The Redwoods, A Community Of Seniors
Inspection history, citations, penalties and survey trends for this long-term care facility in Mill Valley, California.
- Location
- 40 Camino Alto, Mill Valley, California 94941
- CMS Provider Number
- 555826
- Inspections on file
- 19
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Redwoods, A Community Of Seniors during CMS and state inspections, most recent first.
A resident with a medically complex condition had conflicting information between their signed POLST form and the MDS assessment, with the MDS indicating full treatment and artificial nutrition while the POLST specified DNR, selective treatment, and no artificial nutrition. The MDS coordinator and DON confirmed the inaccuracy, and it was noted that the facility lacked a policy for MDS assessment completion.
The facility did not establish or maintain an infection prevention and control program, as required, resulting in a lack of systematic measures to prevent, identify, and control infections among residents and staff.
The facility did not provide written notice to the LTC Ombudsman when two residents were transferred to the hospital, as required by policy and regulation. Multiple staff members, including the DSD, Admin, LNs, and SSD, were unaware of the requirement and confirmed that no notifications were made for these transfers.
Two residents at risk for falls in an LTC facility experienced multiple falls due to inadequate supervision and ineffective care plans. One resident suffered two hip fractures, while the other fell seven times in four months. The facility failed to update care plans with appropriate interventions and did not increase supervision, despite the residents' high fall risk.
The facility failed to track mandatory training compliance, resulting in overdue trainings for a licensed nurse and a CNA. Additionally, an unlicensed staff member worked with an expired BLS certification for 4.5 months, and was observed not following infection control protocols. The DSD admitted to not having a system to track certifications, contrary to facility policy.
The facility did not post daily nursing staffing information as required, with the posting from the previous Friday still displayed on Monday. The Staffing Coordinator was responsible for weekday postings, but on weekends, charge nurses were tasked with this duty, which was not consistently fulfilled. This failure contradicted federal regulations requiring daily postings at the beginning of each shift.
The facility did not ensure timely responses to the Pharmacist's Drug Regimen Review reports, affecting all residents receiving medications. Reviews for May and June lacked follow-up, and earlier months showed incomplete documentation. The Consulting Pharmacist had to seek physician responses, and the DON admitted to not following through on recommendations, despite policy requiring action within 30 days.
A resident with dementia and no documented aggression was prescribed Seroquel without proper justification or monitoring. The facility failed to document aggression or attempt non-pharmacological interventions before administering the medication. The prescribing physician did not respond to the pharmacist's recommendation to discontinue Seroquel, and the facility did not adhere to its policy on psychotropic medication use.
The facility failed to maintain proper medication storage conditions, with a refrigerator consistently at 28°F instead of the required 36-46°F, affecting medications for two residents. The medication room door was found propped open, risking unauthorized access, and an expired medication was stored with active ones in a cart. The DSD confirmed these issues, indicating a need for staff education on proper procedures.
A resident with a history of falls and Alzheimer's Disease suffered multiple falls resulting in major injuries due to inaccurate fall risk assessments. The assessments failed to accurately reflect the resident's condition, including her fall history, need for supervision, incontinence, and the number of medications increasing fall risk. This led to inadequate care planning and interventions.
The facility failed to follow its Infection Control and QAPI policies by not tracking chronic UTIs among residents. Licensed Staff A admitted to not maintaining surveillance data, leaving the chronic infections section blank for several months. Specific cases included residents with multiple UTIs, yet no data was captured for root cause analysis, contrary to the facility's policies.
A staff member failed to follow Enhanced Barrier Precautions and Hand Hygiene policies while providing care to a resident who was incontinent of stool. The staff member did not wear an isolation gown or perform hand hygiene after care, despite facility policies requiring these measures for high-contact activities. This lapse was acknowledged by the staff member and confirmed by a licensed staff member, highlighting the risk of infection spread.
The facility failed to provide adequate annual training in abuse and dementia care for three CNAs. Unlicensed Staff N received only one hour of abuse training and no dementia training, while Unlicensed Staff O and P received one hour each of abuse and dementia training. The facility's assessment required at least 12 hours of training annually, but only about 5 hours were provided, as confirmed by the DSD.
A facility failed to document a resident's advance directives and POLST, despite the resident's serious medical conditions. Staff interviews revealed reliance on verbal communication and manual chart checks, which led to the oversight. The facility's policies required documentation of these directives, but they were not followed.
A facility failed to create a resident-centered care plan for a resident with a stage 4 pressure ulcer. The care plan lacked specific treatments ordered by the physician and included only generalized interventions. This deficiency was confirmed by the DSD, highlighting a failure to meet the facility's policy for comprehensive care plans.
Inaccurate MDS Assessment Due to POLST Discrepancy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a medically complex condition. The resident's MDS assessment, specifically section S which documents Physician Orders for Life-Sustaining Treatment (POLST), indicated that the resident had chosen to receive full treatment, including resuscitation and a trial period of artificial nutrition via feeding tube. However, a review of the resident's signed POLST form revealed that the resident had actually chosen Do Not Resuscitate (DNR), selective treatment, and no artificial means of nutrition, including feeding tubes. This discrepancy was confirmed during interviews with the MDS coordinator and the Director of Nursing (DON), both of whom acknowledged that the MDS assessment did not accurately reflect the resident's documented wishes as indicated on the POLST form. Further investigation revealed that the facility did not have a policy or procedure in place regarding the completion of MDS assessments. The DON confirmed that the information in section S of the MDS should be transcribed directly from the signed POLST form, and that any mismatch would render the MDS assessment inaccurate. The lack of an accurate MDS assessment could result in care and treatment that does not align with the resident's documented preferences. The findings were supported by a review of relevant professional guidance, which emphasized the importance of accurate documentation for MDS accuracy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as required by regulations. The report specifically notes the absence of a comprehensive program designed to prevent, identify, report, investigate, and control infections and communicable diseases among residents and staff.
Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide written notice of transfer to the Long-Term Care Ombudsman for two residents who were transferred to the hospital. Interviews with staff, including the Director of Staff Development, Administrator, Licensed Nurses, and Social Services Director, revealed that none were aware of the requirement to notify the Ombudsman when residents were transferred to the hospital. Staff members confirmed that they had not completed notices of transfer nor notified the Ombudsman in such cases. The Director of Nursing verified that no notice was completed and the Ombudsman was not notified for the two residents transferred to the hospital at the end of March 2025. A review of the facility's policy and procedure indicated that the Ombudsman should be notified in all cases of transfer or discharge, in accordance with regulatory requirements. Additionally, an All Facilities Letter specified that notice must be sent to the local LTC Ombudsman for any transfer or discharge initiated by the facility. Despite these requirements, the facility did not notify the Ombudsman for the two residents transferred to the hospital, as confirmed by staff interviews and record review.
Inadequate Supervision and Care Plan Implementation for Fall Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective care plans for two residents at risk for falls, leading to multiple incidents. Resident 190, with a history of falls and severe cognitive impairment, suffered three falls within a short period, resulting in two hip fractures. The facility did not create a care plan before the first fall and failed to update the care plan with appropriate interventions after subsequent falls. Despite being at high risk for falls, the supervision for Resident 190 was not increased, and the documentation of staff checks was inconsistent. Resident 34, who was completely dependent on staff for daily activities, experienced seven falls over four months. The facility's care plans for Resident 34 lacked specific interventions to prevent falls and did not increase supervision despite the repeated incidents. Documentation of neurological checks and fall risk assessments was incomplete or missing, and the facility did not revise care plans promptly after each fall. The facility's policies on fall prevention and management were not followed, as evidenced by the lack of adequate supervision and failure to update care plans with effective interventions. The Director of Nursing acknowledged the need for improvement in managing falls, including accurate fall risk assessments and documentation of visual checks. The facility's failure to implement and monitor appropriate interventions contributed to the residents' repeated falls and injuries.
Deficiencies in Staff Training and Competency Tracking
Penalty
Summary
The facility was found to lack a system for tracking staff compliance with mandatory training requirements, leading to overdue trainings for two out of four sampled employees. Specifically, one licensed nurse and one certified nursing assistant (CNA) had not completed their annual mandatory trainings on time. The Director of Staff Development (DSD) confirmed that there was no tracking system in place to ensure these trainings were completed annually, which is a requirement according to the facility's Employee Benefits document and the DSD's job description. Additionally, the facility failed to ensure that a competent Director of Staff Development was in place to enforce training and verify competencies for nursing staff. This was evidenced by the fact that an unlicensed staff member's Basic Life Support (BLS) certification had been expired for 4.5 months while they were working at the facility. The DSD was unaware of this expiration and admitted that it was her responsibility to track current competencies and certifications, not the payroll department as she initially stated. Furthermore, during an observation, the unlicensed staff member was seen providing care without following proper infection control protocols, such as wearing a gown or washing hands after providing care to a resident. This incident, along with the expired BLS certification, highlighted the facility's failure to maintain sufficient and competent staffing as per their policy and procedure, which requires all staff to be appropriately trained and certified to perform their duties.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nursing staffing information was posted in a conspicuous place, as required, on one of the five days surveyed. On 7/08/24, it was observed that the staffing information posted was from the previous Friday, 7/05/24, indicating that the information had not been updated over the weekend. The Director of Staff Development confirmed this finding during an observation and interview, noting that the unit clerk was typically responsible for posting the information daily around 10:00 a.m. Further interviews revealed that the Staffing Coordinator was responsible for creating and posting the daily staffing information on weekdays, usually by 8:30 a.m. However, on weekends, this task was delegated to charge nurses, who did not always post the information if they were busy. The facility's policy required posting within three hours of each shift's start, but this contradicted federal regulations, which mandated daily posting at the beginning of each shift. This discrepancy led to the failure to post updated staffing information on 7/06/24 and 7/07/24, potentially impacting the ability of residents, visitors, and staff to review and advocate for appropriate staffing levels.
Failure to Act on Pharmacist's Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely responses from physicians and the Medical Director to the Pharmacist's Drug Regimen Review (DRR) reports, which are monthly summaries of each resident's medication irregularities. This deficiency was identified during a review of the monthly Drug Regimen Review binder, which revealed that for the months of May and June, there were no follow-up responses to the recommendations made by the Consulting Pharmacist. Additionally, previous months' reports from February, March, and April also showed incomplete documentation of physician responses or follow-through on the pharmacist's recommendations. Interviews conducted with the Consulting Pharmacist and the Director of Nursing (DON) highlighted the lack of timely follow-up and documentation. The Consulting Pharmacist noted that she had to actively seek out physicians for responses, although there had been some improvement with a new Medical Director. The DON acknowledged her oversight responsibility and admitted to not following through with the pharmacist's recommendations. The facility's policy, dated September 2018, requires that recommendations be acted upon within 30 days, but this was not adhered to, placing all residents receiving medications at risk for negative clinical outcomes.
Inappropriate Use of Psychotropic Medication for a Resident
Penalty
Summary
The facility failed to ensure that Resident 16 was free from unnecessary psychotropic drugs, specifically Seroquel, which was prescribed without proper justification or monitoring for aggression. Resident 16 was admitted with dementia without behavioral disturbance and a history of repeated falls. Despite this, she was prescribed Seroquel for aggression, although there was no documentation or evidence of aggressive behavior in her care plans or medical records. The Director of Staff Development (DSD) confirmed the absence of monitoring for aggression and the lack of evidence for other interventions prior to the administration of Seroquel. During observations, Resident 16 was noted to be pleasant and polite, with no signs of aggression. The prescribing physician, Physician R, was unavailable for an interview but indicated via text that Resident 16 had behavioral issues upon admission and suggested a gradual dose reduction. However, the facility's records did not support the presence of aggression, and the pharmacist had recommended discontinuing Seroquel due to the lack of aggression issues, but received no response from the physician. The facility's policy on psychotropic medications requires that such medications be used only when necessary and with proper documentation of the condition being treated. The policy also mandates that physicians respond to feedback from staff regarding medication use. In this case, the facility did not adhere to its policy, as there was no documented need for Seroquel, and the physician did not respond to the pharmacist's recommendation to discontinue the medication.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain the appropriate temperature for a medication refrigerator, which was consistently recorded at around 28 degrees Fahrenheit, below the required range of 36 to 46 degrees Fahrenheit. This issue persisted for several months, as indicated by the temperature logs dating back to December 2023. Medications stored in this refrigerator, including Lorazepam oral liquid for two residents and an emergency medication kit, were potentially compromised due to improper storage conditions. The Director of Staff Development (DSD) confirmed the findings and acknowledged the need for staff education on maintaining correct refrigerator temperatures. Additionally, the medication room door was found propped open and unattended, contrary to the facility's policy requiring it to be locked at all times. This lapse in security could have allowed unauthorized access to medications. Furthermore, an expired medication was discovered in a medication cart used for the south hall, stored alongside active medications. Licensed Staff I confirmed the presence of the expired medication, which was intended for resident use but was rarely utilized. The facility's policy mandates that outdated medications be returned to the pharmacy or destroyed, highlighting a failure to adhere to established procedures.
Inaccurate Fall Risk Assessments Lead to Resident Injuries
Penalty
Summary
The facility failed to maintain accurate medical records for a resident who suffered multiple falls, resulting in major injuries. The resident, who had a history of falling, Alzheimer's Disease, restlessness, and agitation, was inaccurately assessed as being at low risk for falls after a significant fall that resulted in a hip fracture. The fall risk assessment did not reflect the resident's true condition, including her history of falls, need for supervision with ambulation, incontinence, and the number of medications that increased her fall risk. This inaccurate assessment potentially contributed to inadequate care planning and interventions to prevent further falls. The resident experienced a second fall, resulting in another hip fracture. Although the subsequent fall risk assessment correctly identified the resident as high risk, it still inaccurately documented the number of medications increasing fall risk. The facility's policy on medical record documentation emphasizes the need for factual, complete, and accurate entries, which was not adhered to in this case. The Director of Nursing confirmed the inaccuracies in the fall risk assessments during a review of the resident's records.
Failure to Track and Surveil Chronic UTIs
Penalty
Summary
The facility failed to adhere to its Infection Control and QAPI policies by not tracking and surveilling data for residents with chronic urinary tract infections (UTIs). This deficiency was identified through interviews, observations, and record reviews. Licensed Staff A admitted to not tracking chronic UTIs, which is a critical component of the facility's infection control and QAPI processes. The lack of tracking and surveillance was confirmed during a review of the Infection Control Surveillance Report Tool, where the section for chronic infections was left blank for several months. This oversight was further highlighted by the absence of data for root cause analysis during QAPI and IDT conferences. Specific cases of residents with multiple UTIs were noted, including a resident who experienced three UTIs within three months and another resident with two UTIs in two months. Despite these occurrences, the facility did not capture or analyze data to investigate the root causes of these chronic infections. The facility's policies, including the Infection Control Plan and the QAPI program, emphasize the importance of systematic surveillance and data-driven quality improvement efforts, which were not followed in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Policies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions and Hand Hygiene policies, as observed during a survey. A staff member, identified as Unlicensed Staff F, was seen providing hygiene care to a resident who was incontinent of stool without wearing the required isolation gown. This occurred despite the presence of an Enhanced Barrier Isolation Cart outside the resident's room, which contained the necessary personal protective equipment (PPE) such as gloves, masks, and gowns. Furthermore, Unlicensed Staff F exited the resident's room without performing hand hygiene, either by washing hands or using hand sanitizer, after completing the care. During an interview, Unlicensed Staff F admitted to forgetting to wear a gown and to perform hand hygiene after providing care to the resident. Licensed Staff A confirmed that the care provided to the resident was considered a high-contact activity under the facility's Enhanced Barrier Precautions policy, which mandates the use of gowns and gloves, as well as hand hygiene before and after resident care. Licensed Staff A acknowledged the risk of a serious infection outbreak in the facility if such precautions are not followed. The facility's policies on Enhanced Barrier Precautions and Hand Hygiene emphasize the importance of using PPE and practicing hand hygiene to prevent the transmission of infections, including multiple drug-resistant organisms. The Infection Preventionist's role includes ensuring compliance with these procedures. The facility's policies also highlight the importance of treating residents with respect and dignity, and ensuring a safe and sanitary environment to prevent communicable diseases and infections.
Inadequate Training for CNAs in Abuse and Dementia Care
Penalty
Summary
The facility failed to provide adequate annual training in abuse and dementia care for three out of four unlicensed staff members, specifically Certified Nursing Assistants (CNAs) identified as Unlicensed Staff N, O, and P. During an interview and record review with the Director of Staff Development (DSD), it was revealed that Unlicensed Staff N received only one hour of abuse training and no dementia training. Unlicensed Staff O received one hour each of abuse and dementia training, while Unlicensed Staff P also received one hour each of abuse and dementia training. This was confirmed by the DSD during the interview. The facility's document titled 'Facility Assessment' from 2023 indicated that nurse aides are required to receive no less than 12 hours of in-service training annually, which must include dementia management and resident abuse prevention training. However, the DSD stated that the CNAs were provided with only about 5 hours of such training per year. This discrepancy highlights the facility's failure to meet the required training standards, potentially impacting the competency of the staff in providing quality care to residents.
Failure to Document Advance Directives and POLST
Penalty
Summary
The facility failed to ensure that a resident's medical records were updated to reflect discussions and documentation regarding advance directives and Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with serious medical conditions including pyonephrosis, kidney stones, sepsis, hypokalemia, and dysphagia, did not have an advance directive or executed POLST documented in their medical record. This oversight was identified during a record review, which revealed the absence of these critical documents. Interviews with facility staff, including the Social Services Director and Licensed Staff, highlighted gaps in the process of obtaining and documenting advance directives and POLST forms. The Social Services Director admitted that the process relied on verbal communication and manual checks of resident charts, which failed in this instance. Additionally, Licensed Staff confirmed that the resident's code status was not listed in the electronic medical administrative record, and a manual chart review showed an unexecuted POLST. The facility's policies required that residents be provided with information about their rights to make medical decisions and that POLST forms be completed and signed, but these procedures were not followed for the resident in question.
Deficient Care Plan for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to develop a resident-centered, comprehensive care plan for a resident with a stage 4 pressure ulcer. The resident, who was admitted with a pressure ulcer on the left heel and a history of repeated falls, was observed using a special boot on the left lower leg. A document titled 'Skin Only Evaluation' indicated that the resident had a stage 4 pressure ulcer on the left heel, with specific treatment orders including washing with normal saline, applying Medihoney, and covering with Mepilex dressing. However, the care plan initiated for the resident's pressure wound did not include these specific treatments and instead contained generalized interventions that were not resident-specific or measurable. During a review with the Director of Staff Development, it was confirmed that the care plan lacked specific information tailored to the resident's needs. The facility's policy on care plans emphasized the need for comprehensive, person-centered care plans with measurable objectives, but this was not reflected in the care plan for the resident. The interventions listed were basic and did not address the specific treatments ordered by the physician, leading to a deficiency in providing adequate care for the resident's pressure ulcer.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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