The Orchards Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Bakersfield, California.
- Location
- 730 34 Street, Bakersfield, California 93301
- CMS Provider Number
- 555702
- Inspections on file
- 77
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Orchards Post-acute during CMS and state inspections, most recent first.
A resident with dementia, prior traumatic brain hemorrhage, contractures, and total dependence for toileting and bed mobility experienced a fall and head laceration while being provided toileting hygiene on a fully inflated LAL mattress. A longstanding MD order and care plan intervention for bilateral landing mats at the bedside were not implemented, and LNs did not document required shift checks of mat placement. The care plan for the resident, who had limited ROM, history of falls, and was totally dependent for ADLs, did not specify two‑person assistance during care on the LAL mattress, even though staff reported that residents on LAL mattresses were always treated as two‑person assists. During toileting care, a CNA, who had been told the resident was a one‑person assist, rolled the resident while changing chux; the resident tensed, his legs moved toward the bed edge, and he slid off the bed, with no landing mats in place. The resident was found on the floor with bleeding from the back of the head and was transferred to the hospital, where CT imaging showed a subarachnoid hemorrhage.
A resident with a history of UTI reported painful urination, and the physician ordered a one-time UA C&S. An SBAR documented the complaint and new order, but there was no documentation that urine was collected or that attempts were made to collect it for approximately two days. The DON confirmed that urine should have been collected as soon as possible and could not find records of collection or attempted collection until a later nurse’s note and SBAR indicated the specimen was finally obtained. The resident’s pain with urination increased, and the resident chose to go to the hospital rather than wait for UA C&S results; the ED later diagnosed a UTI. An LVN assigned when the order was received could not recall attempting to collect the urine, despite acknowledging responsibility to do so in a timely manner.
A resident's restroom was found to have torn and lifted linoleum flooring, creating an uneven surface. The Maintenance Director confirmed this presented a tripping hazard, and facility policy requires maintenance to keep the building in good repair and free from hazards.
After an allegation was made that a contracted phlebotomist was reusing needles on residents and at other facilities, the facility did not prevent the phlebotomist from entering and providing services during the investigation. The phlebotomist was allowed to return and perform a blood draw on a resident, despite facility policy requiring removal from resident contact during abuse investigations.
The facility failed to maintain clean linen carts and the laundry room in a sanitary condition. Linen carts were damaged and improperly disinfected, while the laundry room had unclean conditions, including a debris-covered fan blowing onto clean linens. Facility policies for maintaining cleanliness were not followed.
The facility failed to follow its infection surveillance policy, resulting in deficiencies in infection control and tracking. The Antibiotic Stewardship Log showed 64 infections without documented signs and symptoms, and the Infection Control Committee Report revealed untracked infections, except for UTIs. Additionally, 11 infections did not meet antibiotic treatment criteria, lacking organism or culture records. These failures compromised effective infection control and tracking.
The facility failed to ensure staff communicated in a language understood by residents, affecting their dignity and self-esteem. A resident felt uncomfortable when staff spoke Spanish in front of them, while two others noted staff spoke in a language they couldn't understand. The facility's policy emphasizes promoting residents' well-being and self-esteem, which was not upheld.
The facility failed to obtain informed consents for psychotropic medications for three residents, potentially leaving them unaware of the risks and benefits of their treatments. A resident's consent form lacked dosage and frequency details for Divalproex and Olanzapine. Another resident was prescribed Lexapro without a signed consent, and a third resident received Xanax without prior consent. The facility's policy mandates informed consent for such medications, which was not followed.
The facility failed to maintain daily completed Direct Care Service Hours Per Patient Day (DHPPD) records from early January to late February 2025. This deficiency was confirmed during a review and interview with the Administrator, who acknowledged the absence of DHPPD documentation for the specified period. The facility's policy requires daily posting and maintenance of staffing records, which were not adhered to, potentially affecting resident care.
The facility did not complete annual performance evaluations for two CNAs, as required by its policy. CNA 1's last review was in 2023, and CNA 2's was in 2011. This oversight could lead to CNAs being unaware of needed improvements, potentially impacting resident care.
The facility did not act on the January 2025 Medication Regimen Review (MRR) for four residents, failing to document actions on 139 pharmacy recommendations. Issues included non-compliance with CMS guidelines for antipsychotic dose reduction, extended use of PRN psychotropic medications, and long-term use of Naproxen despite risks. The MRR was not completed within the expected timeframe, as confirmed by the DON.
The facility failed to manage and store medications properly, with expired medications found on a cart, improper storage of Bisacodyl suppositories with Ensure, and incomplete Controlled Drug Records lacking dual nurse signatures. Additionally, medications were found on bedside tables of three residents, posing risks of unauthorized access and administration errors.
A facility failed to maintain a clean and sanitary bathroom for a resident with a right leg amputation. The bathroom had dark brown stains and crumpled paper towels, and the CNA responsible was unaware of cleaning duties. The resident, who is cognitively intact, confirmed the lack of cleanliness, contrary to the facility's policy requiring clean and sanitary bathrooms.
The facility failed to complete quarterly smoking assessments for two residents, as required by their policy. A resident's smoking assessment was not completed upon admission or quarterly, and another resident, at risk of injury related to smoking, also did not have the required assessments. This failure resulted in the residents not being evaluated for safety while smoking, posing a potential risk of injury.
A facility failed to implement a care plan for a resident at high risk for falls. The resident was observed in bed with the bed in a high position, contrary to the care plan's directive to keep it low to reduce fall impact. The resident's care plan and Morse Fall Assessment indicated a high fall risk due to factors like a history of falls and unsteady gait. Despite these assessments, the facility did not follow the precautionary measure, risking serious injury.
A facility failed to check a resident's blood pressure before administering Losartan Potassium for hypertension, as required by the physician's order. The resident's MAR showed no blood pressure documentation for several days, which was confirmed by the ADON. This oversight violated the facility's medication administration policy, which mandates verifying vital signs when necessary.
A resident's catheter tubing and urine collection bag were not changed for two months, despite visible signs of discoloration and material buildup. Nurses acknowledged the need for a change but did not perform it. The resident had a history of UTIs, and facility policy suggested changes based on clinical indications.
A facility failed to follow its oxygen administration policy for a resident with a history of aspiration and pneumonia. The resident, who required continuous oxygen to maintain saturation above 92%, was found without a nasal cannula, resulting in an oxygen level of 90%. The facility's policy required periodic observation to ensure proper oxygen administration, which was not adhered to.
A facility failed to document and follow up on a resident's eyeglasses, leading to a deficiency. The resident, who was cognitively intact, reported waiting three months for her eyeglasses and experiencing poor vision. An eye consultation had been conducted two months prior, prescribing bifocal lenses, but the Social Services Director did not document any follow-up, contrary to facility policy.
The facility failed to reorder medications timely, resulting in two residents not receiving their prescribed medications. One resident experienced repeated unavailability of multiple medications, while another resident's Metformin was not available despite being reordered. The facility's policy required medications to be reordered at least three days before the last dose, but this was not followed.
A facility failed to maintain a functional call light system for a resident with quadriplegia and contracted hands, as observed during an inspection. The resident's care plan required a working call light within reach, but the system was non-functional, and the Environmental Service Director was unaware of the issue. The facility's policy mandates a functional call system and alternative communication means for residents with disabilities.
A resident's room was found with a ripped baseboard, approximately 10 inches long and 1 inch open, during an observation with the Housekeeper/Laundry Supervisor. Despite daily inspections by the maintenance department, the Environmental Services Director acknowledged the oversight. The facility's policy requires maintenance to keep the building in good repair and free from hazards.
A resident with a history of a right femur fracture and respiratory disorders was not readmitted to the facility after hospitalization, violating their rights. The facility cited refusal of care and low functioning as reasons, despite policy prioritizing readmission. The administrator acknowledged the resident should have been taken back.
A resident with a G-tube experienced aspiration pneumonia due to the facility's failure to follow enteral feeding protocols. The resident, with a history of respiratory issues, showed signs of vomiting and wheezing, but the LVN delayed notifying the physician for over four hours. The G-tube placement and residual volume were not checked, and medications were administered despite ongoing symptoms. The resident's condition worsened, leading to a hospital transfer.
The facility failed to document the administration of medications and treatments for two residents as per physician orders. One resident's antibiotic for osteomyelitis was not documented as given, and another resident's wound care treatments were not recorded on multiple occasions. The DON confirmed these documentation lapses, which violated facility policies.
The facility failed to ensure that an LVN and a CNA were competent in caring for residents with G-tubes. The LVN lacked skills in checking G-tube placement and monitoring for complications, while the CNA was not competent in resident positioning and care during feedings. This deficiency was identified during a review of employee files and confirmed by the DSD and DON, highlighting a failure to adhere to the facility's competency policy.
The facility did not follow its investigation report to monitor a resident's smoking privileges after a verbal altercation in the smoking area. The DON found no documentation of monitoring in the resident's record, despite the facility's policy requiring direct supervision for residents needing monitoring while smoking.
A resident with wound dehiscence did not receive physician-ordered wound care on two occasions, as documented in the Treatment Administration Record. The facility's staff failed to administer the treatment due to a shift change and lack of follow-up, resulting in a lapse in the facility's wound care policy.
A resident experienced severe abdominal pain for seven hours due to inadequate foley catheter care, as staff failed to assess the catheter for kinks or blockages. Despite the resident's complaints, pain medication was delayed, and the situation escalated until emergency services were called. The resident was diagnosed with a UTI after the catheter was unclogged, releasing over a liter of urine.
A facility failed to report and investigate an alleged abuse incident where a resident threw objects at another resident, causing fear and anxiety. Despite documentation of the aggressive behavior and the affected resident's expressed fear, the incident was not reported to the CDPH, nor was an investigation conducted, contrary to the facility's policy.
The facility's kitchen was found to be unsanitary, with black debris, scattered butter containers, and lifeless flies on the floor of the dry storage room. The walk-in freezer and area under the sink also had debris. The Dietary Director acknowledged these conditions, and the Administrator confirmed the absence of a contracted deep cleaning agency, despite the facility's policy recommending quarterly deep cleaning.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in resident rooms and the kitchen. Cognitively intact residents reported seeing cockroaches, and staff confirmed the issue, with sightings primarily at night. Observations in the kitchen revealed both dead and live cockroaches, and the Dietary Director acknowledged the problem. Despite the facility's pest control policy, the Administrator was unaware of the issue.
A resident with cognitive impairment was found with long, dirty fingernails and brown stains on the palm, indicating a lack of proper nail care and hand hygiene. The CNA did not trim the nails due to uncertainty about the resident's diabetic status, which was later clarified by an LVN. The facility's policy requires assistance with hygiene for residents unable to perform ADLs independently.
A resident fell and was assisted to the floor by a charge nurse, but the incident was not documented, and the Physician was not notified immediately. The resident later complained of leg pain, leading to a delayed hospital transfer.
The facility failed to administer Debrox solution as ordered for a resident, resulting in the medication not being given for three consecutive days. Staff interviews confirmed that central supply should have been notified to provide the medication, but this did not occur, violating the facility's medication administration policy.
A resident did not receive scheduled showers on multiple occasions, despite being cognitively intact and requiring assistance. The facility's policy required documentation of showers, which was missing for the specified dates.
Failure to Implement Bedside Safety Devices and Appropriate Assistance on LAL Mattress Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for one resident with significant cognitive and physical impairments. The resident had diagnoses including traumatic cerebral hemorrhage, dementia, bipolar disorder, chronic pain, contractures, and abnormal posture, and was assessed as dependent for toileting hygiene and rolling in bed. An MDS showed the resident was unable to complete the BIMS interview and had both short- and long‑term memory problems, as well as impairments of both lower extremities. Despite these conditions, the facility did not consistently implement ordered and care‑planned safety interventions. A physician’s order dated 7/13/2020 directed that the resident "may have bilateral landing mats to sides of bed" and required an LN to check placement every shift, day and night. The resident’s care plan, under the focus of risk for pressure injury development, also included an intervention for bilateral landing mats to the sides of the bed. However, on observation in the resident’s room, no bilateral landing mats were present at the bedside. The DON confirmed that there was no documentation on the TAR or MAR for January that LNs had checked landing mat placement each shift, and stated that the mats were not in place at the time of the resident’s fall and that the physician’s order and care plan were not followed. CNA 2, who was providing toileting care at the time of the fall, also stated there were no bilateral landing mats at the bedside when the resident fell. The facility also failed to update and implement the care plan to reflect the need for two‑person assistance during toileting hygiene for a dependent resident on a low air loss (LAL) mattress. The resident’s care plan for risk of pressure injury indicated use of an LAL mattress for wound management and preventive measures, and the physician’s order and MAR documented that the LAL mattress was in place, functioning, and at correct settings on every shift up to the date of the fall. The care plans addressing contractures, limited ROM, history of falls, and functional loss did not specify two‑person assistance for ADL care. CNA 2 reported she had been told in report that the resident was a one‑person assist and described rolling the resident during toileting care when the resident tensed up and slid off the edge of the bed. CNA 3 stated the resident was totally dependent for ADLs and was always a two‑person assist, and that residents on LAL mattresses were always two‑person assists. The DSD stated she had educated CNAs that residents on LAL mattresses required two‑person assistance, one staff on each side of the bed, and that the LAL mattress was risky because it could move during care, and that the care plan should have been updated to indicate two‑person assistance. The facility did not have specific policies for following physician orders or for care of dependent residents on LAL mattresses, despite a general safety and supervision policy requiring identification of hazards, communication of interventions, assignment of responsibility, training, implementation, and monitoring of safety interventions. These failures culminated in a witnessed fall on the evening of 1/25/26 while CNA 2 was providing toileting care. According to the SBAR/COC, the resident was on a fully inflated LAL mattress with no fall mats present and was found lying on his back next to the bed with blood dripping from the back of his head. The narrative indicated that when the CNA turned the resident, his lower extremities shifted toward the edge of the bed; as the CNA moved to the other side to reposition his legs, he fell from the bed. The resident sustained a laceration to the back of the head and was transferred to an acute hospital, where a CT scan showed a trace subarachnoid hemorrhage in the right frontal and, to a lesser degree, parietal lobes. The resident was admitted to the hospital for three days and later readmitted to the facility with a diagnosis of traumatic subarachnoid hemorrhage status post fall.
Failure to Timely Collect Ordered UA C&S After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered urinalysis with culture and sensitivity (UA C&S) was collected in a timely manner after a resident experienced a change in condition with painful urination. The resident had a history of urinary tract infection and, on 11/5/25, the physician ordered a one-time UA C&S for painful urination. An SBAR dated 11/5/25 documented that the resident complained of pain while urinating, was given pain medication with effective relief, had vital signs within normal limits, and that new orders for a UA C&S were obtained. The Director of Nursing stated that the urine should have been collected as soon as possible and was unable to find documentation that the urine was collected on 11/5/25 or 11/6/25, nor any documentation of attempts or inability to collect the specimen during that time. Documentation shows that the urine was not collected until 11/7/25, as reflected in a nurse’s note and an SBAR on that date indicating that the resident’s urine was collected that morning due to painful urination. Later that day, the resident reported increased pain with urination, refused to wait for the UA C&S results, and requested transfer to the hospital, with family and the physician notified. Emergency department records from the acute hospital documented a discharge diagnosis of urinary tract infection. During an interview, the LVN assigned to the resident on the day shift when the order was received stated she could not recall if she attempted to collect the urine on that shift, and acknowledged she was supposed to collect the urine to ensure it was done on time and without delay of care. The facility’s policy on acute condition changes states that staff will monitor and document the resident’s progress and responses to treatment, and that the physician will authorize appropriate treatments.
Restroom Floor Covering in Disrepair Creates Tripping Hazard
Penalty
Summary
The facility failed to maintain the linoleum floor covering in good repair in one of five residents' restrooms, specifically in room [ROOM NUMBER]. During an observation and interview with the Maintenance Director, it was noted that the restroom floor covering was torn and lifted, resulting in an uneven surface. The Maintenance Director confirmed that this condition created a tripping hazard. A review of the facility's maintenance policy indicated that the maintenance department is responsible for keeping the building in a safe and operable condition, including maintaining the building in good repair and free from hazards, in compliance with applicable regulations.
Failure to Protect Residents from Alleged Abuse by Contracted Phlebotomist
Penalty
Summary
The facility failed to follow its policy and procedure regarding the immediate protection of residents from potential abuse after being informed of an allegation against a contracted phlebotomist. After the Administrator was notified of a report that the phlebotomist was allegedly reusing needles on residents and then using them at other facilities, the Administrator stated he would initiate an investigation by contacting the agency and consultants. However, there was no immediate action taken to prevent the phlebotomist from entering the facility or having contact with residents during the investigation period. Subsequently, it was confirmed through interviews that the phlebotomist did return to the facility and performed a blood draw on a resident after the allegation had been reported to the Administrator. The Administrator later stated he was unaware that the phlebotomist had entered the facility following the report. The facility's policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete, but this was not followed in the case of the contracted phlebotomist.
Deficiencies in Linen Cart Maintenance and Laundry Room Cleanliness
Penalty
Summary
The facility failed to maintain clean linen carts in good repair, as observed during a survey. Three clean linen carts were found with ripped edges exposing metal frames and dark brownish discolorations. The Laundry Aide, when questioned, was unaware of the age of the carts, while the Housekeeping and Laundry Supervisor acknowledged the need for new carts. Additionally, the facility did not adhere to the manufacturer's guidelines for disinfecting the carts. The Laundry Aide admitted to not allowing the Clorox wipes to remain wet for the required 30-second contact time, as specified by the product instructions. Furthermore, the laundry room was not maintained in a clean and sanitary condition. An electric fan with thick grayish debris was observed blowing air onto folded clean linens, and the floor beneath the clean linen table was covered with similar debris. The Housekeeping and Laundry Supervisor confirmed that the fan had not been cleaned for a long time and that there was no cleaning log for the laundry room. The facility's policies and procedures for maintaining hygienically clean linens and clean floors were not followed, contributing to the potential for contamination and infection spread.
Deficiencies in Infection Surveillance and Antibiotic Tracking
Penalty
Summary
The facility failed to adhere to its policy and procedure on Surveillance for Infections, resulting in several deficiencies in infection control and tracking. During a review of the Antibiotic Stewardship Log (ASL) for January 2025, it was found that 64 recorded infections lacked documentation of signs and symptoms. The Infection Preventionist Nurse (IPN) confirmed this absence of documentation. Additionally, the Infection Control Committee Report for December 2024 showed various infections, including skin, respiratory, gastrointestinal, and others, but the facility's Tracking Map did not track these infections, except for urinary tract infections (UTIs). The IPN admitted to only tracking the highest number of infections, which were UTIs. Furthermore, the ASL indicated that 11 infections did not meet the criteria for antibiotic treatment, and there was no record of organism or culture to justify the use of antibiotics. The facility's policy on Surveillance for Infections, dated September 2017, emphasized the importance of identifying infections and trends to guide interventions and prevent future infections. However, the facility's failure to document signs, symptoms, and organism information, as well as inadequate tracking of infection locations, compromised effective infection control and tracking, potentially leading to the spread and increase of infections.
Failure to Communicate in Resident's Language
Penalty
Summary
The facility failed to ensure that staff communicated in a language that three sampled residents could understand, which compromised the residents' right to a dignified existence and self-determination. Resident 74, who was cognitively intact with a BIMS score of 15, expressed discomfort when staff spoke Spanish in front of them, feeling as though the staff were talking about them. Similarly, Resident 88, also with a BIMS score of 15, reported that the morning shift staff spoke in their own language, which they could not understand. Resident 110, with a BIMS score of 15, also noted that staff spoke Spanish to each other. During an observation, a CNA and a housekeeper were overheard speaking loudly in Spanish in the hallway. When questioned, both staff members apologized for speaking Spanish, with the housekeeper explaining that they were asking questions. The facility's policy on dignity, dated February 2021, emphasizes that each resident should be cared for in a manner that promotes their sense of well-being and self-esteem. The failure to adhere to this policy by not communicating in a language understood by the residents potentially affected their feelings of self-worth and satisfaction with life.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and complete informed consents for psychotropic medications for three residents, which could result in them not being fully aware of the risks and benefits of their treatments. During a review of Resident 84's Informed Consent Verification Form, it was found that the form lacked information on medication dosage and frequency for Divalproex and Olanzapine. Licensed Vocational Nurse 2 acknowledged that this information should have been included on the consent form. Additionally, Resident 97 was prescribed Lexapro for depression and anxiety, but there was no signed informed consent for this medication, as confirmed by the Assistant Director of Nursing. Similarly, Resident 77 was prescribed Xanax for anxiety, but the Minimum Data Set Coordinator confirmed that there was no consent obtained before administering the medication. The facility's policy requires informed consent for psychotropic drugs, but this was not adhered to in these cases.
Failure to Maintain Daily DHPPD Records
Penalty
Summary
The facility failed to maintain daily completed Direct Care Service Hours Per Patient Day (DHPPD) records from January 1, 2025, to February 21, 2025. This deficiency was identified during a review of the facility's DHPPD records for the period from January 2025 to March 2025, which revealed a lack of completed DHPPD documentation for the specified dates. During an interview and concurrent record review on March 13, 2025, the Administrator confirmed that no DHPPD had been completed since January 1, 2025, to February 21, 2025. The facility's policy and procedures, titled 'Posting Direct Care Daily Staffing Numbers' and dated July 2016, require the posting of daily staffing numbers for each shift and the maintenance of these records for a minimum of eighteen months or as required by state law. The absence of these records had the potential to impact the provision of sufficient nursing care to all residents.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two Certified Nurse Assistants (CNA 1 and CNA 2), which was identified during an interview and record review with the Director of Staff Development (DSD). CNA 1's last performance review was conducted on April 5, 2023, while CNA 2's last review was on November 15, 2011, with no recent evaluations on file. The facility's policy and procedure, dated June 2010, mandates that employee performance be reviewed annually, with evaluations completed by department directors and supervisors, and reviewed by the HR Director and Administrator. The absence of these evaluations for CNA 1 and CNA 2 could result in them being unaware of areas needing improvement, potentially affecting resident care.
Failure to Act on Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the monthly Medication Regimen Review (MRR) for January 2025 was reviewed and acted upon for four sampled residents. The MRR, dated January 30, 2025, contained 139 pharmacy recommendations, but there was no documentation indicating that these recommendations were acted upon. Specific issues included the continued use of Olanzapine and Depakote for a resident without following CMS guidelines for gradual dose reduction, the use of PRN psychotropic medications beyond the recommended 14-day duration for two residents, and the long-term use of Naproxen for another resident despite its associated risks. Interviews with the Pharmacist and the Director of Nursing (DON) revealed that the MRR was emailed to the facility on January 30, 2025, with the expectation that it would be completed within three working days. However, the DON confirmed that the January MRR was still incomplete as of March 13, 2025. The facility's policy and procedure for Medication Regimen Review, dated May 2019, emphasizes the importance of reviewing each resident's medication regimen monthly to prevent and resolve medication-related problems, but this was not adhered to in this instance.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper management and storage of medications, leading to several deficiencies. One of the medication carts contained expired medications, specifically Latanoprost and Brimonidine eye drops, which were opened beyond their recommended usage period of 42 and 30 days, respectively. Additionally, medications were improperly stored, with Bisacodyl suppositories found alongside Ensure nutritional supplements, which is against proper storage practices. Furthermore, the Controlled Drug Records (CDR) for several controlled medications lacked the required signatures from two licensed nurses, indicating a failure in the documentation process for controlled substances. The facility also failed to ensure the safe administration of medications for three residents. Medications were found on bedside tables, accessible to unauthorized individuals. For instance, Resident 8 had a vial of Cequa on their bedside table, and Resident 9 had Vitamin A&D ointment left out. Resident 4's bedside table contained Calmoseptine cream and antifungal powder, with the latter being part of the facility's supply. The Treatment Nurse confirmed that these medications should not have been stored at the bedside, especially since Resident 4 was unable to self-administer them. These lapses in medication management and storage practices posed potential risks for medication errors and unauthorized access.
Failure to Maintain Clean and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary bathroom environment for one of the sampled residents, Resident 72. During an observation, the bathroom used by Resident 72 was found to have a toilet seat and bowl with dark brown stains, crumpled paper towels on the floor, and a large dark brown stain under the sink. The Housekeeping and Laundry Supervisor indicated that Certified Nursing Assistants (CNAs) should clean when housekeepers are not available. However, CNA 4 stated that cleaning the bathroom was not her responsibility and she was unaware of where to find disinfecting wipes. Resident 72, who is cognitively intact and uses a wheelchair due to a right leg amputation, confirmed that the bathroom was not cleaned. The facility's policy requires that residents have access to a clean and sanitary bathroom, which was not adhered to in this instance.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, Resident 84 and Resident 70, as required by their policy. Resident 84's smoking assessment was not completed upon admission or quarterly, as confirmed by the Assistant Director of Nursing (ADON). Resident 70, who has a diagnosis of tobacco use and is at risk of injury related to smoking, also did not have the required quarterly smoking assessments completed, as confirmed by the Director of Nursing (DON). The facility's policy mandates that a resident's ability to smoke safely be re-evaluated quarterly, upon a significant change, and as determined by staff. This failure to conduct timely assessments resulted in the residents not being evaluated for safety while smoking, posing a potential risk of injury.
Failure to Implement Fall Precaution Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as being at high risk for falls. During an observation, the resident was found lying in bed with the bed in a high position, contrary to the care plan's directive to keep the bed in the lowest position to minimize fall impact. The resident's care plan, dated December 19, 2024, highlighted the resident's risk factors, including a history of falls, medications, poor safety awareness, and an unsteady gait. The Morse Fall Assessment conducted on December 18, 2024, scored the resident at 50, indicating a high risk for falls. Despite these assessments and care plan interventions, the facility did not adhere to the specified precautionary measure, posing a potential risk for serious injury to the resident.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to adhere to professional standards of quality by not checking the blood pressure of Resident 8 before administering blood pressure medication. Resident 8 had a physician order for Losartan Potassium Tablet 25 MG to be given at bedtime for essential hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110. However, a review of the Medication Administration Record (MAR) for March 2025 revealed that there was no documentation of blood pressure readings from March 3 to March 12, 2025. This was confirmed by the Assistant Director of Nursing (ADON) during an interview and record review. The facility's policy on administering medications, dated April 2019, requires that medications be administered safely, timely, and as prescribed, including verifying vital signs if necessary. The lack of blood pressure documentation indicates a failure to comply with these requirements.
Failure to Provide Timely Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, identified as Resident 91, whose catheter tubing and urine collection bag had not been changed for two months. During observations, the catheter exhibited thick whitish to grayish material, and the urine collection bag showed dark brownish discoloration. Treatment Nurse (TN) and Licensed Vocational Nurse (LVN) 5 acknowledged the need for a change but did not perform it. The Medication Administration Record (MAR) for January, February, and March 2025 indicated that the catheter drainage bag was last changed on January 19, 2025, and there was no documentation of recent changes, despite the order being PRN (as needed). Resident 91 had a history of urinary tract infections (UTIs), as evidenced by the administration of antibiotics such as Flagyl and Macrobid for UTIs and ESBL in the urine. The facility's policy and procedure for catheter care, dated September 2014, suggested changing catheters and drainage bags based on clinical indications such as infection or obstruction. The failure to adhere to these guidelines and the lack of timely catheter care had the potential to contribute to Resident 91's repeated UTIs.
Failure to Follow Oxygen Administration Protocol
Penalty
Summary
The facility failed to adhere to its policy and procedures for oxygen administration for one of the residents, identified as Resident 99. The physician's order for Resident 99 specified that oxygen should be administered at 3 liters per minute via nasal cannula continuously, with adjustments to maintain oxygen saturation above 92%. The resident's care plan also highlighted the risk of impaired gas exchange due to a history of aspiration and pneumonia, with interventions including the application of oxygen as per the medical doctor's orders. During an observation and interview, it was noted that Resident 99 was not wearing the nasal cannula, and the Licensed Vocational Nurse (LVN) confirmed that the resident required supplemental oxygen. Upon checking, the resident's oxygen saturation level was found to be at 90%, below the prescribed threshold. The facility's policy on oxygen administration emphasized the need for periodic observation to ensure oxygen is being tolerated, which was not followed in this instance, leading to the deficiency.
Failure to Document and Follow Up on Resident's Eyeglasses
Penalty
Summary
The facility failed to ensure that the Social Services Department documented and followed up on a resident's eyeglasses, which resulted in a deficiency. A resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported during an interview that she had been waiting for her eyeglasses for three months and was experiencing poor vision. The resident's eye consultation, conducted two months prior, indicated a prescription for bifocal lenses. However, the Social Services Director admitted to not documenting any follow-up on the resident's eyeglasses, which was a requirement according to the facility's policy and procedure for social services. This lack of documentation and follow-up had the potential to affect the resident's vision quality.
Medication Reordering Deficiency
Penalty
Summary
The facility failed to ensure the timely reordering and availability of medications for two residents, resulting in them not receiving their physician-ordered medications. Resident 8 had multiple medications that were not available, including Ketorolac Ophthalmic Solution, Prednisolone Acetate Ophthalmic Suspension, Losartan Potassium, Omeprazole, and Clobetasol Propionate Ointment. The progress notes indicated repeated instances where these medications were not available, and the pharmacy was notified, but no alternative orders were obtained. Resident 8 expressed that their medication, Omeprazole, had run out, and this was a recurring issue. The Director of Nursing acknowledged that medications should be reordered at least five days prior, and there was an over-the-counter supply of Omeprazole available in the facility. Resident 1 also experienced a lack of medication availability, specifically Metformin, which was not available when the LVN was preparing medications. The LVN stated that the medication was reordered the previous day, but no dosage was available at the time. The facility's policy and procedure for ordering and receiving medications indicated that medications should be reordered not less than three days before the last dosage is administered to ensure availability. However, this policy was not adhered to, leading to the deficiency in medication management for the residents.
Non-Functional Call Light System for Resident with Limited Mobility
Penalty
Summary
The facility failed to maintain a functional call light system for one of its residents, identified as Resident 99. During an observation and interview, it was noted that Resident 99's call light did not activate when used, and the resident was unable to move his hands due to contractures. A Licensed Vocational Nurse (LVN) confirmed that the call light was non-functional and acknowledged that Resident 99 would benefit from a push call light due to his limited hand mobility. The resident's care plan, which addressed his musculoskeletal status and quadriplegia, emphasized the importance of having the call light within reach and responding promptly to requests for assistance. Further interviews revealed that the Environmental Service Director was unaware of the non-functional call light. The facility's policy on the resident call system, dated September 2022, mandates that each resident should have a means to call staff directly for assistance and that the system should remain functional at all times. Additionally, if a resident has a disability that prevents them from using the call system, an alternative means of communication should be provided and documented in the care plan. This deficiency highlights a failure to adhere to the facility's policy and ensure the safety and communication needs of Resident 99.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to maintain a resident's room in good repair, as observed in room [ROOM NUMBER], where a baseboard was found ripped from the wall, measuring approximately 10 inches long and 1 inch open rip. This issue was identified during a concurrent observation and interview with the Housekeeper/Laundry Supervisor (HLS). Despite the maintenance department's daily inspections of each room, the Environmental Services Director (EVSD) admitted that they had not noticed the baseboard rip in room [ROOM NUMBER]. The facility's policy and procedure, titled Maintenance Service and dated December 2009, mandates that maintenance services should ensure the building is in good repair and free from hazards, which was not adhered to in this instance.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident after hospitalization, violating the resident's rights to return to the facility. The resident, who had a history of a right femur fracture and respiratory disorders, was initially admitted to the facility and later discharged to an acute hospital. Upon being ready for discharge from the hospital, the facility refused to readmit the resident, citing reasons such as refusal of care and low functioning. Interviews and record reviews revealed that the facility's marketing director communicated the refusal to the hospital's case manager, and the facility's administrator acknowledged that the resident should have been readmitted. The facility's policy on readmission, which prioritizes residents returning from hospital or therapeutic leave, was not followed. This oversight had the potential to negatively impact the resident's well-being.
Failure to Follow Enteral Feeding Protocols Leads to Aspiration Pneumonia
Penalty
Summary
The facility failed to adhere to its policy and procedure for enteral feedings, resulting in a significant deficiency in the care of a resident with a gastrostomy tube (G-tube). The resident, who had a history of acute and chronic respiratory failure, paraplegia, dysphagia, and gastrostomy status, was on continuous G-tube feeding. The facility did not check the G-tube placement or gastric residual volume before administering medications, nor did they report signs and symptoms of complications to the physician in a timely manner. These oversights led to the resident being transferred to an acute hospital and diagnosed with aspiration pneumonia. The resident exhibited symptoms of nausea, vomiting, and wheezing shortly after the start of a shift, but the Licensed Vocational Nurse (LVN) on duty delayed notifying the physician for over four hours. During this time, the resident continued to vomit, and the G-tube feeding was stopped without a specific time being documented. The LVN administered medications via the G-tube despite the resident's ongoing vomiting and wheezing, which were not immediately reported to the physician. The resident's condition worsened, leading to labored breathing, diaphoresis, and cyanosis, prompting the staff to eventually send the resident to the hospital. Interviews with the Director of Nursing (DON) and review of the resident's medical records confirmed the lack of documentation regarding G-tube placement checks and residual volume assessments. The DON acknowledged that the physician should have been notified immediately after the first signs of vomiting and wheezing. The facility's policy on enteral feedings emphasized the importance of checking tube placement, monitoring for respiratory distress, and promptly reporting complications, all of which were not followed in this case.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in administering medications and treatments as prescribed by physicians for two residents. For one resident, the facility did not document the administration of cefazolin, an antibiotic prescribed to treat osteomyelitis, at the scheduled 5 a.m. time on October 8, 2024. The Director of Nursing confirmed the absence of documentation, which was contrary to the facility's policy requiring timely and accurate recording of medication administration. For another resident, the facility did not document the administration of prescribed treatments on multiple occasions. Specifically, treatments for a keloid, moisture-associated skin damage, and a suprapubic catheter site were not documented as administered during the 6 a.m. shift on October 17 and October 25, 2024. The Director of Nursing confirmed these omissions, which violated the facility's wound care policy that mandates detailed documentation of wound care procedures, including the date, time, and signature of the person administering the treatment.
Lack of Staff Competency in G-Tube Care
Penalty
Summary
The facility failed to ensure that two staff members, an LVN and a CNA, were competent in caring for residents with gastrostomy tubes (G-tubes). During an interview and record review with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that the LVN lacked competencies in checking G-tube placement, monitoring gastric residual volume, recognizing signs of respiratory distress, identifying complications, and reporting these to a physician. Similarly, the CNA did not have competencies related to resident positioning and care during feedings for residents with G-tubes. The DSD acknowledged the importance of these competencies to ensure staff have the necessary knowledge to care for residents effectively. The facility's policy and procedure on the competency of nursing staff, revised in May 2019, outlines that all nursing staff must meet specific competency requirements as defined by state law. It also mandates participation in a facility-specific, competency-based staff development and training program. The policy emphasizes the need for staff to demonstrate competencies necessary for resident care, including carrying out physician's orders, person-centered care, communication, and basic nursing skills. Competency evaluations are to be conducted upon hire, annually, and as needed based on facility assessments. However, the lack of competencies for the LVN and CNA in caring for residents with G-tubes indicates a failure to adhere to these policies, potentially affecting resident well-being.
Failure to Monitor Resident Smoking Privileges
Penalty
Summary
The facility failed to adhere to its Five-Day Investigation Report by not implementing follow-up monitoring for a resident involved in a verbal altercation in the smoking area. The report, dated 9/17/24, indicated that the resident's smoking privileges would be closely monitored following the incident. However, during an interview and record review on 9/30/24, the Director of Nursing (DON) could not find documentation of such monitoring in the resident's clinical record. The DON acknowledged that the staff responsible for monitoring the resident's smoking privileges was not documenting it. The facility's policy and procedure titled 'Smoking Policy-Residents,' dated August 2022, requires that any resident with smoking privileges needing monitoring must be directly supervised by a staff member, family member, visitor, or volunteer worker at all times while smoking. This policy was not followed, as evidenced by the lack of documentation and monitoring for the resident involved in the altercation.
Failure to Provide Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide wound treatment as ordered by the physician for a resident, which had the potential to result in delayed wound healing. The resident had glue stitches on her right groin and right upper thigh, which later developed into wound dehiscence. The physician's orders required daily and as-needed wound care, including cleansing with normal saline, applying medicated ointments, and covering with a dry dressing. However, the Treatment Administration Record indicated that no wound treatment was provided on two specific days. Interviews with facility staff revealed that the wound care was not administered due to the resident returning from an appointment during a shift change, and the subsequent shift did not follow up on the treatment. The facility's policy and procedure for wound care required documentation of the type of wound care given, the date and time, any changes in the resident's condition, and assessment data. However, there was no documentation of the wound treatments being performed on the specified days, indicating a lapse in following the facility's wound care policy.
Inadequate Foley Catheter Care Leads to Resident Discomfort and UTI
Penalty
Summary
The facility failed to provide adequate foley catheter care for a resident, leading to significant discomfort and potential health risks. The resident, who was cognitively intact with a BIMS score of 15, experienced severe abdominal pain for approximately seven hours due to a lack of catheter assessment. Despite the resident's complaints of pain, the catheter was not checked for kinks or blockages during this period, as required by the care plan. The resident's pain was not addressed with medication until much later, and there was no documentation of pain reassessment. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty did not assess the catheter during her shift, and the Certified Nursing Assistant (CNA) reported the resident's pain to the LVN without any action being taken. The situation escalated to the point where the resident was yelling and cursing due to the pain. Eventually, the resident had to call 911, and emergency medical technicians unclogged the catheter, releasing over a liter of urine. The resident was diagnosed with a urinary tract infection, as documented in the emergency department records.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the reporting and investigation of abuse, neglect, exploitation, or misappropriation. Specifically, the facility did not report an allegation of abuse involving Resident 1 to the California Department of Public Health (CDPH) and did not complete an investigation of the incident. The incident involved Resident 2 throwing a tray lid and a glass plate at Resident 1, causing the plate to shatter near Resident 1's foot. Resident 1 expressed feeling unsafe and scared due to Resident 2's aggressive behavior. The Minimum Data Set (MDS) for Resident 1 indicated a Brief Interview for Mental Status (BIMS) score of 15, suggesting cognitive intactness. The Situation, Background, Assessment, and Recommendation (SBAR) and Social Services Notes documented Resident 2's aggressive behavior towards Resident 1 and another roommate. Despite these documented incidents and Resident 1's expressed fear, the Director of Nursing (DON) confirmed that no report was filed to the CDPH, and the Social Services Assistant (SSA) acknowledged that no investigation summary was completed. The facility's policy required immediate reporting and thorough investigation of such incidents, which was not followed in this case.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could lead to food contamination and the spread of infectious diseases. During an observation, black debris, scattered small containers of butter, and lifeless flies were found on the floor of the dry storage room. The walk-in freezer floor had debris and unidentified particles, and the area under the sink also had black debris. The Dietary Director acknowledged the presence of these unsanitary conditions during an interview. Additionally, the facility's cleaning schedule policy indicated that deep cleaning by an outside agency should occur quarterly, but the Administrator confirmed there was no contracted deep cleaning agency in place.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of cockroaches in three resident rooms and the kitchen. Resident 1, who was cognitively intact with a BIMS score of 15, reported seeing cockroaches crawling on the floor and even on a neighbor's face. The resident described the issue as occurring primarily at night, with staff members, including a CNA, confirming the presence of cockroaches and taking measures to kill them. Resident 2 and Resident 3, both also cognitively intact with BIMS scores of 15, reported similar sightings of cockroaches in their bathrooms. In the kitchen, an observation revealed both dead and live cockroaches under the sink area. The Dietary Director acknowledged the presence of cockroaches and indicated a need to contact the Administrator for pest control intervention. However, the Administrator stated that no reports of cockroaches had been made to them. The facility's pest control policy, dated May 2008, indicated an ongoing program to keep the building free of insects and rodents, but the observations and interviews suggest that this program was not effectively implemented.
Failure to Provide Nail Care and Hand Hygiene
Penalty
Summary
The facility failed to provide adequate nail care and hand hygiene for a resident, which was observed during a survey. The resident, who was non-verbal and had cognitive impairment, was found lying in bed with long fingernails containing black debris and brown stains on the right palm. The resident's care plan indicated a need for assistance with personal hygiene due to a self-care performance deficit and a high risk for functional decline. The Minimum Data Set (MDS) assessment confirmed the resident required substantial assistance with personal hygiene. During interviews, a CNA admitted to not trimming the resident's nails, citing uncertainty about the resident's diabetic status, which was later clarified by an LVN as non-diabetic. The CNA also mentioned the resident's brown stains were due to picking at his buttocks. The LVN stated that CNAs are responsible for nail care but did not recall being informed about the resident's nail condition. The facility's policy on Activities of Daily Living (ADLs) emphasized providing appropriate care and services for residents unable to perform ADLs independently, including hygiene support.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to ensure timely notification of the Physician when a resident fell, resulting in a delay in medical intervention. On 5/3/24 at approximately 2:20 am, a resident was found half off the bed with legs dangling and was assisted to sit on the floor by the charge nurse. The incident was not documented as a fall, and the Physician was not notified immediately. Later that day, the resident complained of right leg pain, which was not relieved by the ordered medication. It was only at 6:30 pm that the Physician was called, and an order for hospital transfer was obtained. Interviews with the staff revealed that the Licensed Vocational Nurse (LVN) assigned to the resident during the night shift was unaware that assisting a resident to the floor constituted a fall and did not notify the Physician. The facility's policies and procedures clearly state that any incident involving a resident, including falls, should be reported to the attending Physician immediately. The failure to follow these protocols led to a delay in addressing the resident's medical needs promptly.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered by the physician for one resident. Specifically, Resident 2 did not receive Debrox solution, an over-the-counter medication prescribed to remove ear wax, as indicated in her Medication Administration Record (MAR) for three consecutive days. The MAR showed that the medication was not given on 5/3, 5/4, and 5/5, and a progress note should have been documented. During interviews, the Assistant Director of Nursing (ADON) and Registered Nurse Supervisor (RNS) confirmed that central supply should have been notified to provide the medication, but this did not occur. The facility's policy and procedure for administering medications, which requires medications to be administered in accordance with prescriber orders, was not followed.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers to a resident, which had the potential to negatively impact the resident's self-image and increase the risk of infection. The resident, who was cognitively intact and required partial to moderate assistance with showering, reported issues with receiving showers. The resident's care plan indicated the need for assistance with showering, and the resident was scheduled to receive showers three times a week. Upon review of the resident's documentation, it was found that the resident did not receive showers on multiple occasions in February 2024, and there was no documentation to indicate that the showers were provided. The facility's policy and procedure for bathing required documentation of the date, time, and staff involved, as well as any assessment data and the resident's tolerance of the shower. This documentation was missing for the specified dates, indicating a failure to adhere to the facility's policy.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
