Vacaville Convalescent And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vacaville, California.
- Location
- 585 Nut Tree Ct., Vacaville, California 95687
- CMS Provider Number
- 555349
- Inspections on file
- 20
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Vacaville Convalescent And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with vascular dementia, fall risk, and impaired decision-making was placed in a W/C and secured with a bedsheet that was wrapped under the arms and tied behind the chair, preventing independent release. Staff documented that the resident used a W/C and had a history of falls, and assessments showed significant cognitive and communication impairments, yet there was no MD order for restraints. Video reviewed by the ADM and statements from the DON, DSD, and a CNA confirmed that the sheet was tied in a way the resident could not remove, and staff acknowledged that using a bedsheet in this manner was considered a restraint and contrary to facility policy, which defines restraints as devices the resident cannot easily remove and requires a physician’s order.
The facility failed to store medications properly, with loose pills found in a medication cart and issues with medication refrigerators, including ice buildup and incorrect temperatures. These deficiencies were confirmed by nursing staff, who acknowledged the potential for compromised medications. The facility's policy requires proper storage and maintenance of medication areas.
The facility failed to maintain infection control practices, as the wound treatment nurse did not sanitize equipment or label wound dressings, and housekeeping staff used the same mop and solution for multiple rooms without hand hygiene. Enhanced Barrier Precautions were not applied for residents with wounds and indwelling devices, contrary to facility policy.
The facility failed to provide mandatory abuse prevention training to CNAs on the night (NOC) shift, as required by policy. The Director of Staff Development (DSD) did not conduct in-services for the NOC shift, resulting in a lack of documentation for 13 CNAs. This deficiency had the potential to affect all 82 residents, exposing them to risks of harm.
A facility failed to implement a baseline care plan within 48 hours for a resident prescribed Divalproex Sodium for seizure prevention. Despite the medication being administered, there were no orders for seizure monitoring or a seizure-specific care plan. This was confirmed by a Licensed Nurse and the DON, who acknowledged the absence of necessary monitoring and care planning, contrary to facility policy.
A resident with a history of pulmonary embolism and thrombosis was receiving apixaban without an anticoagulant monitoring care plan in place. The facility's policies required monitoring for side effects, but interviews with staff confirmed the absence of necessary orders and care plans, potentially putting the resident at risk.
A resident with respiratory failure and hypoxia did not receive respiratory care consistent with facility policy. The nasal cannula was unlabeled, and the humidifier bottle was incorrectly labeled, contrary to the facility's policy requiring changes every 24 hours for the bottle and every seven days for the cannula. Observations and interviews revealed discrepancies in staff practices and understanding of the policy, increasing the risk of respiratory infections.
A resident with dementia was admitted to the facility without a comprehensive dementia care plan, despite having moderate cognitive impairment and non-Alzheimer's dementia. This deficiency was confirmed by a nurse and the DON, who acknowledged the importance of such a plan for proper assessment, staff interaction, and intervention. The facility's policy requires care plans to meet residents' psychosocial and functional needs.
The facility did not display complete nurse staffing data, omitting actual hours worked by LNs and CNAs, potentially misleading residents and visitors. The Medical Records Director and Administrator confirmed the omission, which contradicted the facility's policy requiring the posting of actual hours worked.
A resident with dementia was slapped on the back by another resident, who was frustrated by sleep disturbances caused by the former's behavior. The incident was witnessed by CNAs, and the facility's abuse prevention policy was not followed, increasing the affected resident's potential for social withdrawal and fear for his safety.
Improper Use of Bedsheet as Physical Restraint in Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints when a bedsheet was used to secure the resident to a wheelchair without a physician’s order. The resident, admitted in the spring of 2026, had vascular dementia with behavioral disturbance, a history of falls, was cognitively impaired, rarely or never understood, had memory problems, and was moderately impaired in decision-making. The baseline care plan documented wheelchair use and fall history, and the history and physical identified the resident as a fall risk with no capacity for decision making. Despite this, there was no physician’s order for restraints in the resident’s record as of late April. According to the plan of care note and staff interviews, during a night shift shortly after admission, a licensed nurse placed a sheet under the resident’s arms and tied it behind the wheelchair after the resident, identified as a fall risk, was standing at the nurse’s station and was hard to get to cooperate with sitting. Video reviewed by the administrator showed the sheet tied at the back of the wheelchair, and the DON confirmed the resident was unable to release the sheet. Staff, including the DSD and a CNA, acknowledged that using a bedsheet in this manner constituted a restraint and that staff had been instructed not to use bedsheets as restraints. The facility’s physical restraint policy defined a physical restraint as any manual method or device attached to the body that the individual cannot easily remove and that restricts freedom of movement, and required verification of a physician’s order for restraint use, which was not present in this case.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during a survey. Loose pills were found in the bottom of a medication cart drawer, which was confirmed by a licensed nurse who acknowledged the risk of these pills being accidentally administered to residents. Additionally, the medication refrigerator in the north station was found to have significant ice buildup, preventing the freezer door from opening, and puddles of water were present at the bottom and on the shelving. The external areas of the fridge were also damaged. A licensed nurse confirmed that improper maintenance of the fridge could compromise the medications stored within, potentially leading to residents receiving ineffective medications. Further observations revealed that the medication fridge in the south station had a temperature of 24°F, which is outside the expected range of 36-46°F. This discrepancy was confirmed by another licensed nurse, who stated that such a temperature could damage the medications, rendering them ineffective. The Director of Nursing acknowledged that loose pills should not be present in the cart and should be disposed of properly. The facility's policy, dated 2001, requires medications to be stored under proper temperature conditions and mandates that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations and interviews. The wound treatment nurse (TN) was observed taking a container of medication from a resident's room and placing it back in the clean supply cart without proper sanitization. Additionally, the TN did not sanitize equipment between uses for different residents and failed to label wound dressings with dates or initials. These actions were confirmed by the TN and the Director of Nursing (DON), who acknowledged the breach in protocol. Housekeeping staff also did not adhere to infection control practices. Observations revealed that housekeepers did not perform hand hygiene between cleaning different resident rooms and used the same mop and sanitizing solution for multiple rooms. Interviews with housekeeping staff confirmed these practices, which were contrary to the facility's policy that required changing mop solutions every three rooms and performing hand hygiene after removing gloves. Furthermore, Enhanced Barrier Precautions (EBP) were not applied for residents with wounds and indwelling medical devices. The Infection Preventionist and a Licensed Nurse (LN) indicated that EBP was only used for residents with a history of multidrug-resistant organisms (MDROs), not for those with wounds or indwelling devices. The DON confirmed that EBP should have been implemented for these residents, as per the facility's policy, but was not done so, leading to potential risks of infection spread among the residents.
Failure to Provide Mandatory Abuse Training to NOC Shift CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) received mandatory abuse prevention training, as required by their policy and procedure. Specifically, documentation for the required training was unavailable for the 13 CNAs assigned to the night (NOC) shift. This deficiency was identified through interviews and record reviews, revealing that the Director of Staff Development (DSD) did not provide in-services to the NOC shift staff. The DSD confirmed that the mandatory abuse prevention training had not been provided during 2024, and there was no documentation of NOC shift staff participation in the training. The facility's policy, revised in August 2022, mandates that all nurse aide personnel participate in regular in-service education, including training on abuse, neglect, and exploitation of residents. The DSD stated that in-services were scheduled twice a week, but these sessions did not accommodate the NOC shift staff. The DSD admitted to not providing in-person in-services to the NOC shift, instead claiming to ensure they received the information without requiring attendance or signatures on a sign-in sheet. This lack of training documentation and participation had the potential to affect all 82 residents in the facility, exposing them to risks of physical, mental, or psychosocial harm.
Failure to Implement Baseline Care Plan for Seizure Monitoring
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 238, who was prescribed anti-seizure medication, Divalproex Sodium, for seizure prevention. Despite the medication being administered as ordered, there were no corresponding orders for monitoring seizure symptoms, nor was there a seizure-specific care plan in place. This oversight was confirmed during a review of Resident 238's records and through interviews with the Licensed Nurse (LN 3) and the Director of Nursing (DON), both of whom acknowledged the absence of necessary seizure monitoring and care planning. Resident 238 was admitted with diagnoses including a fracture of the left femur and a fall, and was prescribed Divalproex Sodium to prevent seizures. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including necessary instructions for effective, person-centered care. However, the facility did not adhere to this policy, as evidenced by the lack of a seizure monitoring plan and care plan for Resident 238, which was contrary to the facility's established protocols for managing residents on anti-seizure medications.
Failure to Implement Anticoagulant Monitoring
Penalty
Summary
The facility failed to provide services according to professional standards by not implementing anticoagulant monitoring for a resident. The resident, admitted in February 2023, had diagnoses including pulmonary embolism and thrombosis of the left leg and was receiving apixaban, a medication that decreases blood clotting. However, the Medication Administration Record did not include an order to monitor for side effects such as excessive bleeding or bruising. Additionally, the resident's Care Plan lacked an anticoagulant monitoring care plan. Interviews with Licensed Nurse 1 and the Director of Nursing confirmed the absence of orders or a care plan for anticoagulant monitoring. The Director of Nursing stated that her expectations were for all residents on anticoagulants to have orders to monitor side effects and an anticoagulant monitoring care plan. The facility's policy on anticoagulation, dated 2001, and the policy on comprehensive person-centered care plans, revised in March 2022, both indicated the need for monitoring and establishing measurable objectives and expected outcomes of care.
Inconsistent Respiratory Care Practices for a Resident
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards and facility policy for Resident 240, who was admitted with respiratory failure and hypoxia. The resident's nasal cannula (NC) was not labeled with a date indicating when it was last changed, and the humidifier bottle was labeled with a date that did not align with the facility's policy. The facility's orders required the humidifier bottle and NC to be changed every five days, but the facility's policy stated that the humidifier bottle should be changed every 24 hours and the NC every seven days. Observations and interviews revealed discrepancies in the facility's practices and policies. The Infection Preventionist confirmed the lack of labeling on the NC and the incorrect labeling of the humidifier bottle. Licensed nurses provided conflicting information about the frequency of changes and labeling practices. The Director of Nursing acknowledged that the facility's practice of changing the bottle and tubing as one unit was not in agreement with the policy. These inconsistencies increased the risk of respiratory infections for Resident 240.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive dementia care plan for a resident diagnosed with dementia, identified as Resident 57. The resident was admitted to the facility in October 2024 with diagnoses including senile degeneration of the brain and dementia. A review of the resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and non-Alzheimer's dementia. Despite these diagnoses, there was no dementia care plan in place for Resident 57, as confirmed by Licensed Nurse 1 during a record review and interview. The absence of a dementia care plan was acknowledged by both Licensed Nurse 1 and the Director of Nursing (DON), who stated that such a plan is crucial for assessing the resident properly, guiding staff interactions, monitoring behaviors, and implementing appropriate interventions. The facility's policy on comprehensive person-centered care plans, revised in March 2022, emphasizes the importance of including measurable objectives and timetables to meet the resident's psychosocial and functional needs. The lack of a care plan for Resident 57 had the potential to delay necessary dementia treatments and services.
Incomplete Nurse Staffing Data Displayed
Penalty
Summary
The facility failed to ensure that complete nurse staffing data was displayed and accessible for residents and visitors. During an observation at the North Nursing station, the Daily Staffing form was found to include the number of Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) scheduled for each shift, but it did not include the actual hours worked by these staff members. This omission was confirmed during an interview with the Medical Records Director (MRD), who acknowledged that the actual hours worked had never been posted since they began working at the facility. Further review with the Administrator (ADM) confirmed that the daily Staffing form lacked the actual hours worked per shift for LNs and CNAs. The facility's policy and procedure, titled 'Posting Direct Care Daily Staffing Numbers,' revised in August 2022, requires that the actual time worked during each shift for each category and type of nursing staff be recorded and posted. The failure to include this information had the potential to mislead residents and visitors about the actual hours worked by staff responsible for providing direct care.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident slapped him on the back. Resident 1, who was admitted in 2023 with diagnoses including syncope and dementia, was involved in an incident where Resident 2, admitted in 2022 with orthopedic aftercare and hypertension, exhibited aggressive behavior. Resident 2, who had a BIMS score of 14, indicating relatively intact cognition, became frustrated with Resident 1's behavior, which he found disturbing to his sleep. This led to Resident 2 slapping Resident 1 on the back, an act witnessed by two CNAs. The incident occurred when Resident 1 was being assisted by CNAs after Resident 2 complained about sleep disturbances. Despite attempts to redirect Resident 1 back to bed, Resident 2, who was angry and frustrated, got out of his wheelchair and hit Resident 1. The facility's policy on abuse prevention, which states that residents must not be subjected to abuse by anyone, including other residents, was not adhered to in this situation. This failure increased Resident 1's potential for social withdrawal and fear for his safety.
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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