Veterans Home Of California - Redding
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 3400 Knighton Road, Redding, California 96002
- CMS Provider Number
- 555891
- Inspections on file
- 34
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Veterans Home Of California - Redding during CMS and state inspections, most recent first.
Unlabeled pasteurized eggs were found in the kitchen walk-in refrigerator outside of their original container. A Stock Clerk and a Cook could not identify a use-by date, and the FSM stated the eggs should have remained in the original container or been relabeled with the original container information. Facility policy required refrigerated foods to be labeled with the food item name and expiration date.
Failure to provide fingernail care for a resident who needed assistance with ADLs. The resident, who had osteoarthritis and tremor, was observed in a wheelchair with long, exposed fingernails and said staff did not consistently trim his nails. A CNA confirmed the nails were long and should have been trimmed, and the DON stated licensed nurses should provide hygiene care, including nail trimming.
Expired Lidocaine HCL was found in the emergency kit during an observation with the DON in the medication room. The DON confirmed the vials were expired and stated that pharmacy and nursing staff should check the emergency kit for expired medication. Facility policy states the pharmacist checking the emergency drug kit must note the earliest expiration date and the contract production pharmacy is responsible for cycling out the e-kits before that date.
Urinary Catheter Tubing Contacted the Floor: A resident with an indwelling urinary catheter was observed self-propelling in a wheelchair with the catheter tubing touching the floor. An RN confirmed the tubing should not contact the floor due to infection control concerns, and the IP stated catheter tubing must be kept off the floor to reduce infection risk. Facility policy and in-service materials also stated that catheter tubing and bag should be secured and kept off the floor.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents.
A resident with multiple serious diagnoses received Oxycodone for pain indications not specified in the physician's order, such as generalized and neck pain, rather than only for lower back pain as prescribed. Nursing staff administered the medication for these other pain complaints without obtaining a new physician order, contrary to facility policy, and the DON confirmed that an updated order should have been secured.
Surveyors found that staff did not consistently monitor the cooldown of potentially hazardous foods, such as cooked entrees and tuna salad, and failed to document required temperature checks. Additionally, a food service worker was observed chewing gum during food preparation, contrary to facility policy. These actions were confirmed through observation, staff interviews, and review of facility records.
Surveyors found that internal and external medications were stored together without separation in two medication storage areas, contrary to facility policy. Oral medications were placed next to external-use products such as eye drops and enemas, and staff acknowledged this improper practice had likely been ongoing and unrecognized.
A nurse was observed making three medication administration errors involving insulin and nasal spray for a resident with dysphagia and muscle weakness. The nurse did not follow manufacturer instructions for holding the insulin pen needle in the skin and failed to instruct the resident to blow their nose before nasal spray administration, resulting in a medication error rate above 5%.
The facility did not employ a full-time qualified supervisor dedicated to managing the day-to-day operations of dietetic services in the SNF. Leadership positions were vacant or shared between the SNF and RCFE, and the staff responsible for food and nutrition services did not meet regulatory requirements for full-time supervision, resulting in insufficient oversight of dietetic services.
A resident with heart failure and atrial fibrillation was administered psychotropic medications without documented informed consent in the medical record. Physician orders and the MAR confirmed administration of Temazepam and Trazodone, but neither the DON nor nursing staff could provide evidence of a signed consent form, as required by facility policy.
A resident's right to privacy was violated when a staff member opened and viewed the resident's bank statement without proper authorization. The resident's son, who held the Durable Power of Attorney, denied giving consent for this action. The facility's policy required mail to be opened only at the resident's request or forwarded to their representative, which was not adhered to in this case.
The facility's kitchen failed to maintain safe and sanitary conditions, with equipment like a chipped can opener and scratched cutting boards not replaced, and foods found uncovered in storage. Labeling issues were noted, with some items difficult to read or lacking labels, and expired food not discarded promptly. These deficiencies were confirmed by staff and violated facility policies and FDA guidelines.
The facility failed to cover two out of eight dumpsters in the main and satellite kitchens, potentially attracting pests and spreading bacteria, risking food contamination for forty-one residents. Observations revealed uncovered dumpsters, confirmed by the Assistant Administrator and Dietetics Assistant Director, who emphasized the need for dumpsters to be closed when not in use. The facility's Waste Management Program policy requires bins to have tightfitting covers and be closed when not being loaded.
A LTC facility exceeded the acceptable medication error rate, reaching 11.11%, due to improper administration of medications to two residents. A resident received crushed pantoprazole and finasteride, despite guidelines against crushing these medications. Another resident was not instructed to rinse his mouth after using an inhaler, contrary to the medication's instructions. The errors were attributed to staff not following medication administration guidelines.
The facility failed to implement care plans for two residents, leading to potential fall risks. One resident's assistive devices were not within reach, and 'Call don't fall' signs were missing. Another resident had outdated assistive devices and signage in their room, contrary to their care plan. These deficiencies were confirmed through observations and staff interviews.
Expired filter needles were found in the Emergency Drug Kit at an LTC facility, with staff unaware of their expiration. The facility's policy required regular review and cycling out of expired items, but the needles remained, posing a risk of using ineffective supplies.
Unlabeled Pasteurized Eggs Stored Improperly
Penalty
Summary
The facility failed to store and label pasteurized eggs in accordance with professional food service standards and facility policy when an unlabeled tray containing 18 pasteurized eggs was found in the Main Kitchen walk-in refrigerator outside of its marked container. During observation, the tray did not have a label showing the received-on date or use-by date. A Stock Clerk and a Cook were unable to identify a use-by date on the tray during interviews. The Food Services Manager stated that the eggs should have remained in the original container, and if stored outside that container, the tray should have been relabeled using the information from the original container. The facility policy on leftover and extra food required refrigerated foods to be labeled with the food item name and expiration date.
Failure to Provide Fingernail Care
Penalty
Summary
The facility failed to maintain proper grooming by ensuring fingernail care for one resident who was unable to perform activities of daily living independently. The resident was admitted with diagnoses of osteoarthritis and tremor. During observation, the resident was seated in a wheelchair in the hallway with exposed, long fingernails and stated that he wanted his nails trimmed and that staff did not consistently perform nail trimming. A CNA later confirmed that the resident's fingernails were long and should have been trimmed. The DON stated that licensed nurses should provide hygiene care, including nail trimming, to reduce the risk of skin injury. The facility policy on Activities of Daily Living stated that nursing staff must assist residents with activities of daily living, including maintaining proper grooming and providing finger and toenail care.
Expired Lidocaine HCL Found in Emergency Kit
Penalty
Summary
The facility failed to ensure expired medication was not available for use when two vials of Lidocaine HCL were found in the emergency kit after their expiration date. During a concurrent observation and interview with the DON in the medication room, the emergency kit contained the two vials of Lidocaine HCL with an expiration date of 3/2026, and the DON confirmed the vials were expired. The DON stated that pharmacy and nursing staff should check the emergency kit for expired medication. During a later interview, the DON stated that medication should not be expired for resident safety and drug efficacy. Review of the facility policy titled Emergency Drug Kit stated that the pharmacist checking the kit will indicate the earliest expiration date on the outside of the container and that the contract production pharmacy is responsible for cycling out the e-kits before the expiration date listed on the exterior of the kit.
Urinary Catheter Tubing Contacted the Floor
Penalty
Summary
The facility failed to maintain an effective infection control program when Resident 20's indwelling urinary catheter tubing was observed touching the floor while the resident was seated in a wheelchair and self-propelling in the hallway. During the observation, RN 1 confirmed that the tubing should not contact the floor because of infection control concerns. Resident 20 had an admission order dated 12/2/25 indicating the need for an indwelling catheter for bladder outlet obstruction. The Infection Preventionist stated that indwelling catheter tubing must not contact the floor to reduce infection risk. The facility policy for urinary catheter use stated that catheter care is provided routinely in accordance with recognized standards, and the in-service lesson plan stated that indwelling catheters should be secured to a wheelchair with tubing and bag kept off the floor and not dragging during mobility.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment or supervision in the specified area was insufficient to prevent potential accidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or supervision lapses are provided in the report.
Pain Medication Administered Outside Prescribed Indication
Penalty
Summary
The facility failed to ensure that pain medication was administered as prescribed for a resident with diagnoses including heart failure, metastatic prostate cancer, and muscle weakness. The physician's order specified that Oxycodone 5 mg immediate release should be given by mouth every four hours as needed for lower back pain. However, review of the medication administration record revealed that the medication was given on ten occasions for indications other than lower back pain, such as generalized pain, body pain, facial pain, and neck pain. Multiple nurses administered the medication for these unapproved indications without obtaining a new physician order to cover the broader pain complaints. Interviews with nursing staff confirmed that the medication was not administered strictly according to the prescriber's order, and the Director of Nursing acknowledged that a physician order should have been obtained for the resident's general pain. Although the physician and pharmacist later stated it was acceptable to administer the medication for other pain indications, the facility's policy required medications to be administered only as ordered by the prescriber. This deviation from the prescribed order resulted in a failure to provide safe and appropriate pain management as required by facility policy.
Failure to Monitor Food Cooldown and Prohibit Gum Chewing in Food Preparation Areas
Penalty
Summary
The facility failed to consistently follow food safety standards in the handling and preparation of potentially hazardous foods (PHFs). Surveyors observed that multiple cooked and frozen food items, such as macaroni and cheese, corned beef, vegetarian meatloaf, and lentil loaf, were stored without proper cooldown temperature monitoring. Additionally, prepared tuna salad made from ingredients stored at room temperature was not monitored for temperature during storage, with staff only checking temperatures shortly before use. Review of the facility's cooldown logs confirmed that these items were not tracked during the cooling process, and the facility's policy did not provide guidance for documenting or monitoring the cooldown of PHFs prepared from room temperature ingredients. During food production observations, a food service worker was seen chewing gum while preparing mechanically altered food items, in direct violation of the facility's policy prohibiting gum chewing in kitchen or serving areas. The worker confirmed having gum in her mouth when questioned. These lapses in food handling and staff conduct were identified through direct observation, staff interviews, and review of departmental documentation.
Failure to Separate Internal and External Medications in Storage Areas
Penalty
Summary
Surveyors observed that internal-use medications, such as oral tablets and capsules, were stored directly adjacent to external-use products, including eye drops and enemas, in two medication storage areas within the facility. There was no physical barrier, labeled bin, or designated shelving to separate medications intended for internal administration from those for external use. This storage practice was noted during a tour of the Clamath and another nursing station, where items like Loperamide tablets, Glucosamine Sulfate capsules, and Calcium Citrate tablets were intermixed with Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops. During an interview at the time of observation, the facility's Quality Assessment Nurse acknowledged the improper storage and indicated that this practice had likely been ongoing and unrecognized by staff. The facility's own policy on medication storage specifically requires that internally administered medications be kept separate from externally used medications, but this policy was not being followed as evidenced by the observed storage conditions.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of twenty-eight opportunities during a medication pass, resulting in a 10% error rate. Specifically, a Licensed Vocational Nurse (LVN) administered two types of insulin to a resident with dysphagia and muscle weakness but did not follow the manufacturer's instructions for holding the insulin pen needle in the skin for the required duration after pressing the dose button. The LVN admitted to routinely removing the pen immediately after pressing the button, rather than adhering to the specified holding time. Additionally, the same LVN administered a nasal spray to the same resident without instructing the resident to blow their nose beforehand, contrary to standard manufacturer instructions for intranasal sprays. The LVN stated that she was unaware of the need for the resident to clear their nasal passages prior to administration. These observed actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Lack of Full-Time Qualified Supervisor for Dietetic Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition service, specifically lacking a full-time qualified position dedicated to supervising and managing the day-to-day operations of the skilled nursing dietetic services. During the survey, it was observed that the Food Manager (FM) was responsible for both the skilled nursing facility (SNF) and a separately licensed residential care facility for the elderly (RCFE), and his position was not dedicated full-time to the SNF. The Dietetics Assistant Director (DAD), a Registered Dietitian, also had responsibilities split between the SNF and RCFE, and her role was not solely dedicated to the SNF. The organizational chart review confirmed that the Director of Dietetics and a Food Service Supervisor (FSS) II positions were vacant, and there was no full-time qualified Food Service Director dedicated to the SNF. Interviews with facility leadership and staff further revealed that the current structure did not provide a full-time qualified supervisor for the SNF dietetic services. The DAD confirmed that all dietetic services leadership positions were shared between the RCFE and SNF, and the Registered Dietitian assigned to the SNF focused on clinical nutrition care rather than day-to-day management of dietetic services. The FM had not completed the necessary training to become a Certified Dietary Manager, and the facility had not attempted to modify position descriptions or minimum qualifications to address the deficiency. Facility policy and regulatory requirements were reviewed, indicating that if a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor must be responsible for the operation of the food service. The facility's failure to meet these requirements resulted in a lack of dedicated, qualified supervision for the SNF dietetic services, as evidenced by vacant leadership positions and shared responsibilities among existing staff.
Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a complete and accurate medical record was maintained for a resident who was prescribed psychotropic medications. Specifically, there was no documentation in the resident's medical record indicating that informed consent was obtained for the administration of Temazepam and Trazodone, both psychotropic medications. The resident's face sheet showed admission with diagnoses including heart failure and unspecified atrial fibrillation. Physician orders for Temazepam and Trazodone were present, and the Medication Administration Record confirmed that these medications were administered on multiple occasions. Interviews with the DON and an RN revealed that the physician was responsible for discussing the treatment and obtaining written consent, and that nursing staff should verify the presence of a signed consent form before administering psychotropic medications. Review of facility policy confirmed that written informed consent must be documented and filed in the resident's health record prior to initiating psychotropic drug therapy. Despite these requirements, no such documentation was found in the resident's record at the time of review.
Unauthorized Access to Resident's Personal Information
Penalty
Summary
The facility failed to respect a resident's right to personal privacy when a staff member opened and viewed the resident's bank account statement without proper authorization. The resident, who was oriented to person and place, had her finances managed by her son and daughter. The resident's son held the Durable Power of Attorney, as indicated in the resident's Face Sheet and the durable power of attorney document dated March 1, 2023. During an interview, the Medical Social Worker (MSW) admitted to opening and viewing the resident's bank account statement for June 2024, claiming that consent was given by the resident's son via telephone. However, the MSW could not provide documented evidence of this consent, and the resident's son later denied giving such consent. The facility's policy stated that mail could only be opened at the resident's request or forwarded to their representative if they had a conservator, power of attorney, or other representative. This policy was not followed, leading to unauthorized access to the resident's personal information.
Food Safety and Sanitation Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the food service department, as observed during a survey. Equipment such as a can opener with metal chipped off the cutting tip and discolored cutting boards with deep scratches were not replaced, posing a risk of contamination. Foods were found uncovered in storage areas, including frozen burritos, chicken breasts, and vegetable patties with ice build-up, as well as a bag of pork and uncooked ravioli left open to the air. These conditions were confirmed by the Food Manager and Dietetics Assistant Director, who acknowledged the potential for cross-contamination and food quality degradation. Additionally, the facility did not appropriately label food items, with black pepper and bay leaves having labels that were difficult to read, and ice cream bowls lacking labels entirely. This oversight was confirmed by the Dietetics Assistant Director, who stated that staff were expected to label food items with a use-by date to ensure safety. Furthermore, expired food items, such as apple juice boxes, were not discarded in a timely manner, leading to confusion about product safety. These deficiencies were in violation of the facility's policies and procedures, as well as the 2022 FDA Food Code.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure that two out of eight dumpsters were covered for the main and satellite kitchens, which had the potential to attract pests, rodents, and spread bacteria, leading to food contamination for a population of forty-one residents. During an observation and interview with the Assistant Administrator, it was noted that one out of four trash dumpsters for the main kitchen was not covered, exposing trash. The Assistant Administrator confirmed that the dumpster should be closed and proceeded to close the two lids. Similarly, an observation in the satellite kitchen revealed that one out of four trash dumpsters was not covered, exposing trash. The Dietetics Assistant Director stated that trash dumpsters need to be closed at all times when not in use to prevent attracting rodents or pests to the facility. A review of the facility's Waste Management Program policy indicated that movable bins used for storing or transporting solid wastes should have tightfitting covers and be closed when not being loaded.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11.11% error rate. This was due to the improper administration of medications to two residents. Resident 26 was given pantoprazole and finasteride in a crushed form, contrary to guidelines. Pantoprazole, a delayed-release medication, was crushed and mixed with applesauce, despite the manufacturer's instructions against crushing. Similarly, finasteride, which requires special handling, was also crushed and administered in the same manner. The Licensed Vocational Nurse (LVN) involved did not notice the 'Do Not Crush' and 'Caution Special Handling' labels on the medication packaging and was unaware of the implications of these labels. Additionally, Resident 21 was not instructed to rinse his mouth after using an inhaler containing fluticasone furoate, umeclidinium, and vilanterol. This step is crucial to prevent potential side effects such as hoarseness and oropharyngeal candidiasis, as indicated by the medication's packaging and prescribing information. The Registered Nurse (RN) administering the medication failed to provide this instruction, and the resident did not have a history of refusing to rinse his mouth after inhalation. The facility's policies and procedures for medication administration were not adhered to in these instances. The Director of Nursing acknowledged that the medications should not have been crushed and that proper instructions should have been given to Resident 21. The facility's guidelines require that altering the form of a medication, such as crushing, should only be done with a physician's order and that special handling instructions should be followed for certain medications.
Failure to Implement Care Plans for Fall Prevention
Penalty
Summary
The facility failed to implement the care plans for two residents, leading to potential safety risks. For one resident, who had a left below-knee amputation and a right transmetatarsal amputation, the care plan required that assistive devices such as a wheelchair and prosthetic leg be within reach. However, during an observation, these items were found across the room and in the bathroom, respectively, making them inaccessible. Additionally, the care plan included the posting of 'Call don't fall' signs, which were not present in the resident's room. Interviews with the Quality Assurance Registered Nurse and the Occupational Therapist confirmed these oversights. For another resident diagnosed with Alzheimer's Disease and ataxic gait, the care plan specified the use of a manual wheelchair, yet a walker and corresponding signage were still present in the room, contrary to the updated care plan. Furthermore, 'Call don't fall' signs, which were part of the fall prevention strategy, were missing from the resident's room. The Assistant Director of Nursing and a Physical Therapist confirmed that the walker had been discontinued and should have been removed, along with the signage. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to adhere to the established care plans.
Expired Filter Needles Found in Emergency Drug Kit
Penalty
Summary
The facility failed to ensure the safe monitoring of pharmaceutical medical supplies when four expired filter needles were found in the injectable Emergency Drug Kit (E-Kit). These filter needles, which are designed to remove particles that might contaminate medication, were found without expiration dates in the Klamath Unit medication room. The Pharmacy Technician initially stated that some filter needles did not have expiration dates, and the most recent expiration date was posted on the E-kit lid for staff to alert the main pharmacy for replacements. However, upon further investigation, it was confirmed by the Manufacturer Representative that the filter needles had expired on January 24, 2022. Interviews with the Director of Nursing and a Registered Nurse revealed uncertainty and lack of awareness regarding the expiration dates of the filter needles. The facility's policy and procedure for the Emergency Drug Kit indicated that the contents should be reviewed by the pharmacy services committee and cycled out before expiration. Despite this policy, the expired filter needles remained in the E-kit, posing a potential risk of using ineffective medical supplies and contaminated medications for residents.
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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