Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tulare Healthcare & Wellness Center, Lp during CMS and state inspections, most recent first.
A resident’s Release for Responsibility for Leave of Absence (RFRFLOA) form was left incomplete when the resident went out for an appointment. The form contained only the date and time out, with no nurse initials, no expected return time, and no documentation of the actual return time or nurse initials upon return. Multiple staff members, including a CNA, RN, LVNs, the Social Services Director, and the receptionist, stated that licensed nurses are responsible for completing the RFRFLOA with transport and when the resident leaves and returns, as required by the facility’s “Out on Pass” policy.
Food was not consistently served at palatable, safe temperatures for several residents, who reported meals were cold and tasteless. During observation, the RD measured hot items below the facility’s stated holding temp and milk above the cold holding temp. Vegetables were also being heated well before lunch and held until service, despite the DS stating they should be prepared as close to serving time as possible to preserve nutritive value.
Food service practices were not maintained according to professional standards. An opened dry pasta package was left in an unsealed plastic bag, produce boxes were not labeled with received dates, clean utensils were stored uncovered, green beans were plated without checking temperature, and a dirty pan was washed but not sanitized or air dried before being reused to warm soup. Facility policy required sealed storage, labeling and dating, temperature checks before serving, and sanitizing pots and pans before air drying.
Excessive Noise Disrupted Resident Rooms: A resident reported frequent hallway alarms, door alarms, and overhead paging that made it hard to rest, while two other residents also said noise in their rooms was loud and disruptive. Observations confirmed repeated alarm sounds from doors and the call light system, including alarms audible across hallways and overhead paging announcements heard near resident rooms. The DON/Administrator acknowledged the constant alarming was a concern for resident comfort and that overhead paging was being used instead of the phone system.
Missing Foley Catheter Care Plans for Three Residents: Three residents were observed with Foley catheter bags in place, and each resident's order summary showed an indwelling catheter with gravity drainage. During record review, the DON could not find a current care plan for the Foley catheter for any of the three residents, and one resident's care plan should have been completed when the catheter was initiated.
A resident's oxygen therapy order was not followed when the concentrator was observed set at 3 Lpm even though the order specified 2 Lpm via NC continuously every shift. An RN stated the resident was receiving 3 Lpm and was unsure of the oxygen order, then later confirmed the resident should have been receiving 2 Lpm. The facility policy stated oxygen and oxygen saturation levels were to be administered as ordered by the provider.
A pack of cigarettes and a working lighter were found unsupervised on a table outside near the 300 hallway exit door during an observation with the Administrator. The Administrator stated the pack contained 16 cigarettes and that anyone could have picked up the lighter and started a fire. The facility’s Smoking Residents policy requires individualized planning for safe storage, use of smoking materials, and needed supervision.
A facility failed to ensure three LVNs had competency validation before performing wound vac dressing changes for a resident with a stage 4 sacral pressure ulcer. The resident, who had intact cognition, said the wound vac was changed every two to three days and felt the staff doing it did not have the skills or training. Record review showed the wound vac was changed by the three LVNs, but none had a wound vac competency in their ECF, and the DON and DSD stated competency should have been completed before the procedure.
A resident received Risperdal without documented informed consent before the first dose and before the dose increase. During record review, staff could not produce a consent form for the psychotropic medication, and the facility policy stated the HCP must obtain informed consent and the nurse must verify it before administering the first or increased dose.
The facility failed to ensure an Ombudsman notice was sent when a resident was transferred to the hospital and later returned. The EHR showed the transfer and return, but interviews found no Ombudsman notification was completed. The SSD, RN, and DON gave differing expectations about who was responsible for the notice, and the facility policy required notification of the resident, responsible party if known, and Ombudsman before transfer or discharge.
The facility failed to ensure that one CNA had a completed initial competency evaluation upon hire. Record review showed the CNA was hired and the personnel file did not contain the required competency document, and the DSD confirmed the evaluation was not completed. Facility policy stated that competency validation is used to evaluate performance and that employees complete a competency skills assessment as part of the formal evaluation process.
The facility failed to ensure one CNA had an annual performance review completed. Record review showed the CNA's most recent evaluation was in 2024, and the DSD confirmed there was no annual performance evaluation in 2025 even though facility policy required formal evaluations at least annually.
Pharmacist MRR recommendation not implemented for a resident’s Lasix order. The MRR noted to consider continuing Lasix 20 mg PO daily, but MR confirmed the recommendation was not carried out and the medication was discontinued instead. The DON stated the expectation was to implement pharmacy recommendations within 24 hours, and there was no documentation that the physician was notified.
Improper medication labeling and unsafe storage were observed in the facility. Two med carts contained opened eye drops and an inhaler with missing or incomplete labels, one med cart was left unlocked and unattended, and a nurse left eye drops and a cup of Megace on a resident's bedside table without a physician order for bedside storage or a self-administer assessment.
Infection prevention and control was deficient when clean laundry bins were found with debris, clean pillows were stored in the dirty laundry area, and staff did not follow PPE requirements during wound care for a resident on EBP. An MD and NP provided sacral wound treatment without gowns, and an LVN did not properly clean and disinfect glucometers between resident uses, instead wrapping the devices in disinfectant wipes and placing them on the med cart.
A resident's feeding pump used for G-tube nutrition was observed sitting on an overbed table next to the bed instead of being attached to a pole. An LVN stated she did not know why the pump was not secured and said it could fall and should have been secured to the pole. The pump's IFU stated it is designed for use on a conventional IV pole.
Unsafe and poorly maintained environmental conditions were observed in multiple areas of the facility. Two dryer filters had thick lint buildup, a shower room ceiling had cracked and bubbling plaster, one housekeeping cart was missing its locking top and exposed chemicals, and cracks were seen in the flooring of two resident bathrooms. Staff interviews confirmed the conditions and that some issues had been known before the survey.
A dessert item on the written winter menu was changed from apple crisp to apple cake without required RD review and approval. A resident’s lunch tray was observed with cake instead of the planned dessert, and the substitution list documented the change due to the original item being out of stock but lacked RD initials. The CDM acknowledged making the substitution without notifying the RD, and the RD confirmed she had not been informed, contrary to facility P&P requiring dietitian review of all menu substitutions.
A resident with a fractured leg and chronic pain was left in bed while maintenance installed side rails using a power drill, causing the bed to shake and resulting in severe pain despite the resident's request to be moved. The procedure continued for about 15 minutes, and the DON later stated that maintenance should have stopped if pain was reported.
A resident with a left tibia fracture missed a scheduled orthopedic follow-up appointment because the facility did not arrange transportation as required. Documentation showed the need for the appointment and transportation, but the resident was not picked up, and the Social Service Designee confirmed that no alternative arrangements were made.
A resident with dementia and a history of elopement was found outside the facility without a required wander guard, despite care plan interventions and facility protocols mandating its use and monitoring. Staff observed the missing device but did not replace it, leading to the resident leaving unsupervised.
A resident reported that a CNA was rough during a wheelchair transfer, causing pain. Although the incident was documented and reported to the DON, the required SOC 341 abuse report was not sent to the Ombudsman as per facility policy, as confirmed by review of fax records and staff interviews.
A facility's generator failed during a planned power outage, leaving 13 residents who required oxygen concentrators without power for approximately 15 minutes. The generator malfunctioned due to a faulty oil pressure sensor, which was not detected during annual maintenance. This failure put residents at risk of respiratory distress.
The facility failed to follow infection control policies, including maintaining cleanliness in the laundry room, proper storage of cleaning tools, and adherence to PPE protocols. Nursing staff did not remove N95 masks after leaving precaution rooms, and some staff entered isolation rooms without full PPE. Hand hygiene was neglected, with CNAs wearing long false nails and not sanitizing hands between resident rooms. The facility also mixed clean and dirty items in utility areas and did not conduct required water testing for Legionella.
The facility failed to schedule regular resident council meetings, denying residents their right to organize and participate in such groups. The last meeting was recorded in July, and interviews revealed that one resident had only met once, while two others were unaware of the council's existence. The facility's policy required monthly meetings, but the administrator confirmed the last available notes were from July.
A resident's leg became red and swollen due to the facility's failure to follow physician orders to wrap the leg daily. Additionally, two residents did not receive required weekly nursing assessments, and three residents lacked assessments for self-administering medications, as observed by the DON and an LVN.
The facility did not complete activity assessments for five residents within the required timeframe, as per their policy. Additionally, an activity care plan was not developed for one resident, despite the policy requiring it after the initial assessment and MDS completion. These oversights meant the facility was unaware of the residents' activity preferences.
The facility did not complete Social Service Assessments (SSA) within the required seven days for three residents, potentially affecting their psychosocial needs. One resident's SSA was started late, while two others had their assessments completed six and nine days overdue, respectively. This was contrary to the facility's policy mandating timely completion of SSAs.
The facility failed to serve meals at safe and palatable temperatures for two residents, who reported consistently cold breakfasts. Observations showed uncovered meal carts and inadequate temperature checks, with food served below required temperatures. This non-compliance with facility policy potentially impacted residents' nutritional needs.
A Dietary Aide in the facility's kitchen failed to wash his hands after changing a sanitizer solution and before handling food, contrary to the facility's infection control policy. The aide acknowledged the oversight, which was observed during an interview. The policy requires hand washing during food preparation to remove contamination when changing tasks.
The facility failed to ensure that call lights were within reach for four residents, potentially preventing them from calling for assistance and delaying care. Observations showed call lights on the floor or behind beds, contrary to the facility's policy requiring them to be accessible. Staff confirmed the call lights should have been within reach.
A resident requested more information on advance directives, as noted in their AHCD. Despite the facility's policy requiring the Social Services Director or Designee to provide such information, the request was not fulfilled. The resident, who was cognitively intact, did not receive the requested information, resulting in a deficiency.
A former DON disclosed a resident's medical diagnosis to the resident's roommate, violating the facility's PHI policy. The incident was confirmed through interviews and a review of the resident's medical record, despite the DON having completed HIPAA education.
A resident with a Stage 3 pressure ulcer did not receive necessary preventative interventions as per the facility's policy. Despite recommendations for a Low Air Loss Mattress, the resident was observed on a regular mattress, and the Plan of Care lacked specific measures to prevent wound worsening. This led to a surgical procedure to remove non-living tissue, indicating a lapse in protocol adherence.
A PTA failed to use a facility-provided gait belt while assisting a resident with ambulation, instead holding onto the resident's pants waistband. The resident's care plan indicated a risk for falls due to balance issues, and the facility's policies required the use of gait belts for safety. The PTA used a personal, fraying gait belt, contrary to facility procedures.
A resident with chronic pain did not receive prescribed pain medications and non-pharmacological interventions as ordered, resulting in unmanaged pain and refusal to eat. The facility failed to administer Tylenol between scheduled Norco doses and did not consistently apply non-pharmacological interventions, despite the resident's high pain levels.
A resident did not receive their prescribed Brinzolamide for glaucoma due to the facility's failure to reorder the medication in a timely manner. The medication was unavailable for administration at scheduled times, as confirmed by an LVN and documented in the resident's records. The facility's policy required medications to be reordered three to four days in advance, which was not followed.
The facility failed to follow its medication storage policy, resulting in medications being found at residents' bedsides, improper storage of Aplisol, and mixing of topical and oral medications in carts. LVNs confirmed these practices were against policy, risking unauthorized access and cross-contamination.
A resident's need for a follow-up dental appointment was overlooked, resulting in her not wearing her loose lower denture. The resident's dental notes indicated that her dentures were 5-6 years old, and no follow-up appointment had been scheduled since her last dental visit. The MDSC confirmed the lack of follow-up dental notes and acknowledged the necessity for a denture realignment appointment.
The facility failed to honor meal preferences for two residents, leading to potential nutritional issues. One resident did not receive the requested juice, and another was served cheese despite a documented dislike. The Dietary Manager confirmed these discrepancies against the Meal Tray Tickets.
The facility failed to obtain a therapeutic diet order for a resident with no teeth and no dentures, who expressed difficulty eating due to their condition. The resident's care plan noted oral health problems and recommended consulting a dietitian if chewing issues were observed. However, the Registered Dietician did not recognize any chewing issues, maintaining a regular texture diet order. This oversight did not align with the facility's policy to ensure diets meet nutritional guidelines and physician orders.
The facility failed to maintain accurate medical records for two residents. One resident's MDS assessment inaccurately reported dental status, and their OSR included a discontinued medication order. Another resident's hospital transfer lacked a physician order, and their H&P and Discharge Summary were inaccessible. These issues contradict the facility's policy on accurate documentation.
The facility did not complete previous employment and personal reference checks for two RNs before hiring them. This was confirmed during a review of their employment records and an interview with the Administrator, who acknowledged the oversight. The facility's policy requires screening potential employees for any history of abuse, neglect, or mistreatment, which was not followed in these cases.
A resident who eloped from the facility was not monitored every 30 minutes as required. The resident was found outside and returned, but subsequent monitoring was inconsistent, with checks ranging from one to three times a day. The DON confirmed the monitoring did not meet the facility's policy for preventing further elopement.
A resident was discharged with another resident's medications due to a failure in the facility's medication verification process. The RN did not perform the required checks, leading to the potential risk of the resident taking incorrect medications. The error was identified when the medications were returned by the resident's family.
A resident with dementia and anxiety was disrespected by a CNA during a dinner service. The resident, known for swinging his arms, nearly hit the CNA, who responded by blocking his arm and telling him he "hits like a girl." The CNA admitted to raising her voice, which violated the facility's policy on treating residents with respect and dignity.
A resident experienced a significant change in condition requiring hospitalization, but the facility failed to notify the physician. The resident's responsible party confirmed the transfer to an acute hospital, and a review of the medical record showed no documentation of physician notification. The facility's administrator and DON acknowledged the lack of documentation, despite the facility's policy requiring such notification.
A resident was transferred to an acute hospital without an assessment or documentation of a significant change in condition by the nurse on duty. The facility's policy requires such documentation, but it was not followed, leading to a deficiency in meeting professional standards of quality.
A resident did not receive wound care as ordered, with missing documentation in the TAR for multiple dates. The resident had a Stage 2 pressure ulcer and abdominal wounds requiring specific treatments. Interviews with an LVN and the DON confirmed the absence of documentation, indicating treatments were not administered. Facility policy requires immediate documentation of treatments.
A resident under respite care fell while attempting to stand from her wheelchair, resulting in a black eye and a cut to the lip. The LVN notified the hospice agency but failed to inform the resident's responsible party, contrary to the facility's policy requiring notification of any change in condition, including falls.
Incomplete Leave-of-Absence Documentation for Resident Out on Pass
Penalty
Summary
The facility failed to follow its policy and procedure for documenting a Release for Responsibility for Leave of Absence (RFRFLOA) for one sampled resident. Review of the resident’s RFRFLOA form dated 4/10/26 showed that only the date and time out (10:00 a.m.) were recorded, while the nurse’s initials at time out, the expected date/time of return, the actual date/time of return, and the nurse’s initials at return were all left blank. The facility’s policy titled “Out on Pass” dated 2/2/26 required a licensed nurse to document the time the resident left the facility, the name of the accompanying responsible person, the destination, a contact phone number if possible, and the expected time of return, and to reassess the resident and account for medications upon return. Multiple staff interviews confirmed that it was the responsibility of the licensed nurse to complete the RFRFLOA when a resident left and returned to the facility. A CNA, an RN, two LVNs, the Social Services Director, and the Receptionist each stated that nurses were responsible for completing the RFRFLOA with the transport driver or when the resident left and returned. During a concurrent interview and record review, the Receptionist confirmed that the resident went to an appointment at 10:00 a.m. on 4/10/26 and that the RFRFLOA was not completed by the nurse at departure or upon return, despite the policy requirements.
Food Served at Improper Temperatures and Vegetables Prepared Too Early
Penalty
Summary
Food and drink were not consistently served at palatable and safe temperatures for four sampled residents. During interviews, Resident 38, Resident 86, Resident 76, and Resident 29 each stated that the facility food was usually cold and did not taste good. During a concurrent observation and interview, the Regional Registered Dietitian took temperatures of the last lunch meal tray and found the meatball at 115 F, pasta at 103 F, spinach at 113 F, and milk at 52 F. The Regional Registered Dietitian stated hot foods were to be held at 140 F and cold foods at 41 F, and also stated there were no specific temperature requirements for foods served in resident rooms and that food was expected to be palatable. The facility policy titled Food Temperatures stated food should be served promptly to maintain safe and palatable temperatures, with hot foods held at 140 F or higher and cold foods at 41 F or below at point of service. Vegetables were not prepared as close as possible to serving time for all sampled residents. During a concurrent observation and interview in the kitchen, two pans of vegetables were being heated on the stove burners for lunch and would be held in the oven until served. The Dietary Supervisor stated one pan contained diced carrots and the other contained vegetable soup, and stated the vegetables should be prepared as close to serving time as possible to conserve their nutritional value. The facility policy titled Vegetable Cookery stated dietary staff ensure food is prepared in a manner that preserves quality and maximizes nutrient retention, and that vegetables are to be prepared as close to time of service as possible to maintain highest quality.
Food Storage, Temperature, and Sanitizing Deficiencies
Penalty
Summary
Food storage and preparation practices were not maintained according to professional standards in the dietary area. During observation with the Dietary Supervisor, an opened package of spaghetti pasta was found on a shelf inside a plastic bag that was not sealed. In a storage room, one box each of oranges, potatoes, and apples were observed without received dates. In another storage area, two uncovered tubs of clean cooking utensils were on a wire rack, and the Dietary Supervisor stated they should have been covered to help keep them clean. During meal service, a pan of green beans was removed from a tabletop steamer and plated without the temperature being checked first, and the Regional Registered Dietitian stated it should have been taken before plating. In a separate observation, dietary staff washed a dirty pan at the three-compartment sink, but the pan was not placed into sanitizer and was not allowed to air dry before reuse; the wet pan was then used to warm tomato soup served with lunch. Facility policies reviewed during the survey addressed sealing opened dry goods, labeling and dating produce, taking food temperatures before serving, and sanitizing pots and pans before air drying.
Excessive Noise Disrupted Resident Rooms
Penalty
Summary
The facility failed to ensure a homelike environment with comfortable sound levels and reduced chronic noise for three sampled residents. During observations, alarm sounds and overhead paging announcements were heard coming from the hallway outside Resident 38's room, and alarm sounds were also heard outside Resident 86's room. Additional observations in other resident rooms and hallways showed repeated alarm sounds from doors and the call light system throughout the facility. In Resident 38's room, the resident stated she preferred her door remain closed because of the noises in the hallway. She reported hearing alarms sounding, doors slamming, and overhead paging announcements frequently, which prevented her from getting rest. Resident 38 also stated she liked her room to be quiet and later said the facility had recently changed the call light system and she could now hear the call light alarms constantly. Resident 86 stated it was loud sometimes in her room and that she preferred her door kept closed because the alarms and overhead announcements were so loud and occurred frequently, making it hard to rest. During another observation, Resident 53 was in her room and stated the beeping sound from the hallway bothered her when she was trying to rest. Staff observations showed the call light panel alarming in hallway 300, with the alarm system sounding for rooms throughout the facility, and the Administrator stated there was no reason hallway 300 should hear call lights for rooms in the 100 and 200 hallways. The Administrator also stated there was no reason staff had to use the overhead paging system when they could use the phone system instead, and acknowledged the constant alarming would be a concern for residents' comfort due to the noise levels.
Missing Foley Catheter Care Plans for Three Residents
Penalty
Summary
The facility failed to follow its Person-Centered Care Planning policy and procedure for three residents by not having care plans in the medical record that addressed their indwelling Foley catheters. During observation, Resident 64 was seated in a wheelchair in her room with a Foley catheter bag containing yellow urine attached to the left side of the bed railing. Her order summary indicated an indwelling catheter with gravity drainage for urinary retention, and the DON later reviewed the record and stated there was no Foley catheter care plan and that it should have been done when the catheter was initiated. Resident 5 was observed in bed with a Foley catheter bag containing yellow urine attached to the right side of the bed railing, and his order summary showed an indwelling catheter with gravity drainage for unspecified hydronephrosis. When the DON reviewed the record, she was unable to provide evidence of a current Foley catheter care plan. Resident 10 was also observed in bed with a Foley catheter bag containing yellow urine, and his order summary showed an indwelling catheter with gravity drainage. The DON reviewed the record and stated she was unable to find a care plan that addressed Resident 10's Foley catheter.
Oxygen Therapy Order Not Followed
Penalty
Summary
The facility failed to ensure that Resident 98 received oxygen therapy according to the physician order. The Order Summary Report dated 3/7/26 indicated oxygen at 2 Lpm via nasal cannula continuously every shift, but during a concurrent observation and interview on 3/9/26 at 10:27 a.m., Resident 98 was observed in bed wearing a nasal cannula and the oxygen concentrator was set at 3 Lpm. RN 1 stated the resident was receiving 3 Lpm of oxygen and was unsure of the resident's oxygen orders. During a follow-up interview at 10:31 a.m., RN 1 stated Resident 98 should have only been receiving oxygen at 2 Lpm. The facility policy titled Oxygen Therapy, dated 10/21/25, stated oxygen and oxygen saturation levels were to be administered as ordered by the provider.
Unsupervised Smoking Materials Left Near Exit Door
Penalty
Summary
The facility failed to maintain an environment free of accident hazards when, during a concurrent observation and interview with the Administrator, a pack of cigarettes and a working lighter were found unsupervised on a table outside near the 300 hallway exit door. The Administrator stated there were 16 cigarettes in the pack and that anyone could have picked up the lighter and started a fire. The report also cited the facility’s Smoking Residents policy, which requires the IDT to develop an individualized plan of care for safe storage, use of smoking materials, and any needed assistance or supervision, and the Resident Rooms and Environment policy, which states the facility provides a safe, clean, comfortable, and homelike environment.
Failure to Validate Wound Vac Competency for LVNs
Penalty
Summary
The facility failed to ensure three of three sampled LVNs completed competency validation for wound vac dressing changes before performing care on a resident with a stage 4 pressure ulcer to the sacral region. Resident 7 had a BIMS score of 14 and an order for wound vac treatment every Tuesday, Thursday, and Saturday. The resident stated the wound vac was changed every two to three days and expressed concern that the nursing staff who changed it did not have the skills or training to do it. During record review and interviews, the TAR showed the resident’s wound vac dressing was changed on 3/3/26, 3/5/26, and 3/7/26. The DSD stated LVN 1 changed the dressing on 3/5/26, LVN 2 changed it on 3/5/26, and LVN 3 changed it on 3/7/26. The DON stated nursing staff should have competencies in their file before performing a wound vac dressing change. Review of each LVN’s ECF showed no competency evaluation for wound vac dressing changes, and the DSD stated each LVN should have had training with return demonstration or competency evaluation before performing the procedure. The facility’s Staff Competency Validation policy stated competency validation is completed to evaluate performance and protect the health, safety, and well-being of residents. The manufacturer’s guidelines for the NPWT system stated it should only be used by qualified and authorized personnel with the necessary knowledge of the specific medical application.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 8 had informed consent for psychotropic medication before administration. Resident 8’s order details showed Risperdal 0.5 mg by mouth daily beginning 7/27/25, and later an increase to Risperdal 0.5 mg twice a day on 8/22/25. During interview and record review, Medical Record staff were unable to provide a Risperdal consent form for the daily dose started on 8/27/26 or for the increased twice-daily dose. The facility’s Informed Consent policy stated that if a resident lacks capacity, the surrogate decision-maker provides consent, the healthcare practitioner is responsible for obtaining informed consent, and the licensed nurse verifies that informed consent was obtained and documents that verification before administering the first dose or first increased dose of psychoactive medication.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to ensure that a discharge notice was sent to the Ombudsman for Resident 85 when the resident was transferred to the hospital and later returned to the facility. Review of the resident’s EHR showed the resident was transferred to the hospital and came back to the facility on 1/3/26. During interviews, the SSD stated there was no Ombudsman notification for Resident 85 and said nurses should notify the Ombudsman when residents are transferred to the hospital. RN 2 stated nurses do not notify the Ombudsman for any discharges to the hospital or home. The DON stated the expectation was for the SSD to notify the Ombudsman each time a resident was transferred or discharged to the hospital. The facility policy titled Notice of Transfer/Discharge stated that before a transfer or discharge occurs, the facility must notify the resident, if known the responsible party, and the Ombudsman of the transfer and reasons for the transfer, and document it in the resident’s clinical record.
Missing CNA Competency Evaluation
Penalty
Summary
The facility failed to ensure that one of five sampled staff members, CNA 2, had a completed initial competency evaluation upon hire. During a concurrent interview and record review on 3/12/26 at 10:15 a.m. with the Director Staff Development, CNA 2's personnel file was reviewed and showed that CNA 2 was hired on 4/23/25, but there was no initial competency evaluation document in the file. The Director Staff Development stated that CNA 2's initial competency evaluation was not completed. The facility's Staff Competency Validation, dated 3/28/24, stated that competency validation is completed to evaluate an individual's performance, evaluate group performance, meet standards set by regulatory agencies, address problematic issues, and enhance performance review. The facility's policy and procedures titled Performance Review, dated May 23, 2019, stated that approximately two weeks prior to the evaluation, the employee will be given a copy of their job description, a performance evaluation form, and the competency skills assessment specific to their position, and the employee will complete the self-assessment portion of the Competency Skills Assessment.
Failure to Complete Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure that one of five staff members, Certified Nursing Assistant (CNA) 1, completed an annual performance review. During a concurrent interview and record review on 3/12/26 at 10:15 a.m. with the Director of Staff Development, CNA 1's personnel file was reviewed and showed the most recent performance evaluation was completed on 8/30/24. The Director of Staff Development stated CNA 1 did not have an annual performance evaluation in August 2025 and should have had one completed. The facility's policy and procedures titled Performance Review, dated 5/23/19, stated formal evaluations for full-time and part-time employees are to be conducted at a minimum annually.
Pharmacist MRR Recommendation Not Implemented
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly medication regimen review recommendation was acted upon for Resident 85. Resident 85’s Order Summary Report showed Lasix 20 mg daily for seven days, from 1/10/26 to 1/17/26. During record review, the resident’s MRR dated 1/17/26 stated, “consider continuing Lasix 20 mg po daily,” but Medical Records staff confirmed the pharmacist’s recommendation was not implemented and that the Lasix was discontinued on 1/17/26 and not continued. The Director of Nursing stated the expectation was to implement pharmacy recommendations documented on the MRR within 24 hours and confirmed there was no documentation that the physician was notified of the pharmacist’s recommendation. The facility policy titled Consultant Pharmacist Reports stated nursing items would be initially reviewed and addressed within 14 days and final action taken in not more than 30 days or by the next monthly pharmacist MRR.
Improper Medication Labeling and Unsafe Storage
Penalty
Summary
Medications and biologicals were not properly labeled in two of four sampled medication carts. During observation and interview, Med Cart 1 contained an opened bottle of Geri Care artificial tears eye drops with a ripped label that showed only a resident's last name on the outer packaging, another opened bottle of Geri-Care artificial tears eye drops with no label on the vial and only the resident's first name and room number on the outer packaging, and an albuterol inhaler with a ripped label showing only a partial name and partial directions for use. Med Cart 2 contained an opened, unlabeled bottle of Refresh eye drops. Staff stated the items should have been labeled properly, and the facility policy required prescription labels to be permanently affixed or placed on an outside container or carton with the resident's name, medication name, strength, prescriber's name, date dispensed, quantity dispensed, and expiration date. Medications were also not stored in a safe and secure manner. Med Cart 2 was observed unlocked and unattended, and staff stated it should not have been unlocked and that medication carts should be locked when not actively being used to pull medications. In Resident 44's room, a bottle of Systane eye drops and a medication cup containing 5 ml of white liquid medication identified by staff as Megace were left on the bedside table. The nurse stated he handed the morning dose of Megace to Resident 44 but did not watch the resident take it. Medical records showed Resident 44 had no physician order to keep medication at bedside, no self-administer order, and no self-administer assessment. The facility policy stated bedside medication storage is permitted only for residents who are able to self-administer, with a written prescriber order and storage that prevents access by other residents.
Infection Prevention and Control Program Deficiency
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility did not follow infection prevention practices in the laundry room, during resident care, and with blood glucose meter disinfection. During a concurrent observation and interview in the laundry room, one clean laundry bin had dirt-like debris and pieces of material at the bottom, and another unmarked laundry bin containing clean pillows was stored in the dirty laundry area. Facility staff stated the clean pillows were kept there because there was not enough storage space, and the maintenance supervisor stated the dirty bin should have been cleaned and the trash removed. During wound care for a resident on enhanced barrier precautions, the resident was in bed and undressed from the waist down while the MD and NP assisted with positioning and wound treatment to the sacral wound. The resident had a sign above the bed indicating enhanced barrier precautions, but the MD and NP were not wearing gowns during the wound treatment. When interviewed, both stated they should have been wearing gowns, and the MD stated he forgot. During blood glucose monitoring for two residents, an LVN used two glucometers and then removed disinfectant wipes, folded them around each glucometer, and placed the devices on the medication cart without wiping the surfaces. The LVN later stated the glucometers should have been wiped down before being placed on the cart and that she only wrapped them in wipes. The facility policy required reusable resident care equipment to be decontaminated between residents according to manufacturer instructions, and the glucometer manufacturer instructions stated the meter should be cleaned and disinfected after each patient and specifically said not to wrap the meter in a wipe.
Feeding Pump Not Secured to Pole
Penalty
Summary
The facility failed to ensure that one sampled resident's feeding pump used to deliver feeding and nutrition through a G-tube was secured to a pole. During an observation in the resident's room, the feeding pump was seen sitting on the overbed table next to the resident's bed. During a later concurrent observation and interview, the pump was again observed on the overbed table next to the bed, and the LVN stated she did not know why it was there instead of attached to the pole. The LVN stated the pump could fall and should have been secured to the pole. Review of the Kangaroo Enteral Feed and Flush Pump with Pole Clamp instructions for use indicated the device is designed for use on a conventional IV pole.
Unsafe and Poorly Maintained Environmental Conditions
Penalty
Summary
Two of two laundry dryer filters were observed with thick lint buildup during a concurrent observation and interview with the Maintenance Supervisor in the laundry room. The Maintenance Supervisor stated the laundry aide must not have cleaned the dryer filters. The facility policy and procedure for laundry required cleaning the dryer lint compartment and screens, and another laundry policy stated that lint filters were to be cleaned after each use of the washing machine or dryer and at least daily. A shower room ceiling had cracked and bubbling plaster around the ceiling light during a concurrent observation and interview with the Maintenance Supervisor, who stated the ceiling plaster was cracked and needed repair. One of two housekeeping carts in the 300-wing hallway was missing the locking top, exposing housekeeping chemicals; the Housekeeper stated the top broke three days earlier, and the Maintenance Supervisor stated he had been notified about the broken cart two or three weeks earlier. In addition, cracks were observed in the flooring around the toilet in Resident 102's bathroom and in Resident 99's bathroom, and the Maintenance Supervisor acknowledged the cracks in the flooring.
Unapproved Menu Substitution Without RD Notification
Penalty
Summary
The facility failed to follow its menu and substitution policy when a planned dessert item was changed without required approval from the Registered Dietician (RD). On the winter menu for a specific lunch date, the written menu indicated that chicken jambalaya, seasoned zucchini with parsley garnish, garlic bread, apple crisp, and milk were to be served. During observation of a resident’s lunch tray in the hallway, the tray instead contained macaroni and cheese, zucchini, and a large piece of cake. Review of the facility’s substitution list for that date showed that apple crisp had been replaced with apple cake due to the apple crisp being out of stock, and the section for RD initials was left blank. In an interview, the Certified Dietary Manager (CDM) stated that apple cake was substituted for apple crisp because not all ingredients for the apple crisp were available and acknowledged that the RD should have been called to approve the substitution but was not. In a separate interview, the RD confirmed she had not been made aware of the substitution and stated she should have been notified prior to the change. Review of the facility’s “Menus” policy and procedure indicated that foods served should adhere to the written menu and that any substitutions must be reviewed by both the dietary manager and the dietitian for appropriateness per the diet order and recorded on the substitution list. The failure to obtain RD review and approval for the dessert substitution was identified as having the potential to place residents at risk of inadequate nutrition.
Failure to Accommodate Resident Needs During Bed Rail Installation
Penalty
Summary
A deficiency occurred when a resident with a left tibia fracture and chronic pain syndrome was left lying in bed while maintenance staff installed metal side rails using a power drill. Despite the resident's request to be removed from bed and placed in a wheelchair due to pain, maintenance continued drilling for approximately 15 minutes, causing the bed to shake and resulting in severe pain for the resident. The resident reported crying and experiencing significant discomfort during the incident. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a full support brace on the affected leg. The maintenance staff stated that the installation was ordered by the DON and confirmed that the procedure was performed while the resident remained in bed. The DON acknowledged that maintenance should have stopped if the resident complained of pain. Facility policy states that residents have freedom of choice regarding their care, but this was not accommodated during the event.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident with a left tibia fracture to attend a scheduled follow-up appointment with an orthopedic doctor. The resident's admission record and order summary indicated the need for a follow-up appointment and transportation arrangements. Progress notes documented the scheduled appointment, but the resident was not picked up by transportation and missed the appointment. During an interview and record review, the Social Service Designee confirmed that transportation was not arranged and acknowledged that the facility should have notified transportation and attempted to find an alternative provider. The facility's policy stated that the Social Service Department could coordinate transportation to outside services as necessary.
Failure to Implement Elopement Prevention Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with a known history of elopement attempts. The resident, who had dementia and a moderate cognitive impairment as indicated by a BIMS score of 9, was identified as being at risk for wandering and elopement. The care plan required that a wander guard be placed on the resident every shift and that its placement and function be monitored. However, on the day of the incident, staff observed the resident without a wander guard, and multiple staff interviews confirmed that the device was not replaced when missing, despite facility protocol requiring immediate replacement. The resident was last seen in the facility hallway and was later found unsupervised outside the facility, approximately 0.2 miles away. Staff interviews revealed that the LVN noticed the missing wander guard but did not replace it, believing it was not her responsibility. The DON confirmed that the resident was not wearing the required wander guard when found outside. Facility policies required comprehensive assessment and implementation of resident-centered care plans to mitigate safety risks, but these were not followed in this instance, resulting in the resident eloping from the facility.
Failure to Report Alleged Abuse to Proper Authorities
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the timely reporting of an allegation of abuse. Specifically, a resident reported to the DON that a male CNA was rough on purpose during a wheelchair transfer, which caused the resident pain. Progress notes documented the resident's statement, and the DON confirmed the report was made. However, during a review of records and interviews, it was determined that the required SOC 341 form, which is used to report suspected abuse, was not sent to the Ombudsman as mandated by facility policy. The fax transmittal record showed the form was not sent to the correct fax number for the Ombudsman, and the Administrator confirmed the omission. The facility's policy required that the SOC 341 be sent to the Ombudsman, Law Enforcement, and CDPH Licensing Certification within two hours of the allegation.
Generator Failure During Power Outage
Penalty
Summary
The facility failed to provide a working generator for 13 residents who required oxygen concentrators during a planned power outage. The generator, which was supposed to supply power during the outage, malfunctioned due to a faulty oil pressure sensor. This malfunction was not detected during the annual maintenance of the generator, leading to a power loss for approximately 15 minutes. During this time, the residents who depended on oxygen concentrators were at risk of being without oxygen, potentially leading to respiratory distress. The issue was identified during an interview with the Administrator, who confirmed the generator's failure during the planned outage. The Maintenance Environmental Services staff also confirmed the generator's malfunction and attributed it to the oil pressure sensor failure. The Director of Nurses acknowledged that all 13 residents required oxygen concentrators, highlighting the critical nature of the generator's failure. The facility's policy on emergency generator testing, dated 9/2017, indicated that generators should be maintained in an operational state, but this was not adhered to, resulting in the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures across multiple areas, leading to potential risks of spreading infectious diseases. In the laundry room, the Environmental Services Director (ESD) and housekeepers observed unclean conditions, including dusty debris, cobwebs, and personal items in the clean area, which violated the facility's policy for maintaining a clean and sanitary environment. Additionally, a used toilet brush was improperly stored on a clean housekeeping cart, contrary to the facility's housekeeping policy. Nursing staff also failed to follow personal protective equipment (PPE) protocols. Two staff members, an LVN and a CNA, did not remove their N95 masks before leaving a transmission-based precaution room, as required by the facility's PPE policy. Furthermore, a speech therapist and a housekeeper entered a droplet precaution isolation room without wearing the full required PPE, despite clear signage indicating the necessity for gowns, gloves, and face shields. Hand hygiene practices were not consistently followed, with CNAs providing resident care while wearing long false nails and failing to perform hand hygiene before entering and after exiting residents' rooms. The facility also did not maintain separate clean and dirty utility areas, as required by CDC guidelines, leading to the mixing of clean and dirty items. Additionally, the facility did not conduct water testing for Legionella, as mandated by CMS guidelines, which could lead to the growth and spread of the bacteria in the water system.
Failure to Schedule Regular Resident Council Meetings
Penalty
Summary
The facility failed to arrange regularly scheduled resident council meetings for three sampled residents, resulting in the denial of their right to organize and participate in resident/family groups. The last recorded resident council meeting was held on July 29, 2024, as indicated by the Resident Council Minutes. Interviews conducted on October 22, 2024, revealed that one resident stated they had only met once, while two other residents were not aware of the existence of a resident council. The facility's policy and procedure, dated November 1, 2013, stated that resident council meetings should be scheduled monthly or more frequently if requested. However, the administrator confirmed that the last meeting notes available were from July 29, 2024.
Failure to Follow Physician Orders and Conduct Assessments
Penalty
Summary
The facility failed to adhere to physician orders for a resident, resulting in the resident's left leg becoming red and swollen. The resident, who was alert and oriented, reported that her leg should have been wrapped daily as per physician orders, but staff had not done so for several days. A family member confirmed that the leg had not been wrapped since the resident's admission to the facility. A Licensed Vocational Nurse (LVN) acknowledged the physician's order to wrap the leg daily and confirmed that the leg was not wrapped during observations. The facility administrator admitted that there was no policy in place for following physician orders. Additionally, the facility did not complete weekly nursing assessments for two residents, which are crucial for monitoring changes and progress in resident status. The Director of Nursing (DON) and an LVN confirmed that these assessments were not conducted as required. Furthermore, the facility failed to follow its policy on medication self-administration for three residents, as assessments to determine their capability to self-administer medications were not completed. This oversight was observed through the presence of eye drops in residents' rooms without proper assessments documented in their medical records.
Failure to Complete Activity Assessments and Care Plans
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Activity Program' by not completing activity assessments for five sampled residents. Specifically, the Minimum Data Set Coordinator (MDSC) confirmed that activity assessments were missing for residents admitted or readmitted on various dates, including Resident 337, Resident 46, Resident 438, Resident 42, and Resident 41. The facility's policy required that these assessments be completed within seven days of admission, but this was not done for any of the mentioned residents. The absence of these assessments meant the facility was not aware of the residents' activity preferences. Additionally, the facility did not complete an activity care plan for Resident 438, as required by their policy. The policy stipulated that after the initial activity assessment and the Minimum Data Set (MDS) are completed, an individualized care plan should be developed and implemented for each resident. However, the MDSC confirmed that no care plan was in place for Resident 438, indicating a failure to follow through with the necessary steps to ensure the resident's activity needs were met.
Failure to Timely Complete Social Service Assessments
Penalty
Summary
The facility failed to complete Social Service Assessments (SSA) within seven days of admission for three residents, potentially impacting their psychosocial needs. Resident 337 was admitted on an unspecified date, but their SSA was not started until 10/21/24. Resident 388 was admitted on 10/8/24, and their SSA was completed on 10/21/24, six days overdue. Resident 438 was admitted on 10/12/24, and their SSA was completed on 10/21/24, also late. The facility's policy requires SSAs to be completed within seven days of admission, which was not adhered to in these cases.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a safe and palatable temperature for two residents. Resident 41 reported that their breakfast was cold and bland, while Resident 42 stated that breakfast was consistently cold, particularly the sausage and eggs. Both residents were cognitively intact, with BIMS scores of 13 and 15, respectively. Observations revealed that meal carts in the B-wing hallway were not covered, and it took approximately 10 minutes to distribute meal trays, contributing to the food cooling down. A CNA confirmed that residents had complained about cold food and that the open food cart contributed to the issue. The facility's policy required meat and eggs to be served at temperatures above 140 degrees, with instructions to reheat if temperatures were not met. In another instance, a dietary aide failed to take the temperature of bread pudding before serving it on a lunch tray. The dietary manager confirmed that all food should have its temperature checked before serving. A random lunch tray was tested, revealing that the pork was at 117.8 degrees, carrots at 121.1 degrees, and rice at 134.9 degrees, all below the required serving temperatures. The facility's policy indicated that meat entrees and other hot foods should be served at temperatures higher than 140 degrees, with a preferred range of 160 to 175 degrees. The failure to adhere to these temperature guidelines resulted in meals being served at unsafe and unappetizing temperatures, potentially affecting residents' nutritional intake.
Failure to Follow Hand Hygiene Protocol in Dietary Department
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Dietary Department-Infection Control' when a Dietary Aide (DA) did not wash his contaminated hands before returning to food service. During an observation and interview, the DA was seen changing the red bucket sanitizer solution and placing the bucket back on the counter. Immediately after, the DA resumed handling food without performing hand hygiene. The DA acknowledged that he should have washed his hands before returning to handle food. The facility's policy indicated that proper hand washing should occur during food preparation as often as necessary to remove soil and contamination when changing tasks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for four residents were within their reach, which could potentially prevent them from calling for assistance and delay care provision. During observations and interviews, it was noted that Resident 337's call light was found on the floor on the right side of her bed, making it inaccessible. Certified Nursing Assistant (CNA) 6 confirmed that the call light should have been within the resident's reach. Similarly, Resident 70's call light was observed on top of the bed frame behind the head of the bed, out of reach, as confirmed by the Director of Nursing (DON), who stated that the call light should be clipped to the sheet. Further observations revealed that Resident 10's call light was hanging on the wall behind the bed, and CNA 7 acknowledged that it should have been within reach. Additionally, Resident 41's call light was found on the floor, out of reach, as confirmed by Licensed Vocational Nurse (LVN) 1. The facility's policy and procedure on the communication-call system, dated 10/09/24, clearly indicated that the call alert device should be placed within the resident's reach. This failure to adhere to the policy resulted in the deficiency noted in the report.
Failure to Provide Requested Information on Advance Directives
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives, resulting in a deficiency. A resident, identified as Resident 41, requested more information on advance directives, as indicated in their Advance Health Care Directive (AHCD) dated June 7, 2024. However, during an interview and record review with the Administrator on October 24, 2024, it was found that no information was provided by social services, and there were no progress notes documenting the provision of additional information. The facility's policy, dated July 31, 2024, states that if a resident requests more information on advance directives, the Social Services Director or Designee should provide a copy of the Advance Directive form for review. Despite this policy, the resident's request was not fulfilled, leading to the identified deficiency. Resident 41 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 13 on May 31, 2024, and 14 on September 12, 2024, indicating their capability to make informed decisions.
Breach of Resident's PHI by Former DON
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information (PHI) as per their policy and procedure titled 'Disclosure of PHI'. This breach occurred when the former Director of Nursing (FDON) disclosed one of Resident 61's medical diagnoses to Resident 61's roommate, Resident 15. The incident came to light when Resident 61's family member was questioned by Resident 15 about the medical condition, which Resident 15 had learned from the FDON. The FDON had previously completed the facility's Health Information Portability and Accountability Act (HIPAA) education, which emphasizes the importance of protecting PHI. The facility's policy, dated December 1, 2012, aims to limit the access, use, and disclosure of PHI to the minimum necessary to accomplish the intended purpose. Despite this, the FDON, who was employed at the facility from October 16, 2023, to July 12, 2024, disclosed sensitive health information without authorization. This disclosure was confirmed through interviews with Resident 15, the Administrator, and the Payroll Clerk, as well as a review of Resident 61's medical record, which included the diagnosis in question.
Failure to Implement Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to adhere to its policies and procedures for pressure injury prevention for a resident with a Stage 3 pressure ulcer. The resident, who was admitted with a pressure injury to the sacrum, did not receive the necessary preventative interventions as outlined in the facility's policy. Despite the presence of a Stage 3 pressure wound for over 19 days, the resident was observed lying on a regular mattress instead of a Low Air Loss Mattress, which was recommended to off-load pressure and prevent further skin breakdown. Interviews with staff confirmed that the resident was not provided with the appropriate pressure-relieving mattress. The resident's Plan of Care did not include specific measures to prevent the worsening of the pressure wound, despite the resident being at moderate risk for skin breakdown according to the Braden scale. The facility's policy on pressure injury prevention included the use of pressure redistributing devices and positioning aids, but these were not implemented for the resident. This oversight resulted in the need for a surgical excisional procedure to remove non-living tissue from the resident's pressure wound, highlighting a significant lapse in the facility's adherence to its own protocols for pressure injury prevention.
Failure to Use Gait Belt During Resident Ambulation
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the use of gait belts during resident ambulation, as observed with Resident 438. A Physical Therapy Assistant (PTA) was seen assisting Resident 438 to walk by holding onto the resident's pants waistband instead of using a facility-provided gait belt. The gait belt on Resident 438 was noted to be fraying, indicating wear and tear. The PTA admitted to not using a gait belt, despite acknowledging its role in reducing falls and maintaining resident safety. The PTA used his own gait belt, which was not in optimal condition, rather than a facility-provided one. Resident 438's care plan highlighted a tendency to lose balance during transfers and ambulation due to decreased motor planning, safety awareness, increased loss of balance, leg weakness, and pain, placing the resident at risk for falls. The care plan included interventions such as gait training and safety measures. The facility's policies, dated 9/16 and 1/1/12, emphasized the use of gait belts to assist clinical staff in moving residents safely and to prevent falls, specifying the use of an underhand grasp for greater safety. The Director of Rehabilitation Services confirmed that holding residents by their pants during ambulation was not appropriate.
Failure to Follow Pain Management Orders
Penalty
Summary
The facility failed to adhere to physician orders for pain management for a resident, resulting in unmanaged pain and refusal to eat. The resident, who experienced chronic pain in the knees, feet, and back, reported a pain level of 8 out of 10. Despite having physician orders for Norco and Tylenol to manage pain, the resident did not receive Tylenol as needed between scheduled doses of Norco. An LVN was unable to administer pain medication during a lunch break due to not having access to the narcotic drawer, further contributing to the resident's unmanaged pain. Additionally, the facility did not implement non-pharmacological interventions as ordered for the resident. The resident's Medication Administration Record indicated that non-pharmacological interventions were not consistently applied on several occasions when the resident reported pain. The resident's plan of care emphasized the need for timely pain relief and evaluation of pain interventions, but these measures were not followed, leading to the resident experiencing significant pain and refusing meals.
Failure to Timely Reorder Medication for Resident
Penalty
Summary
The facility failed to reorder medication in a timely manner for one of the residents, identified as Resident 28, which resulted in the resident not receiving his physician-ordered medication. Resident 28 was prescribed Brinzolamide Ophthalmic Suspension 1% to be instilled as one drop in both eyes three times a day for glaucoma. On the date of the survey, it was observed and confirmed through an interview with LVN 6 that the 12 p.m. dose of Brinzolamide was not available for administration. A review of Resident 28's Medication Administration Record indicated that the doses scheduled for 12 p.m. and 5 p.m. were missed. Additionally, the facility's progress notes documented that the eye medication was missed earlier that day. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply, which was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure titled 'Medication Storage in the Facility' for three residents when medications were found at their bedsides. During observations, single-use vials of eye drops were found on the bedside tables of three residents. A Licensed Vocational Nurse (LVN) confirmed that medications should not be at the bedside as it allows unauthorized access. The facility's policy indicates that medications should be stored safely and securely, accessible only to authorized personnel. Additionally, the facility did not follow the manufacturer's instructions for storing Aplisol, a tuberculosis testing medication, which was found in a medication cart instead of being refrigerated as required. This could lead to a loss of potency and inaccurate test results. Furthermore, the facility's policy was not followed when topical and oral medications were stored together in medication carts, risking cross-contamination. LVNs acknowledged that medications should be stored separately, as per the facility's policy.
Failure to Schedule Follow-Up Dental Appointment
Penalty
Summary
The facility failed to ensure that a resident received a follow-up dental appointment, which was necessary for the adjustment of her dentures. During an observation and interview, the resident indicated that her lower denture was loose, leading her to not wear it. A review of the resident's dental notes revealed that her dentures were 5-6 years old, and there was no record of a follow-up appointment with the dentist since her last visit several months prior. The Minimum Data Set Coordinator confirmed the absence of follow-up dental notes and acknowledged that a follow-up appointment should have been scheduled for denture realignment.
Failure to Honor Meal Preferences for Residents
Penalty
Summary
The facility failed to honor meal preferences for two residents, which could potentially impact their nutritional needs. In the first instance, a Certified Nursing Assistant (CNA) delivered a lunch tray to a resident that was missing the requested juice. The Meal Tray Ticket (MTT) for this resident indicated that 4 ounces of juice should have been included, but it was not present. The resident confirmed that he did not receive the juice he had requested. In the second instance, another resident was served a meal that included cheese, despite her documented dislike for it. The resident expressed dissatisfaction with being served cheese quesadillas, which she did not like. The Dietary Manager confirmed that the MTT for this resident indicated a dislike for cheese, and acknowledged that the resident should not have been served cheese. The facility's policy requires that meals be consistent with residents' preferences, and if a preferred item is unavailable, a substitute should be provided.
Failure to Obtain Therapeutic Diet Order for Edentulous Resident
Penalty
Summary
The facility failed to obtain a therapeutic diet order for Resident 388, who was observed to have no teeth and no dentures. During an observation and interview, Resident 388 expressed difficulty eating an uncut zucchini due to their edentulous condition. The resident's care plan, dated 10/14/24, indicated a nutritional problem with interventions including a No Added Salt diet and regular texture. However, the care plan dated 10/22/24 noted oral/dental health problems related to being edentulous, with an intervention to consult with a dietitian if chewing or swallowing problems were noted. Despite this, the Registered Dietician stated that Resident 388's diet order was regular texture and did not acknowledge any chewing issues, even though the resident had no teeth. The facility's policy on therapeutic diets, dated 6/1/14, aims to ensure diets meet nutritional guidelines and physician orders, which was not adhered to in this case.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, which could potentially impact their care. For one resident, the Minimum Data Set (MDS) assessment inaccurately indicated that the resident had no natural teeth, despite being edentulous. Additionally, the Order Summary Report (OSR) incorrectly included a physician order to monitor for adverse reactions to Zoloft, an antidepressant medication that had been discontinued earlier in the month. The Minimum Data Set Coordinator (MDSC) confirmed these inaccuracies during a review. For another resident, the Director of Nursing (DON) was unable to locate a physician order for a hospital transfer that occurred the previous year. Furthermore, the facility could not obtain the resident's History and Physical (H&P) or Discharge Summary from the hospital due to issues accessing the hospital's electronic health record system. The facility's policy and procedure on medical record completion and correction emphasize the need for complete and accurate documentation, which was not adhered to in these instances.
Failure to Conduct Employment and Reference Checks for RNs
Penalty
Summary
The facility failed to ensure that previous employment and personal reference checks were completed for two registered nurses (RN 1 and RN 2) before they were hired. This oversight was identified during a review of the Employee Information Sheets and Previous/Current Employment Verification forms for both RNs, which showed that these checks were not conducted prior to their hire dates. During an interview and record review with the Administrator, it was confirmed that the necessary checks were not performed, despite the facility's policy requiring screening of potential employees for any history of abuse, neglect, or mistreatment of residents. The policy mandates obtaining information from previous or current employers and checking with appropriate boards and registries.
Inadequate Monitoring After Resident Elopement
Penalty
Summary
The facility failed to adequately monitor a resident who had previously eloped from the facility, as required by their policy. The resident was found outside the facility on Prosperity Ave in Tulare, CA, in their wheelchair, and was redirected back by a staff member. Despite the recommendation for monitoring every 30 minutes, the resident was only checked once on the day of the incident and inconsistently monitored in the following days, with checks ranging from one to three times a day. The Director of Nursing acknowledged that the documentation showed insufficient monitoring, which did not align with the facility's policy for preventing further elopement.
Medication Error During Resident Discharge
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was sent home with another resident's prescribed medications. During an interview, the resident expressed concern about the potential risk of taking the wrong medication. The incident occurred when a Licensed Vocational Nurse handed the resident a bag filled with medications without verifying that they were the correct prescriptions. The Registered Nurse admitted to not performing the necessary double or triple checks to confirm the medications were intended for the discharged resident. The Director of Nurses confirmed that the resident was mistakenly sent home with another resident's medications, which were later returned by the resident's family. The facility's policy and procedure for the discharge and transfer of residents, dated February 2018, requires a triple check of all prescribed medications before they are given to a resident upon discharge. This policy was not followed, leading to the potential for the resident to take incorrect medications.
Violation of Resident's Rights Due to Disrespectful Treatment
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, resulting in a violation of the resident's rights. The incident involved a resident with unspecified dementia and anxiety, who was admitted to the facility with cognitive impairments that made communication challenging. During a dinner service, the resident exhibited a behavior of swinging his arms at staff, which was a known behavior pattern. A Certified Nursing Assistant (CNA) was assisting the resident when he began to hit the table and nearly struck her arm. In response, the CNA blocked the resident's arm and verbally admonished him by saying, "We don't hit," and further remarked that he "hits like a girl," which she later acknowledged was disrespectful. The CNA admitted to raising her voice during the incident, which was confirmed by the facility's administrator. The administrator stated that the CNA should not have raised her voice and should have sought assistance instead. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in this situation. The incident was documented in a Facility Reported Event, and the CNA's actions were found to be in violation of the resident's rights to a dignified existence and respectful treatment.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for one resident, which required hospitalization. During an interview, the resident's responsible party stated that the resident was transferred to an acute hospital. A review of the resident's medical record showed no documented evidence that the physician was notified of this significant change in condition and subsequent transfer. The facility's administrator confirmed the lack of documentation and was unaware of the specific change in condition that necessitated the transfer. The Director of Nurses stated that it was the facility's practice to notify the physician of significant changes in a resident's condition, as outlined in the facility's policy and procedure for alert charting documentation.
Failure to Document Change in Condition
Penalty
Summary
The facility failed to assess and document a significant change in condition for one of the sampled residents, leading to a deficiency in meeting professional standards of quality. The incident involved a resident who was transferred to an acute hospital without an assessment being completed by the nurse on duty. The resident's Responsible Party reported the transfer, and upon review, there was no documented evidence of an assessment or a completed Change of Condition form in the resident's medical records. Interviews with the facility's Administrator and Director of Nurses (DON) confirmed that the nurse on duty did not perform the required assessment or documentation. The facility's policy, titled 'Alert Charting Documentation,' mandates that licensed nurses must note and document any change in a resident's medical condition. However, this procedure was not followed, resulting in a lack of awareness about the specific change in condition that necessitated the resident's transfer to the hospital.
Failure to Document and Administer Wound Care
Penalty
Summary
The facility failed to provide wound care for a resident according to the physician's orders, as evidenced by missing documentation in the Treatment Administration Record (TAR). The resident had multiple wounds requiring specific treatments, including a Stage 2 pressure ulcer on the coccyx, surgical sutures and scarring on the abdomen, and a dehisced surgical wound on the abdomen. The prescribed treatments involved cleansing with wound cleanser, applying topical ointments, and covering with dressings as needed. However, the TAR lacked signatures on several dates, indicating that the treatments were not documented as completed. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nurses (DON) confirmed the absence of documentation for the specified dates, which suggested that the treatments were not administered. The facility's policy and procedure for medication administration emphasized the importance of documenting the time and dose of treatments in the patient's medication record. The LVN acknowledged that the facility's practice was to document treatments immediately after completion, and the DON confirmed that the treatments were not provided on the specified dates.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party of a resident after a fall incident, which resulted in the resident sustaining a black eye and a cut to the left lower lip. The incident occurred when the resident, who was under respite care, attempted to stand from her wheelchair in the front lobby and fell. The Licensed Vocational Nurse (LVN) on duty notified the hospice agency but did not inform the resident's responsible party, despite the facility's policy requiring notification of any change in condition, including falls. The resident's medical records indicated that her son was the responsible party and had given consent for treatment. The facility's Fall Management Program policy, dated March 13, 2021, mandates that the licensed nurse notify both the resident's attending physician and responsible party of all incidents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Tulare
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchards At Tulare | 0 mi | ★★★★★ | 4 | 0 |
| Grand Oaks Care | 0.1 mi | ★★★★★ | 13 | 0 |
| Westgate Gardens Care Center | 6.8 mi | ★★★★★ | 4 | 0 |
| Sequoia Vista | 6.8 mi | ★★★★★ | 12 | 0 |
| Linwood Meadows Care Center | 6.9 mi | ★★★★★ | 0 | 0 |
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