia and a history of delusions eloped from the facility without staff knowledge or authorization. Despite a care plan identifying behavioral risks and interventions, the resident was able to leave unsupervised. Staff interviews confirmed a lack of awareness regarding the resident's absence, and facility policy requiring supervision for at-risk residents was not effectively followed.
A nurse administered a resident’s scheduled medications four hours late, disposed of a refused medication in the trash instead of the approved disposal system, and inaccurately documented that all medications were given on time. Facility leadership confirmed the nurse did not follow physician orders or facility policy, and the MAR showed discrepancies in medication administration and documentation.
A facility failed to report an injury of unknown source within the required timeframe for a resident who sustained a broken left wrist. The incident was reported to the CDPH the day after it occurred. The DON and ADM were unaware that such injuries should be reported within two hours if they result in serious bodily harm, as per the facility's policy.
The facility failed to label clothing for two residents, risking the loss of personal possessions. A resident reported missing clothing after laundry, and staff confirmed the issue of unlabeled clothing. Observations revealed unlabeled clothing for another resident. Facility policies require labeling to ensure respect and dignity.
A resident was found with unattended medications, including controlled substances, on their bedside table. The resident, who was cognitively intact, reported that nurses had been leaving medications without supervision. The facility's policy requires staff to observe residents taking medications, which was not followed.
A facility failed to implement proper infection control practices when an LPN did not perform hand hygiene after leaving a resident's room. The LPN placed medication bubble packs on the resident's bed, compared them with medication cups, and returned the packs to the medication cart without hand hygiene, increasing the risk of infection spread. The DON confirmed the breach of protocol, which violated the facility's policies on hand hygiene and medication administration.
Staff failed to follow infection prevention protocols by removing gloves and gowns in the hallway after exiting a droplet isolation room, not changing N95 masks after leaving the room, and providing care to a COVID-19 positive resident without eye protection, all in violation of facility PPE policies.
A resident with severe cognitive impairment and multiple diagnoses refused ordered blood draws and diagnostic tests, but the physician was not notified as required by facility policy. The DON confirmed that the physician had not been informed, resulting in a lack of proper medical supervision for the resident.
A resident with multiple chronic conditions and severe cognitive impairment did not receive physician-ordered laboratory tests on two occasions. The facility lacked documentation or results for these tests, and the DON was unable to confirm if the tests were ever performed. This failure was confirmed through record review and interviews, despite facility policy requiring completion and reporting of all ordered labs.
A resident with congestive heart failure did not receive her prescribed diuretic medication for several days and was not informed of changes to her medication regimen. The resident experienced shortness of breath and anxiety due to the lack of communication and missed doses. The facility's policies on medication administration and resident notification were not followed, as confirmed by the nurse practitioner and Director of Nursing.
A resident with severe medical conditions had an IVCL dressing that was not changed as per the physician's order and facility policy, which required a change every 7 days. Multiple licensed nurses administered antibiotics through the IVCL without checking or changing the dressing, and the Director of Nursing confirmed the expectation for regular dressing changes to prevent infection.
A facility failed to properly discard a used syringe, which was left on a resident's bedside table. The resident, who was cognitively intact and had serious medical conditions, received an injection from a nurse who admitted to not disposing of the syringe in the sharps container. The DON confirmed that the expectation is for nurses to discard used syringes in sharps containers, as outlined in the facility's policy.
A facility failed to ensure call lights were within reach for four residents, leading to a deficiency in accommodating their needs. A resident with Parkinson's Disease and legal blindness, another with hemiplegia, and two others with cognitive impairments and fall risks were unable to access their call lights. Staff confirmed the call lights were not within reach, contrary to facility policies.
The facility failed to provide proper respiratory care for three residents, leading to deficiencies in oxygen therapy administration. A resident with COPD did not receive oxygen as ordered, resulting in shortness of breath. Another resident with acute respiratory failure was observed without the nasal cannula properly placed, risking low oxygen levels. A third resident with pneumonitis and congestive heart failure used a nasal cannula incorrectly and lacked an active physician's order for oxygen therapy.
The facility failed to ensure safe pharmaceutical services, with issues in controlled drug documentation, administration of expired medications, and improper storage of hazardous drugs. A resident missed cancer medication doses due to unavailability, and staff did not follow up with the pharmacy or notify the doctor. These deficiencies could lead to drug diversion and compromised resident care.
The facility failed to properly label and store medications, leading to the presence of loose pills, expired medications, and unlabeled opened medications in various medication carts. This resulted in the administration of expired medications to two residents and posed potential risks to others. Licensed nurses and the consultant pharmacist confirmed these deficiencies, which were not in accordance with the facility's policies and procedures.
A facility failed to ensure meal tray tickets matched the meals served to 11 residents, impacting their nutritional status and preferences. Despite documented dislikes for pork, residents were served pork loin, which was confirmed by the Dietary Manager Assistant. The residents had various medical conditions requiring dietary attention, and the facility's policy mandates meals consistent with resident preferences.
The facility failed to provide meals at appropriate temperatures and times, leading to resident dissatisfaction. Multiple residents reported receiving cold and late meals, particularly breakfast. Staff confirmed delays in meal service, and temperature checks showed food was not within recommended ranges. The facility's policies on meal service were not followed, impacting residents with chronic conditions.
The facility failed to comply with food safety standards, as staff did not wear hair nets or perform hand hygiene upon entering the kitchen. Additionally, expired food products were found in storage, posing a risk of foodborne illness to residents. The facility lacked a policy for handling expired food.
A long-term care facility failed to implement proper infection control measures, including the use of PPE by housekeeping staff, proper handling of linens, labeling and storage of urinals, and sanitization of shared medical equipment. These deficiencies were observed during a survey, highlighting potential risks for infection spread among residents.
The facility failed to document an injury for a resident with Alzheimer's and did not initiate physical therapy for another resident with muscle weakness and cerebral palsy. The injury was reported by family but not documented by an LPN, and the necessary insurance authorization for therapy was not obtained, leading to unmet nursing needs and potential decline in resident conditions.
A facility failed to ensure an accurate MDS assessment for a resident who was on oxygen therapy. The resident, admitted with conditions like pneumonitis and congestive heart failure, was inaccurately documented as not receiving oxygen therapy in the MDS assessment. This discrepancy was confirmed by the MDS Coordinator and noted by the DON, who both emphasized the importance of accurate assessments.
The facility failed to accommodate the beverage preferences of two residents. One resident, with diabetes and muscle weakness, was not served coffee during breakfast despite it being on the meal ticket. Another resident, with diabetes and Alzheimer's, preferred decaf coffee, which the facility did not provide. Staff acknowledged these preferences but did not fulfill them, citing reasons such as cost and lack of awareness.
The facility failed to maintain a clean environment for two residents, as their room had soiled privacy curtains and dirty windows. The residents reported infrequent cleaning, and the Resident Council's minutes noted similar complaints. Despite claims of daily cleaning, logs showed the room was last cleaned a week prior. The administrator could not provide a housekeeping policy.
The facility failed to report an abuse allegation involving a CNA and a resident within the required two-hour timeframe and did not submit an investigative summary within five working days. The incident was reported late to the Department, potentially delaying the investigation. The Administrator confirmed the delay but could not explain the late reporting, which was against the facility's policy.
A resident with a history of stroke and falls was admitted to the facility without a completed Fall Risk Assessment, leading to a lack of personalized interventions to prevent falls. The resident later experienced an unwitnessed fall resulting in injury. The DON revealed that the nurse filled out the wrong form, omitting the necessary assessment.
A resident was hospitalized with sepsis due to the facility's failure to ensure staff were aware of and monitored for UTI symptoms. Despite a physician's order, the resident was not properly monitored, leading to severe sepsis. Interviews revealed staff lacked understanding of UTI and sepsis symptoms, contributing to the oversight. The facility's policies on change of condition and UTI management were not effectively implemented.
The facility failed to implement its smoking policy and ensure supervision for two residents, both of whom were required to have supervised smoking sessions with their smoking materials stored by staff. Despite this, the residents kept their own smoking materials and sometimes smoked without supervision, posing a safety hazard. Staff interviews confirmed the policy requirements, but inconsistencies in enforcement were reported.
A resident with multiple health issues missed a medical appointment due to the facility's failure to arrange transportation and communicate with the resident and her responsible party. Despite the facility's policy, staff did not ensure transportation was secured, and the Director of Nursing did not inform the resident's family about the inability to attend the appointment.
The facility failed to implement its smoking policy and ensure supervision for two residents who required it. Despite having a policy that mandates staff supervision and storage of smoking materials, both residents reported smoking unsupervised and keeping their own cigarettes and lighters. Staff interviews confirmed these actions were against policy and posed safety risks. The deficiency highlights a failure to adhere to established protocols, compromising resident safety.
A resident missed a medical appointment due to the facility's failure to arrange transportation and communicate effectively with the resident and her responsible party. Despite the resident's daughter providing appointment details, the information was not relayed to the appropriate staff, resulting in no transportation being arranged. The Director of Nursing did not inform the resident's daughter that the appointment was unnecessary, leading to a missed opportunity for medical assessment.
A resident with chronic kidney disease and other conditions experienced altered mental status, including confusion and hallucination, but the facility failed to notify the physician or conduct a urinalysis to rule out a UTI. Despite the facility's policy requiring immediate physician consultation for significant changes, staff did not monitor the resident's mental status or suspect a UTI, leading to the resident's hospitalization with sepsis, acute UTI, and delirium.
A resident reported rough treatment by a CNA, but the facility delayed reporting the abuse allegation to authorities and did not immediately suspend the alleged staff. Despite staff understanding the need for timely reporting and suspension, the facility failed to act according to its policy, resulting in a deficiency.
A resident with cognitive impairments eloped from a facility during a smoking session due to inadequate supervision. The Activity Department, responsible for supervising smokers, lacked a set schedule or assignment, and the Wander Guard alarm was disarmed, allowing the resident to leave unnoticed. The facility could not provide a policy on smoking supervision, highlighting a procedural gap.
Failure to Separate Roommates After Suspected Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prevention policy after an incident of suspected resident-to-resident abuse. Resident 1, admitted in December 2025 with diagnoses including diabetes mellitus, depression, and mild cognitive impairment, was found on 4/11/26 during routine rounds by a licensed nurse (LN 1) with new left eye redness, scant bleeding, and a facial abrasion. At that time, Resident 2 was observed squatting or kneeling beside Resident 1’s bed and holding both of Resident 1’s arms. Resident 1 reported severe left eye pain rated 10/10, and was transferred to the emergency department for further evaluation, where injuries including a corneal abrasion and subconjunctival hemorrhage were later documented in the care plan. Resident 2 had been admitted in April 2026 with dementia, disorientation, and anxiety, and had a care plan initiated on 4/9/26 indicating risk for behavioral dysregulation with potential for unintended physical contact with others, impaired impulse control, poor safety awareness, and decreased ability to interpret the environment. Progress notes dated 4/12/16 documented that Resident 2 exhibited increased confusion and restlessness, attempted to aggressively attack his roommate (Resident 1), and then attempted to hit the LN and other staff, threw water at a CNA, and tried to swing at staff. The physician was called and advised transfer to the emergency department for further evaluation. Resident 2 was also described as confused and attempting to stand, walk to rooms, and hit residents. Despite the incident on 4/11/26 in which Resident 2 was found holding Resident 1’s arms and Resident 1 was noted with a new eye injury and facial abrasion, Resident 1 and Resident 2 continued to be roomed together after Resident 1 returned from the emergency department. LN 1 confirmed that the residents were not separated into different rooms following the incident. The Director of Nursing (DON) also confirmed that the two residents were not placed in separate rooms after the reported injury and stated she could not provide documentation that the residents were continually monitored by staff in the room after the incident. This was inconsistent with the facility’s Abuse Prohibition policy, which states that if suspected abuse is resident-to-resident, the resident who has threatened or attacked another will be removed from the setting or situation while an investigation is completed.
Failure to Timely Report Suspected Abuse Incident Between Roommates
Penalty
Summary
The facility failed to timely report an abuse-related incident involving two residents when a licensed nurse observed one resident in a compromising position over his roommate, who had a new eye injury. Resident 1, admitted with diabetes mellitus, depression, and mild cognitive impairment, was found during routine rounds in bed with Resident 2 squatting or kneeling beside the bed and holding Resident 1’s arms. Resident 1 was immediately assessed and noted to have new redness of the left sclera with scant bleeding of approximately 0.5 mL, a 0.5 cm abrasion on the left cheek, and severe left eye pain rated 10/10, leading to transfer to the ED for further evaluation. Resident 1’s care plan later documented minor facial abrasion, corneal abrasion, and subconjunctival hemorrhage related to this incident. Resident 2, admitted with dementia, disorientation, and anxiety, had a care plan indicating risk for behavioral dysregulation and potential for unintended physical contact with others. A progress note for Resident 2 described increased confusion and restlessness, with Resident 2 attempting to aggressively attack Resident 1 and then staff, throwing water at a CNA and trying to swing at staff, resulting in a physician order to send Resident 2 to the ED. The administrator confirmed that the incident involving the eye injury to Resident 1 was documented on 4/11/26 but not reported to authorities until 4/13/26, despite facility policy requiring immediate reporting within two hours for allegations involving abuse or resulting in serious bodily injury. The administrator acknowledged that the incident should have been reported within two hours, demonstrating the failure to follow the facility’s abuse, neglect, exploitation, or misappropriation reporting and investigating policy.
Failure to Ensure Accessible and Adequate Fluids for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were offered and had access to sufficient fluids to maintain hydration. One resident with severe cognitive impairment, dependent for eating, and care planned as being at nutritional risk and at risk for dehydration was repeatedly observed over several hours lying in bed with very dry lips and tongue, with only an empty, dry cup on the bedside table and no fluids available. During multiple observations throughout the late morning and early afternoon, no staff were seen offering or assisting this resident with fluids, despite the care plan interventions to encourage oral intake, offer fluids of choice, and monitor for signs and symptoms of dehydration such as dry mucous membranes and mental status changes. A licensed nurse stated that CNAs were expected to offer fluids and supplements every two hours and document intake according to any fluid or dietary restrictions. Another resident with end stage renal disease, muscle weakness, and kidney stones was observed with a water pitcher placed on an overbed table pushed against the window behind him; he stated he was unable to reach the pitcher and that he was thirsty. A third resident, with diagnoses including type 2 DM, need for assistance with personal care, chronic kidney disease, and anxiety disorder, was heard repeatedly calling out for water in Spanish from the hallway. When staff entered the room, the resident again requested water, and an empty water pitcher was observed on the overbed table; the resident continued to call out for water several minutes later, with the pitcher still empty. The facility’s policies on encouraging and restricting fluids and on resident hydration and prevention of dehydration state that staff should be supportive of fluid intake, take fluid containers to residents’ rooms, encourage residents to drink, and that nurse aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care.
Failure to Keep Call Lights Accessible to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call light buttons were accessible and within reach as required by policy and resident care plans. For one resident with end stage renal disease, muscle weakness, mobility abnormalities, and moderate cognitive impairment, the care plan identified fall risk and required the call light to be placed within reach while in bed or near the bed. During observation and interview, this resident stated he did not call for assistance because he did not have a call light button, while the surveyor observed the call light tied to the bed side rail next to him, indicating it was not readily identifiable or usable by the resident. Another resident with severe cognitive impairment, gait and mobility abnormalities, dementia, anxiety disorder, and need for assistance with personal care was observed with the call light button on the floor by the bedside table; the Director of Staff Development confirmed its location and stated call lights should be kept within reach. A third resident, with osteomyelitis of the right ankle and foot, hemiplegia and hemiparesis, muscle weakness, and dependence on staff for most ADLs, had a care plan identifying fall risk and requiring the call light to be within reach while in bed or near the bed. During observation, this resident reported having a call light but being unable to find it; the call light was on top of the bedside table and remained there later, with the resident again stating he could not find it and that no one had checked on him to provide it. The facility’s policy on answering call lights required that the call light be accessible to residents from the bed, toilet, shower or bathing facility, and from the floor, which was not followed in these instances.
Failure to Provide Required Repositioning and Incontinence Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically turning, repositioning, and incontinence care, for two residents who required extensive help. Resident 1’s admission record showed diagnoses including Type 2 diabetes mellitus, generalized muscle weakness, and morbid obesity. A recent MDS indicated intact cognition and a need for maximal assistance with turning and repositioning. The care plan, initiated in 2021, identified Resident 1 as at high risk for pressure ulcer development related to bladder and bowel impairment, impaired mobility, and obesity, with an intervention to turn and reposition at least every 2–4 hours, more often as needed. Despite this, observations on one survey day at 10:35 a.m., 11:00 a.m., 12:00 p.m., and 1:30 p.m. showed Resident 1 in bed on her back with the head of bed elevated, with no staff observed providing repositioning or incontinence care. Resident 2’s admission record documented diagnoses including UTI, need for assistance with personal care, and unspecified dementia. A recent MDS showed severe cognitive impairment and total dependence on staff for toilet hygiene and repositioning. Review of Resident 2’s care plan, revised in 2026, revealed no evidence of a person-centered care plan addressing toilet hygiene and repositioning needs. Observations on the same survey day at 10:30 a.m., 11:00 a.m., 12:00 noon, 1:30 p.m., and 2:00 p.m. showed Resident 2 lying flat on her back, with no incontinence care or repositioning assistance observed during these times. At 1:40 p.m., a CNA entered Resident 1’s room and performed incontinence care, but after completion at 1:51 p.m., Resident 1 remained in the same supine position with the head of bed at 60 degrees and no repositioning was provided. In an interview at 1:51 p.m., Resident 1 reported that the last incontinence care and repositioning before 1:40 p.m. had occurred at approximately 2:00 a.m., and confirmed she had not been changed or repositioned since then, stating that staff never turned her every 4 hours and that if she did not call, they would not come to help. Staff interviews with a CNA, an LN, and the DON confirmed the facility’s expectations that residents be turned and repositioned every 2–3 hours and that incontinent care be provided as needed, and facility policies required comprehensive, person-centered care planning and turning to prevent skin irritation and breakdown. These observations and interviews demonstrate that the facility did not follow the established care plan for Resident 1 and did not develop or implement an appropriate care plan for Resident 2 regarding toileting and repositioning.
Failure to Maintain a Safe, Clean, and Pest-Free Resident Environment
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to provide a safe, sanitary, and homelike environment for multiple residents when flies were observed in several resident rooms. One resident with major depressive disorder, anxiety disorder, muscle weakness, and inability to walk reported that there were bugs "everywhere" in her room; surveyors observed a small fly on her privacy curtain, several small flies hovering in the air, and several flies on the wall. Another resident’s room contained several flies flying in the room, including one on the lid of a cup. In a shared room occupied by three residents with diagnoses including dementia, failure to thrive, major depressive disorder, need for assistance with personal care, difficulty communicating, muscle weakness, and lack of muscle coordination, surveyors observed extensive fly activity. One resident’s bed was unmade, with a small black fly on the pillowcase, multiple flies on the privacy curtain and wall, and a sandwich in plastic wrap on the bedside table that had multiple small flies on and inside the wrapper, as well as flies on the speaker end of his phone and on his drinking cup. Another resident in the same room was lying in bed on sheets and a bedframe with a thick yellow dried substance on the sheets, bed frame, and pooled on the floor; numerous small black flies were on his mattress, bed frame, wall, privacy curtain, and gown, with one on his pillowcase and multiple flies slowly flying around his head. A third resident in that shared room was lying in bed and unable to answer questions, while multiple small black flies were observed on the privacy curtain and flying around. Staff interviews confirmed the unsanitary conditions. A CNA and the Housekeeping Manager both acknowledged the presence of flies on multiple surfaces, including the sandwich and phone of one resident and the mattress and pillow of another, and stated that it was not supposed to be like that. The Administrator, when brought to the shared room, confirmed the presence of multiple flies and stated, "It should not be like this." The Infection Preventionist, after being shown pictures of the flies, stated that her expectation was for residents to have a safe and clean environment to prevent infections and that flies could cause GI and respiratory issues. The Assistant DON, after viewing pictures of flies on a resident’s bed and clothing and the dried tan liquid on his sheets and bedframe, stated she would not expect to see that in the facility and that it was not good for someone with depression or for anyone. These conditions were inconsistent with the facility’s written policies on infection prevention and control, pest control, homelike environment, and resident rights.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled appropriately when surveyors found loose pills, non-medication items, bisacodyl suppositories, and a tube of triamcinolone cream in the 400 Even medication cart. In the 600 Hall medication cart, surveyors found a box of bisacodyl suppositories stored with oral medications and observed brownish residue in the first drawer. The DON stated the medication carts were expected to contain only medications, that non-medication items were not to be stored in the carts, and that the carts were to be kept clean and free of loose pills to prevent contamination and reduce the risk of infection. Surveyors also found expired OTC medications in medication room [ROOM NUMBER], including antacid liquid, diphenhydramine, probiotic acidophilus, antacid tablets, guaifenesin, senna, and nasal saline spray. The ADON verified the medications were expired. In addition, Resident 1, who was admitted with acute and chronic respiratory failure with hypoxia and had no memory impairment on the MDS, had two medications at the bedside without labels or original packaging and without a documented order or care plan for self-administration at bedside. The resident identified the calcium carbonate tablets and fluticasone nasal spray as her medications, and LN 3 confirmed there were no orders for bedside self-administration and acknowledged leaving the medications at the bedside.
Improper Storage of Frozen Food Items
Penalty
Summary
Food was not stored in accordance with professional standards in kitchen Freezer #1 for a census of 161 residents. During an observation and interview with the Dietary Manager, surveyors found 2 small plastic containers of ice cream with no open or use-by date, a bag of unsealed donut holes with a prep date of 10/30/29 and a use-by date of 11/30/25, a lemon cake with a prep date of 10/30/25 and a use-by date of 11/30/25, and a bag of flour tortillas in an unsealed and undated bag. The Dietary Manager confirmed the findings and stated that expired food should be thrown out and that food should be properly sealed. Review of the facility policy for cold food storage indicated that all foods will be stored in wrapped or covered containers, labeled and dated.
Residents Not Informed of Construction Noise; Food Discarded Before Required Holding Period
Penalty
Summary
The facility failed to respect residents’ rights when several residents were not informed in advance about roof construction and the loud noise associated with it. Resident 1, admitted with acute and chronic respiratory failure with hypoxia and with no memory impairment on MDS, stated the constant noise from the roof construction triggered anxiety and that the banging started before 8 a.m. daily for over two weeks. Resident 81, also admitted with acute and chronic respiratory failure with hypoxia and with no memory impairment, stated she was not told ahead of time about the construction, that the banging was very loud, and that it interfered with her ability to rest and nap. Resident 122, admitted with DM2 and severe cognitive impairment on MDS, stated she had difficulty sleeping at night and woke early because of the banging on the roof and did not know what was going on. Resident 67, admitted with DM2 and with no memory impairment on MDS, stated she was not informed ahead of time about the roof construction or the loud noise and that she had been restless since the work began. She stated the early start time was disruptive and that being heard and consulted about a better start time would have made her feel important and cared for. During a resident council meeting, residents were observed grimacing and frowning because of the loud noise, and they had to speak very loudly to be heard. The DON confirmed that residents have the right to be fully informed, including advance notice of changes affecting daily life such as disruptive construction noise. The facility also failed to respect residents’ rights when food brought in by family or residents was discarded before the required holding period. Resident 114, admitted with multiple diagnoses including CKD, stated his wife brought Thanksgiving food to the facility, he gave it to staff to label and date, and he watched it be placed in the resident refrigerator, but it was thrown away the next morning. Resident 68, admitted with multiple diagnoses including DM, stated he gave leftover food to LN 7 to label and place in the resident refrigerator, and that it was thrown away the next day. LN 7 verified she labeled and dated the food and stated the policy was to keep resident food at least 2 days before discarding it. The ADON, Administrator, and DON confirmed the refrigerator was emptied before 10 a.m., that policy was not followed, and that the incident affected residents’ dignity.
Infection prevention failures with respiratory equipment and urinary drainage devices
Penalty
Summary
The facility failed to ensure infection prevention measures were implemented for multiple residents with respiratory equipment and indwelling urinary catheters. During observation and interview, Resident 156’s nebulizer mask was found unbagged and undated on the bedside dresser. Resident 156 had COPD and moderate cognitive impairment, and the facility’s Infection Preventionist stated the mask should have been in a dated plastic bag. The facility policy for respiratory therapy stated the nebulizer circuit should be stored in a plastic bag marked with the date and resident’s name between uses. The facility also failed to keep urinary drainage equipment off the floor. Resident 93’s Foley bag was observed lying on the floor, and the CNA confirmed it should not have been there. Resident 20’s catheter tubing was observed on the floor, Resident 170’s catheter tubing and Foley bag were on the floor, and Resident 163’s catheter tubing and catheter bag inside a dignity bag were on the floormat. The Infection Preventionist stated catheter tubing and bags should not touch the floor because of the risk for transmission of bacteria or infection. A facility policy for prevention of infection for indwelling urinary catheters was requested but not provided. Additional respiratory equipment storage issues were observed for Resident 47 and Resident 81. Resident 47, who had asthma and was ordered CPAP and oxygen, had an open bottle of distilled water on the floor that was not dated, and oxygen tubing that was unlabeled when connected to a portable tank. The DON stated open distilled water should be stored on a clean surface and labeled with open and use-by dates, and oxygen tubing should be labeled with a date. Resident 81’s oxygen tubing was wrapped around the side rail and not placed in a secured storage bag when not in use. The Infection Prevention nurse stated oxygen tubing must be placed in a secured storage bag when not in use to prevent contamination.
Ineffective Pest Control Program With Gnats and Flies in Resident Areas
Penalty
Summary
The facility failed to implement an effective pest control program when gnats and flies were observed in multiple resident rooms and hallways. During observations on 12/2/25 and 12/3/25, gnats were seen flying around in several rooms at different times, and one room was observed to have both flies and gnats. During a concurrent observation on 12/2/25, four to five gnats were seen flying above Resident 9's head of bed, and CNA 4 confirmed this was a problem in the building. Residents and staff also reported that gnats were present throughout the facility, including in rooms and hallways. During interviews, CNA 1 stated, "Gnats are everywhere," and CNA 2 stated that gnats were everywhere in the building, including other rooms and hallways. Resident 63 stated they saw gnats all the time in their room and the hallway, and Resident 81 stated gnats were present every day and landed in food or water. The Maintenance Supervisor stated pest control treatment had only been performed in hallway 600 where gnats/pests were reported, and that no treatments were provided on other hallways. The Infection Preventionist stated gnats had been an issue in the building for three to four months. The facility policy titled Pest Control stated the facility shall maintain an effective pest control program and keep the building free of insects and rodents.
Failure to Provide and Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for one resident with hemiplegia affecting the right side. The resident was admitted in July 2024 with multiple diagnoses, including right-sided hemiplegia, and the care plan initiated on 7/15/25 included a restorative nursing program intervention for active range of motion to the right upper extremity three times a week. During interview, the RNA confirmed the resident should have received restorative nursing services three times a week for right upper hand range of motion and stated she did not provide those services that week. She also stated she was not sure whether another RNA had provided the services because there was no documentation available. Review of the medical record showed no documented evidence that the resident was offered RNA services from 7/15/25 through 12/4/25. The ADON and DON both confirmed there was no documentation indicating the resident received RNA services per the care plan, and the DON stated the expectation was for care plan interventions to be followed and documented.
Unsafe Bed Arrangement in Resident Room
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when two beds in Resident 93's room were situated side by side and put together. Resident 93 was admitted in December 2022 with diagnoses including aphasia following a cerebral infarction, monoplegia affecting the right dominant upper limb, need for assistance with personal care, and generalized muscle weakness. The resident's MDS dated 9/20/25 indicated severe cognitive impairment, and the care plan dated 5/18/24 noted behaviors of sliding down or crawling to the floor from a low bed and identified that the resident needed a safe environment. During a concurrent observation and interview on 12/4/25 at 9:18 a.m., an LN confirmed that bed A and bed B were situated side by side and put together in Resident 93's room. Later that day, the DON stated that the resident's family did not sign consent for the beds to be together and confirmed that Resident 93's bed was not locked. On 12/5/25, the RC acknowledged that Resident 93 could be at risk of entrapment with the current bed arrangement. The facility policy on Safety and Supervision stated that the facility strives to make the environment as free from accident hazards as possible and identified bed safety as a risk factor and environmental hazard.
Medication Record and IV Antibiotic Preparation Errors
Penalty
Summary
Pharmaceutical services were not maintained when a controlled medication record for a resident receiving hydrocodone acetaminophen 5/325 mg was not signed immediately after administration. During inspection of medication cart 400 with LN 5, the controlled drug count for the resident’s hydrocodone acetaminophen was found to be inaccurate, with five tablets present while the log indicated six. LN 5 stated she had given the medication at 11:34 a.m. and forgot to sign after administering it. The DON stated nurses were expected to sign the narcotic count record immediately after removing the medication from the bubble pack, and the facility policy required the licensed nurse to enter the date, time, amount administered, and signature at the time the medication was removed from the supply. Pharmaceutical services were also not maintained when LN 8 did not follow the correct dilution protocol for an IV antibiotic for a resident admitted with endocarditis and severe sepsis. The resident had an order for ceftriaxone sodium 2 gm IV every 12 hours and a separate one-time order for ceftriaxone sodium 1 gm. LN 8 stated she used a 2 gm vial instead of the expected 1 gm vial, reconstituted it with 10 mL of normal saline, withdrew 5 mL, discarded it, and infused the remaining 5 mL into the IV bag. The DON stated that if there were no instructions for preparing an IV antibiotic, the LN was expected to contact the pharmacist for guidance. The pharmacy vendor’s IV department pharmacist stated that to prepare a 1 gm dose from a 2 gm vial, the vial should have been reconstituted with 19.2 mL of normal saline and 10 mL withdrawn into a 50 mL normal saline bag, and confirmed the dose was not prepared accurately.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required two-hour timeframe after a resident reported inappropriate touching by another resident and a staff member. The resident, who had diagnoses including left and right hemiplegia and dysarthria but no memory impairment, informed the charge nurse that a male resident kissed her forehead while she was asleep and that an X-ray technician touched her inappropriately on her shoulder, forehead, and breast, and made inappropriate comments. Documentation showed that the report of suspected abuse was not received by the state agency until two days after the initial allegation was made to the charge nurse. Interviews with facility staff, including the administrator, CNA, and RN, confirmed that the resident reported the incident promptly and that facility policy required immediate reporting of abuse allegations, but this protocol was not followed. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency in the facility's response. The delay in reporting resulted in a delayed investigation of the allegations.
Failure to Timely Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to timely investigate and report the results of abuse allegations within five days as required by policy. A resident with left and right hemiplegia and dysarthria, but no memory impairment, reported to the charge nurse that another resident allegedly kissed her forehead while she was asleep and that a staff member, specifically an X-ray technician, touched her inappropriately on her shoulder, forehead, and breast, and called her beautiful. Documentation showed that the resident reported these incidents on 8/3/25, but the 5-day investigation letters for both the staff-to-resident and resident-to-resident allegations were not completed until 8/11/25, eight days after the initial report. Interviews confirmed that the administrator, who was the primary investigator, acknowledged the investigation was not conducted in a timely manner. The resident expressed feeling uncomfortable, ignored, and disappointed by the lack of urgency from the facility. Staff interviews indicated awareness of the protocol to report and document abuse allegations promptly, and a CNA observed the resident crying after the incident. The facility's policy required a written report of the investigation findings to be provided to the appropriate agencies within five working days of the incident, which was not met in this case.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of schizophrenia, who had a history of delusions and behavioral issues, eloped from the facility without staff knowledge or authorization. The resident's care plan, which was revised shortly before the incident, identified behavioral risks related to schizophrenia and included interventions to anticipate the resident's needs. Despite these measures, the resident was able to leave the premises unsupervised. Interviews with facility staff revealed that the receptionist noticed the resident was missing from the front patio and subsequently notified other staff, but was unsure how long the resident had been absent. The Director of Nursing acknowledged both the risk of elopement due to the resident's mental health condition and the facility's responsibility to provide adequate supervision. Review of facility policy confirmed that residents at risk for elopement should receive appropriate supervision in accordance with their care plan, which was not effectively implemented in this case.
Late Medication Administration, Improper Disposal, and Inaccurate Documentation
Penalty
Summary
A Licensed Nurse failed to follow facility policy and professional standards by administering a resident’s scheduled medications four hours late, improperly disposing of a refused medication, and inaccurately documenting medication administration. The nurse gave the resident her 8 a.m. and 9 a.m. medications at 1:40 p.m., and when the resident refused MiraLAX, the nurse disposed of it in the trash instead of using the designated drug disposal system. The nurse then documented in the Medication Administration Record (MAR) that all medications, including the refused MiraLAX, were given at the scheduled times, rather than reflecting the actual time of administration and the refusal. The resident involved had a medical history including rhabdomyolysis, bariatric surgery status, and hypomagnesemia, and was admitted in January 2025. Facility leadership, including the DON and ADON, confirmed that the nurse did not follow physician orders, failed to notify the physician of the refusal, and did not adhere to the facility’s medication disposal policy. Review of the MAR and interviews confirmed the discrepancies in documentation and medication handling.
Plan Of Correction
Services Provided Meet Professional Standards Corrective Action(s): On 04/24/2025, LN 1 had a discussion with Resident 1 regarding her medication time preferences and notified the physician, resulting in a change to the medication administration schedule. On 04/24/2025, the Assistant Director of Nursing initiated an eLenteract CIC to evaluate Resident 1 for any undesired effects of medications that were not given timely and notified the physician. On 04/24/2025, the Director of Nursing re-educated LN 1 regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. Identification of other residents at risk: On 04/24/2025, the Assistant Director of Nursing checked if any other residents did not receive medications at the scheduled time, and no other residents were affected by this deficiency. Systemic Changes: On 05/08/2025, the Director of Staff Development will re-educate staff regarding the Policy and Procedure of Physician Orders, Discarding and Destroying Medications, Administering Medications, Medication Errors, and Nursing Documentation. The Director of Staff Development or designee will weekly skills check the Licensed nurses for Medication Observation Pass, including discarding and destroying medications, until competency is met. Monitoring: The Director of Staff Development or designee will report the results of the Licensed Nurses' skills checks for Medication Observation Pass, including discarding and destroying medications, to the Director of Nursing for further intervention if needed. The Director of Staff Development will report the findings and trends of the Medication Observation Pass, including discarding and destroying medications, to the QAPI committee monthly for three months or until compliance is met. Compliance Date: 05/08/2025
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source within the required timeframe for one of the five sampled residents, identified as Resident 2. The incident involved Resident 2 sustaining a broken left wrist on March 20, 2025, which was reported to the California Department of Public Health (CDPH) the following day, March 21, 2025. During an interview on March 28, 2025, the Director of Nursing (DON) and Administrator (ADM) admitted they were unaware that such an injury, resulting in serious bodily harm, should have been reported within two hours. A review of the facility's policy and procedure on abuse, neglect, exploitation, or misappropriation indicated that injuries of unknown source should be reported within two hours of occurrence if they result in serious bodily injury.
Failure to Label Residents' Clothing
Penalty
Summary
The facility failed to ensure respect and dignity for two residents by not labeling their clothing, which had the potential to result in the loss of their personal possessions. Resident 4, who was admitted in October 2024 and is cognitively intact, reported issues with clothing being lost after being sent to the facility laundry, specifically mentioning the loss of two pairs of grey sweatpants. During an interview, a Certified Nursing Assistant (CNA) acknowledged the issue of missing laundry when clothing was not labeled, and the Laundry Supervisor confirmed that clothing should be inventoried and labeled upon admission and when new clothes are brought in. Additionally, during observations, the Director of Staff Development (DSD) confirmed that several items of clothing belonging to Resident 7, who was admitted in December 2021 with osteoarthritis, were not labeled. The facility's policy and procedure on personal clothing, revised in June 2016, requires all clothing to be labeled and for staff to ensure that any clothing brought in by families is labeled properly. The facility's policy on Resident's Rights, dated February 2021, emphasizes the residents' rights to be treated with respect, kindness, and dignity.
Failure to Safely Administer Medications
Penalty
Summary
The facility failed to administer medications safely and in accordance with professional standards for one resident. The resident was found with unattended medications on his bedside table, which included controlled substances. The resident, who was cognitively intact and had no memory issues, reported that nurses had been leaving his medications without observing him take them. There were no care plans or physician orders allowing the resident to self-administer medications. Licensed Nurse 1 confirmed that she had provided the medications earlier and was supposed to supervise the resident taking them, but failed to do so. The Director of Nursing acknowledged that the resident had not been assessed for self-administration and that leaving medications unsupervised was unacceptable. The facility's policy requires medications to be administered according to prescriber orders and for staff to observe residents taking their medications, which was not followed in this instance.
Infection Control Breach Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as observed during a survey involving a licensed nurse (LN 1) and a resident. LN 1 did not perform hand hygiene after leaving a resident's room, which is a critical step in preventing the spread of infections. The incident occurred when LN 1 was administering medications to the resident. LN 1 placed medication bubble packs on the resident's bed and compared them with medication cups on the bedside table. After completing this task, LN 1 left the room without conducting hand hygiene and returned the medication bubble packs to the medication cart, acknowledging the increased risk of infection spread due to this action. The Director of Nursing (DON) confirmed that staff are required to perform hand hygiene upon exiting residents' rooms and acknowledged that returning medication packs that had been in contact with surfaces inside the resident's room to the medication cart posed a risk of cross-contamination. The facility's policies and procedures on administering medications and hand hygiene emphasize the importance of following infection control procedures, including handwashing before and after contact with residents and after contact with contaminated surfaces. The failure to adhere to these procedures decreased the facility's potential to prevent the spread of infections among residents.
Failure to Follow Droplet Isolation Precautions and PPE Protocols
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols for droplet isolation precautions. During observation, a housekeeping staff member exited a droplet isolation precaution room while still wearing an N95 mask, gown, and gloves, and then removed the used gloves and gown in the hallway where other staff and residents were present. The staff member confirmed awareness of the room's isolation status and acknowledged removing the PPE outside the room, contrary to facility policy, which requires removal and disposal of gloves and gowns before leaving the resident room or care area. Additionally, both the housekeeping staff and a certified nurse assistant (CNA) exited the same droplet isolation precaution room without changing their used N95 masks. Both staff members confirmed in interviews that they did not change their masks after leaving the room, despite facility policy stating that disposable respirators must be removed and discarded after exiting the resident's room or care area. Furthermore, the CNA entered the droplet isolation precaution room and assisted a resident who had tested positive for COVID-19 without wearing any eye protection, such as a face shield or goggles. The CNA confirmed this omission during an interview, and the infection preventionist and director of nursing both stated that eye protection is required when providing care to residents with confirmed COVID-19. Facility policy also specifies that eye protection must be applied upon entry to the resident room or care area.
Failure to Notify Physician of Resident's Refusal of Ordered Tests
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's physician after the resident refused a blood draw and diagnostic tests, despite having physician orders for these procedures. The resident, who had diagnoses including metabolic encephalopathy, diabetes mellitus, and dementia, was assessed as having severely impaired cognition with a BIMS score of 6 out of 15. The care plan required monitoring changes in cognitive status and notifying the physician as needed. However, documentation showed that while the resident's responsible party was informed of the refusals, there was no evidence that the physician was notified. The Director of Nursing confirmed during record review that the physician had not been informed of the resident's refusal of the ordered laboratory and diagnostic tests. Facility policy required the attending physician to be involved in monitoring changes in the resident's medical status and to be notified regarding care, diagnostic tests, and treatment. The lack of communication with the physician meant the resident's care was not properly supervised as required.
Failure to Complete and Document Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide quality and timely laboratory services for one resident when laboratory tests ordered on two separate occasions were not completed. The resident, who was admitted in January 2024, had multiple diagnoses including metabolic encephalopathy, diabetes mellitus, and dementia, and was assessed as having severely impaired cognition. Physician orders for a series of laboratory tests, including CBC, CMP, HBA1C, Vitamin D, TSH, and lipid panel, were documented on two dates, but there was no evidence in the clinical record or progress notes that these tests were performed or that results were obtained. During interviews, the responsible party confirmed that the resident's laboratory tests were not being done, and the DON acknowledged that the facility did not have the results and was unaware if the tests had been completed or why the results were missing. Facility policy required that all physician-ordered laboratory tests be completed and results reported to the physician, but this was not followed in this case.
Failure to Administer Diuretic Medication and Inform Resident of Changes
Penalty
Summary
The facility failed to provide quality care and treatment for a resident with congestive heart failure, who was not informed of changes to her diuretic medication and did not receive the medication as prescribed. The resident, who had intact cognition, was admitted with multiple diagnoses including congestive heart failure, which can cause leg swelling. The resident's care plan indicated that she should not experience signs of fluid overload, and her medication administration record showed she was to receive a diuretic twice daily. However, the resident did not receive her medication from February 14 to February 18, as evidenced by the lack of nurse initials on the medication administration record. The resident expressed anxiety over sudden medication changes and reported shortness of breath and wheezing. The nurse practitioner confirmed that the resident missed doses and that the medication should have been resumed after a temporary increase. The licensed nurse acknowledged receiving the new order but failed to document the changes or notify the resident. The Director of Nursing stated that licensed nurses are expected to ensure orders are correct, administered, and documented, and that residents are notified of medication changes. The facility's policies require documentation of physician orders, changes in condition, and notification of residents, which were not followed in this case.
Failure to Change IVCL Dressing as Ordered
Penalty
Summary
The facility failed to adhere to the physician's order for changing the dressing around an Intravenous Central Line (IVCL) every 7 days for a resident. The resident, who was admitted with severe medical conditions including necrotizing fasciitis, severe sepsis with septic shock, and gangrene, had an IVCL dressing that was not changed since the date of admission. This oversight was confirmed during an observation and interview with a licensed nurse, who acknowledged that the dressing should have been changed according to the facility's policy and procedure to prevent infection. Multiple licensed nurses administered antibiotics through the resident's IVCL without checking or changing the dressing, as required by the physician's order and facility policy. The Director of Nursing also confirmed the expectation for registered nurses to change the dressing every 7 days. The facility's policy clearly outlined the responsibility of licensed nurses to document and implement physician orders, including the timely change of IVCL dressings to prevent potential infections.
Failure to Properly Discard Used Syringe
Penalty
Summary
The facility failed to properly discard a used syringe for one of the residents, which was observed on the resident's bedside table. This incident involved a resident who was admitted with serious medical conditions, including necrotizing fasciitis, severe sepsis with septic shock, and gangrene. The resident was cognitively intact, as indicated by the Brief Interview for Mental Status (BIMS). During an observation and interview, a licensed nurse admitted to administering an injection to the resident and leaving the used syringe on the bedside table instead of discarding it in the designated sharps container. The Director of Nursing (DON) confirmed that the expectation for nurses is to dispose of used syringes in sharps containers. The facility's policy and procedure for subcutaneous injections, revised in March 2011, also specified that a sharps container should be used to discard uncapped needles and syringes. The failure to follow this procedure had the potential to cause injury to the resident and staff due to accidental needle sticks.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating their needs and preferences. Resident 11, who was legally blind and had Parkinson's Disease, was unable to locate or reach her call light on multiple occasions. Despite being a fall risk, her call light was either at the head of her bed or wrapped around the bed's side rail, making it inaccessible. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged that Resident 11 could not see or reach the call light. Resident 96, who had hemiplegia affecting the left side of her body, was also unable to reach her call light, which was found on the floor next to her bed. She required substantial assistance with activities of daily living and had an impairment in upper and lower range of motion. During an observation, a CNA confirmed that the call light was not within Resident 96's reach, which was contrary to the facility's policy and procedure that emphasized the importance of having call lights within reach. Similarly, Resident 28 and Resident 234 experienced issues with inaccessible call lights. Resident 28, who had dementia and a history of falls, was found with her call light button on the floor, out of reach. Resident 234, with moderately impaired cognition and a history of falls, had his call light hanging on the back side of his bed, making it unreachable. Both residents expressed their inability to reach the call lights, and staff confirmed these observations. The facility's policies clearly stated that call lights should be within residents' reach, yet this was not adhered to, leading to the deficiency.
Deficiencies in Oxygen Therapy Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy administration. Resident 11, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), did not receive oxygen as ordered, resulting in shortness of breath. The resident's care plan required oxygen therapy at 2 liters per minute via nasal cannula, but during an observation, the resident was found without the nasal cannula and reported not receiving oxygen for the past 30 minutes. A Certified Nursing Assistant confirmed the absence of oxygen delivery, which contradicted the physician's orders and the facility's policy on oxygen administration. Resident 280, admitted with acute respiratory failure and severe cognitive impairment, was observed without the nasal cannula properly placed, despite being on continuous oxygen therapy as per physician orders. The nasal cannula was found under the resident's chin, and the Infection Preventionist confirmed the improper placement, acknowledging the risk of low oxygen levels and shortness of breath. The resident's care plan lacked documentation for oxygen therapy initiation upon admission, further highlighting the facility's oversight in ensuring proper respiratory care. Resident 254, with diagnoses including pneumonitis and congestive heart failure, was using a nasal cannula incorrectly, with the prongs not inserted into the nose. The resident had no active physician's order for oxygen therapy from the time of admission until the observation date. The Director of Nursing confirmed the absence of a physician's order and emphasized the necessity of having such orders as part of professional standards. The facility's policy required verification of a physician's order for oxygen therapy, which was not adhered to in this case.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for its residents, as evidenced by several deficiencies in medication management. Controlled drugs for two residents were not properly documented in their Medication Administration Records (MAR) after being signed out from the Controlled Drug Record (CDR), and another resident's controlled drug use was inaccurately recorded. This lack of documentation could lead to discrepancies in drug accountability and potential drug diversion. The Director of Staff Development and the Consultant Pharmacist confirmed these findings, emphasizing the importance of accurate documentation for controlled drug handling. Additionally, the facility administered expired medications to two residents. One resident received 15 doses of insulin past its discard date, while another resident received 16 doses of expired buspirone. The Licensed Nurses confirmed these observations during medication cart inspections, acknowledging that administering expired medications could negatively affect the residents' health. The facility's policies and procedures require the removal and disposal of outdated medications, but these were not followed, leading to the administration of ineffective medications. Furthermore, hazardous medications were stored without proper labeling, and a resident missed two doses of a critical cancer medication due to unavailability. Valproic Acid, a hazardous drug, was found without a warning label, which is necessary for safe handling by nursing staff. The Director of Nursing and the Consultant Pharmacist confirmed the need for proper labeling to ensure safety. Additionally, a resident's cancer medication was not administered for two days, and there was no documented follow-up with the pharmacy or notification to the doctor about the missed doses. This oversight could increase the resident's risk for infection and compromise their treatment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored according to their policies and procedures, as well as accepted professional principles. During inspections of various medication carts, surveyors found loose pills in the 100, 700, and 400-Odd Hallway medication carts. Licensed nurses confirmed the presence of these loose pills and acknowledged that they were unsure of the medications' identities, which posed a risk of diversion and potential harm to residents. Additionally, the facility did not adhere to proper storage protocols for insulin and other medications. Two opened insulin medications past their discard dates were found in the 100 Hallway medication cart, and an expired bubble pack of buspirone was discovered in the 300 Hallway medication cart. These expired medications were confirmed by licensed nurses and the consultant pharmacist as unsafe for administration to residents, yet they remained in the carts, leading to the administration of expired medications to residents. Furthermore, the facility failed to label medications with opened dates, which is crucial for determining when they should be discarded. Five eye medications, an insulin, and three semaglutide medications in the 300 Hallway medication cart lacked opened date labels. This oversight was confirmed by licensed nurses and the consultant pharmacist, who emphasized the importance of labeling to ensure medications are discarded after 28 days of opening. The facility's policies and procedures clearly outlined the need for proper labeling and storage, yet these were not followed, resulting in potential risks to resident safety.
Inaccurate Meal Tray Tickets Impact Resident Preferences
Penalty
Summary
The facility failed to ensure that meal tray tickets for 11 sampled residents were accurate and followed, which had the potential to negatively impact their nutritional status and meal preferences. During an observation and interview with the Dietary Manager Assistant (DMA), it was noted that the meal tray tickets did not match the meals served to the residents. Specifically, pork loin was served for lunch, despite all 11 residents having indicated a dislike for pork on their meal tray tickets. The DMA acknowledged that the facility's system had not been updated to reflect the correct meals on the tray tickets. The residents involved had various medical conditions, including hypertensive heart and chronic kidney disease, severe sepsis with septic shock, acute posthemorrhagic anemia, pulmonary hypertension, congestive heart failure, anemia, atherosclerotic heart disease, and spinal stenosis. These conditions necessitate careful attention to dietary preferences and restrictions to maintain their health. The failure to adhere to the meal tray tickets meant that the residents were not provided meals consistent with their documented preferences, which could potentially affect their health and well-being. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the meal tickets and the meals served should match. The facility's policy, titled 'Resident Food Preferences,' also indicated that the Dietary Department is responsible for providing meals consistent with residents' preferences as indicated on their tray cards. This discrepancy between the meal tickets and the meals served represents a deficiency in the facility's adherence to its own policies and procedures.
Deficiency in Meal Service Temperature and Timing
Penalty
Summary
The facility failed to provide palatable, attractive, and appetizing food at preferred temperatures for eight residents. Residents reported that meals, particularly breakfast, were consistently served cold and late. Observations confirmed that food temperatures were below recommended levels, with hot foods being served cold and cold foods not being adequately chilled. This issue was corroborated by multiple residents and staff members, who noted dissatisfaction with the meal service. Several residents, including those with chronic conditions such as diabetes, chronic kidney disease, and end-stage renal disease, expressed dissatisfaction with the quality and temperature of the food. Interviews with residents revealed that meals were often served late, with breakfast sometimes arriving as late as 10 a.m., well past the scheduled meal service times. Staff members, including a Licensed Nurse and a Certified Nursing Assistant, confirmed that meal carts were frequently delayed, leading to complaints from residents about hunger and cold food. The Registered Dietician and Director of Nursing acknowledged the issues with meal service timing and food temperature, confirming that meals were not served according to the facility's policy and procedure. Temperature checks conducted during a test tray service further validated the residents' complaints, showing that food temperatures were not within the recommended range. The facility's policies on meal service times and food safety were not adhered to, contributing to the residents' dissatisfaction and potential health risks.
Non-compliance with Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Several staff members, including the Maintenance Director, Registered Dietician, a food delivery driver, and the Dietary Manager Assistant, did not comply with the facility's policy on hygiene and sanitary practices. Specifically, these individuals entered the kitchen without wearing hair nets or performing hand hygiene, which is a requirement to prevent contamination and ensure infection control. The Maintenance Director and Registered Dietician acknowledged their failure to wash hands upon entering the kitchen, while the Dietary Manager Assistant confirmed that the delivery driver should have worn hair and facial hair nets. Additionally, the facility was found to have expired food products in both the walk-in freezer and dry storage room. Items such as mayonnaise, cilantro, corn meal, iced tea, and raisins were either unlabeled or past their expiration dates, posing a risk of foodborne illness to residents. The Dietary Manager Assistant admitted that these items should have been discarded and could not explain how the expiration dates were overlooked. The facility lacked a specific policy and procedure for handling expired food products, further contributing to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention measures, as evidenced by several observations. Housekeeping staff did not wear the required Personal Protective Equipment (PPE) when cleaning a room under Enhanced Barrier Precautions, despite clear signage and policy requirements. The housekeeper admitted to bypassing the sign and acknowledged the mistake. The Infection Preventionist confirmed that the expectation was for staff to wear PPE in such situations. Additionally, a Certified Nursing Assistant (CNA) was observed placing dirty linen into a clean linen storage closet, which could lead to cross-contamination. The CNA admitted to forgetting to use a plastic bag for the linens and confirmed the error. The Infection Preventionist highlighted the risk of microorganisms being transferred back to residents due to this oversight. Further deficiencies included the improper storage of urinals without labels or dates, posing a risk of cross-use among residents. Personal items were found stored in medication carts, which could contaminate medications. Lastly, a shared glucometer was not sanitized properly between uses on different residents, as it was not kept wet for the required two minutes with germicidal wipes. These actions collectively increased the potential for infection spread among the resident population.
Failure to Document Injury and Initiate Physical Therapy
Penalty
Summary
The facility failed to ensure that Resident 103 received care meeting professional standards when an injury of unknown origin was reported by the family but not documented in the nursing notes until the following day. Resident 103, who was admitted with Alzheimer's Disease and severe memory impairment, had a bruise on her right forearm that was not documented in the body check assessment or weekly summary by Licensed Nurse 2 (LN 2). The Director of Nursing (DON) acknowledged that the bruise was a change of condition that should have been documented and communicated to the family and physician, as per the facility's policy. Additionally, the facility did not obtain authorization for physical therapy treatment for Resident 97, who was admitted with multiple diagnoses including muscle weakness and cerebral palsy. Despite a physician's order for physical therapy due to weakness, the therapy was not initiated because the facility failed to follow up on obtaining the necessary insurance authorization. The physical therapist confirmed that Resident 97 was not on the therapy caseload, and the Clinical Coordinator (CC) admitted that the facility did not follow up on the order, resulting in the resident not receiving the needed therapy. These failures resulted in inaccurate assessment documentation for Resident 103 and had the potential to result in unmet nursing needs. For Resident 97, the lack of physical therapy had the potential to cause a decline in activities of daily living and worsening weakness, as the resident expressed concern about becoming bedbound without continued activity. The facility's policies on skin integrity management and notification of change of condition were not adhered to, leading to these deficiencies.
Inaccurate MDS Assessment for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 254, upon admission. The resident was admitted in November 2024 with several diagnoses, including pneumonitis, hemiplegia, hemiparesis, and congestive heart failure. Despite being on oxygen therapy at 2 liters per minute via nasal cannula, the resident's MDS assessment inaccurately indicated that the resident did not receive oxygen therapy upon admission or while residing in the facility. The inaccuracy was confirmed during a review of the resident's clinical records and an interview with the MDS Coordinator, who acknowledged the mistake and stated that MDS assessments should accurately reflect the resident's status. The Director of Nursing also emphasized the expectation for timely and accurate MDS assessments. The facility's policy on resident assessments, revised in October 2023, mandates that MDS assessments consistently reflect information in progress notes, care plans, and resident observations or interviews.
Failure to Accommodate Resident Beverage Preferences
Penalty
Summary
The facility failed to provide food that accommodates the needs and preferences of two residents. Resident 130, who was admitted in November 2024 with diagnoses including diabetes mellitus and muscle weakness, was not served coffee during a breakfast meal despite it being listed on his meal ticket. Resident 130, who had intact cognition, expressed frustration over not receiving coffee consistently, which was confirmed by a Licensed Nurse and the Director of Nursing, both acknowledging that coffee should have been served as per the meal ticket. Resident 240, admitted in November 2024 with diagnoses including diabetes mellitus and Alzheimer's disease, expressed a preference for decaffeinated coffee, which the facility did not provide. The resident, with moderately impaired cognition, had informed staff of this preference, but the facility only served regular coffee. The Registered Dietician was aware of the preference but was unsure if decaf coffee had been ordered. The Dietary Manager Assistant was unaware of the preference and cited cost as a reason for not ordering decaf coffee, despite acknowledging that resident preferences should be honored.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for Residents 2 and 3, as evidenced by soiled privacy curtains and dirty windows in their shared room. Resident 2 reported that their room was not cleaned daily, and they were fortunate if it was cleaned twice a week. Both residents confirmed the lack of regular cleaning, and Resident 2 noted that the privacy curtains had not been washed in months. The Resident Council's minutes from August 2024 also documented complaints about room cleanliness. Despite the Housekeeping Director's claim that rooms were cleaned daily, logs showed that the last cleaning for Residents 2 and 3's room occurred on 8/23/24. The facility's administrator was unable to provide a housekeeping policy and procedure when requested.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe to the Department and did not submit an investigative summary within five working days. The incident involved a Certified Nursing Assistant (CNA) verbally abusing a resident on October 12, 2023. The facility became aware of the abuse allegation on the same day but reported the incident to the Department via voicemail on October 14, 2023, and faxed the SOC 341 form on October 16, 2023. This delay in reporting had the potential to hinder the Department's timely investigation of the abuse allegation. Furthermore, the facility's investigative report, dated October 20, 2023, was not faxed to the Department until October 25, 2023. During interviews conducted on August 29 and 30, 2024, the Administrator confirmed the details of the SOC 341 and the investigative report but could not provide an explanation for the late reporting and submission. The facility's policy, dated February 23, 2021, clearly stated that all allegations of abuse should be reported within two hours and an investigative report submitted within five working days, which was not adhered to in this case.
Failure to Complete Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to complete a Fall Risk Assessment for one of the residents prior to developing interventions to reduce the risk of falls. This deficiency was identified during a review of the facility's records and interviews with staff. The resident in question was admitted to the facility with a history of stroke, encephalopathy, previous falls, and difficulty walking, which necessitated assistance with personal care. Despite these conditions, no Fall Risk Assessment was completed for the resident, which is a critical step in identifying appropriate interventions to prevent falls. The deficiency was discovered after the resident experienced an unwitnessed fall, resulting in an injury that required hospital evaluation. During an interview, the DON explained that the nurse responsible for the resident's admission mistakenly filled out the wrong report form, omitting the necessary Fall Risk Assessment. The facility's policy mandates that fall risk assessments be conducted upon admission and after any fall incidents, but this protocol was not followed in this case, leading to a lack of personalized fall prevention strategies for the resident.
Failure to Monitor and Recognize UTI and Sepsis Symptoms
Penalty
Summary
The facility failed to ensure that staff were adequately trained and aware of the symptoms and risks associated with sepsis and urinary tract infections (UTIs). This deficiency was highlighted by the case of a resident who was hospitalized due to sepsis. The resident, who had intact cognition and required assistance with activities of daily living, was not properly monitored for signs and symptoms of a UTI, despite a physician's order to do so. The lack of monitoring and awareness among staff led to the resident developing severe sepsis, which was confirmed upon hospitalization. Interviews with various licensed staff members revealed a general lack of understanding and vigilance regarding the symptoms of UTIs and the progression to sepsis. Staff members acknowledged that some residents might not present with classic UTI symptoms, yet they failed to monitor residents closely for subtle changes in condition, such as altered mental status or general malaise. The staff's failure to recognize these signs and take appropriate action contributed to the resident's condition worsening to sepsis. The Director of Staff Development confirmed that the resident was transferred to the emergency department due to altered mental status and that no urinalysis was conducted to check for a UTI. The facility's policies on change of condition and UTI management were not effectively implemented, as evidenced by the lack of immediate consultation with a physician and failure to identify and treat the infection in a timely manner. The absence of a provided policy and procedure for sepsis further underscores the facility's deficiency in managing and preventing such critical conditions.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and follow the smoking interventions identified in the Smoking Risks Assessment form and smoking care plan for two residents. Both residents were required to have supervised smoking sessions, and their smoking materials were to be kept by the facility staff. However, it was observed that these protocols were not consistently followed, leading to a safety hazard. Resident 1, who has diagnoses including Bipolar disorder, Heart Failure, and COPD, was found to be keeping her own smoking materials and sometimes smoked without staff supervision, contrary to her care plan which required supervision and storage of smoking materials by the nursing station. Similarly, Resident 2, diagnosed with Multiple Sclerosis and Quadriplegia, also kept his own cigarettes and lighter and smoked without supervision, despite his care plan indicating the need for staff supervision and storage of smoking materials by the Social Services office. Interviews with various staff members, including licensed and unlicensed personnel, confirmed that the facility's policy required staff supervision during smoking and that residents were not allowed to keep their smoking materials. The Director of Nursing also confirmed these requirements. Despite this, both residents reported inconsistencies in supervision, and staff interviews revealed that the facility's smoking policy was not consistently enforced, posing a risk of accidents, burns, and injuries.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident attended her medical appointment, which was crucial for assessing her ongoing health issues. The resident, who had diagnoses including hyperlipidemia, major depression, and anxiety, required assistance with activities of daily living. Despite the facility's policy to arrange transportation for medical appointments, the resident and her responsible party were not informed that transportation could not be secured, leading to a missed appointment. Interviews with various staff members revealed a breakdown in communication and adherence to policy. Unlicensed staff and social services assistants confirmed that the facility was responsible for arranging transportation and notifying residents or their responsible parties if transportation could not be arranged. However, the social services assistant did not receive the necessary appointment information from the Director of Nursing (DON), resulting in no transportation being arranged for the resident's appointment. The DON acknowledged receiving the appointment information from the resident's daughter but failed to communicate this to the necessary parties or arrange transportation. Furthermore, the DON did not inform the resident's daughter that the appointment would not be attended due to transportation issues. This lack of communication and failure to follow the facility's policy led to the resident missing a potentially important medical appointment, which could have addressed her health concerns.
Failure to Implement Smoking Policy and Supervision
Penalty
Summary
The facility failed to implement its smoking policy and follow the smoking interventions identified in the Smoking Risks Assessment form and smoking care plan for two residents. Resident 1, who has diagnoses of Bipolar disorder, Heart Failure, and Chronic Obstructive Pulmonary Disease, was assessed to require supervised smoking. However, she reported keeping her own smoking materials and sometimes smoking without staff supervision, contrary to the facility's policy. Similarly, Resident 2, diagnosed with Multiple Sclerosis, Quadriplegia, and Muscle Weakness, also required supervised smoking but admitted to keeping his own cigarettes and lighter and smoking without supervision at times. Interviews with various staff members, including licensed and unlicensed staff, confirmed that the facility's policy required residents to be supervised while smoking and that smoking materials should be kept by the staff. Despite this, both residents reported instances where they smoked unsupervised and retained their smoking materials, indicating a failure to adhere to the policy. Staff members acknowledged that these actions were against the facility's policy and posed safety risks, including potential accidents, burns, and injuries. The Director of Nursing and other staff confirmed the facility's responsibility to supervise residents during smoking and to keep their smoking materials for safety reasons. The facility's policy, effective since August 2022, emphasized the need for reasonable precautions and a safe environment for residents who smoke, including individualized plans for safe storage and supervision. The failure to follow these protocols was identified as a deficiency, posing a safety hazard to the residents involved.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that Resident 1 attended her medical appointment, which was crucial for assessing her ongoing health issues, including bouts of diarrhea. Despite the resident's daughter providing the appointment details to the Director of Nursing (DON), the information was not effectively communicated to the Social Services Assistant responsible for arranging transportation. As a result, no transportation was arranged, and the resident missed her appointment. Interviews with various staff members, including unlicensed staff, social services assistants, and licensed staff, revealed a lack of communication and adherence to the facility's policy regarding transportation arrangements. Staff members acknowledged that the facility should have arranged transportation and communicated any issues to the resident or her responsible party (RP). However, this did not occur, leading to the resident missing her medical appointment. The DON admitted to receiving the appointment information but failed to communicate it effectively to ensure transportation was arranged. Furthermore, the DON did not inform the resident's daughter that the appointment was deemed unnecessary due to the resident's status as a [Medical Organization] recipient. This lack of communication and failure to arrange transportation resulted in the resident missing a potentially important medical assessment, which could have addressed her symptoms and prevented them from worsening.
Failure to Notify Physician and Conduct Urinalysis for Resident with Altered Mental Status
Penalty
Summary
The facility failed to adhere to its Change of Condition policy and professional standards of practice in diagnosing a Urinary Tract Infection (UTI) for a resident, leading to a significant health decline. The resident, who had a history of chronic kidney disease, hyperlipidemia, and depression, exhibited altered mental status, including confusion, hallucination, and agitation. Despite these symptoms, the facility staff did not immediately notify the physician or conduct a urinalysis to rule out a UTI, which is a standard procedure for such symptoms. Interviews with licensed staff revealed that the resident's confusion and hallucination were new symptoms, yet there was no documentation indicating that the physician was notified of these changes. The staff confirmed that they were not monitoring the resident's mental status for several days and did not suspect a UTI, despite the resident's acute change in condition. The facility's policy required immediate consultation with a physician for significant changes in a resident's physical, mental, or psychosocial status, which was not followed in this case. The resident was eventually hospitalized with diagnoses of sepsis, acute UTI, and delirium. The facility's failure to monitor the resident's mental status and notify the physician of the change in condition resulted in a delay in treatment. The facility's policy on urinary tract infections also emphasized the importance of identifying signs and symptoms of a UTI, which was not adhered to, contributing to the resident's hospitalization.
Failure to Timely Report and Act on Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner for one resident, leading to a deficiency in their abuse reporting protocol. The resident, who had intact cognition and required assistance with activities of daily living, reported that a CNA was rough during care. Despite the report being made on a Sunday, the facility did not notify the appropriate agencies until the following day. This delay in reporting was acknowledged by the Director of Nursing and the Administrator, who confirmed that the abuse allegation was not reported until the next day. Additionally, the facility did not suspend the alleged staff member immediately after the abuse allegation was made, allowing the CNA to continue working until the next day. Interviews with various staff members, including licensed and unlicensed personnel, revealed a general understanding that abuse allegations should be reported within 24 hours and that the alleged staff should be suspended pending investigation. However, these procedures were not followed, as confirmed by the facility's policy, which mandates immediate removal of the alleged staff from duty and reporting of the incident within two hours.
Inadequate Supervision During Smoking Sessions Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision during resident smoking sessions, which led to a resident eloping from the facility. Resident 10, who had a history of chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, congestive heart failure, and moderate dementia, was admitted to the facility with a BIMS score indicating moderate to severe cognitive impairment. On a particular day, Resident 10 was found wandering with a cigarette wrapper on his lap, suggesting he had been smoking. Despite being considered for a Wander Guard due to his mental deficits, Resident 10 managed to elope from the facility grounds during a smoking session. The facility's Activity Department was responsible for supervising resident smokers, but there was no set schedule or assignment for supervision. Activity Assistant B, who often supervised smoking sessions, indicated that the Wander Guard alarm was disarmed during these sessions, which allowed Resident 10 to leave without triggering an alarm. On the day of the incident, Resident 10 walked through the patio area and left the facility grounds, later being found on a nearby street. The Assistant Director of Nursing confirmed that the alarms did not go off as expected when Resident 10 left, although they were functioning properly when tested afterward. Interviews with various staff members, including Activity Assistants and the Activity Director, revealed a lack of awareness and communication regarding Resident 10's elopement. The facility was unable to provide a policy on supervision during smoking sessions, indicating a gap in procedural guidelines. This lack of structured supervision and policy contributed to the resident's ability to elope, posing a potential risk to his safety.
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Illustrative
What surveyors actually found near you
We read the 868 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vallejo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs Road Healthcare | 1.7 mi | ★★★★★ | 2 | 0 |
| Heartwood Avenue Healthcare | 2.4 mi | ★★★★★ | 17 | 0 |
| Dept Of State Hospitals - Napa D/p Snf | 9.8 mi | ★★★★★ | 25 | 0 |
| Alhambra Post Acute | 10.3 mi | ★★★★★ | 2 | 0 |
| The Meadows Of Napa Valley | 10.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.