Villa Gardens Health Care Unit
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 842 East Villa Street, Pasadena, California 91101
- CMS Provider Number
- 555429
- Inspections on file
- 19
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Villa Gardens Health Care Unit during CMS and state inspections, most recent first.
A facility failed to follow its policy on advance directives by not informing a resident with chronic kidney disease and thrombocytopenia about their right to formulate an advance directive. The absence of an acknowledgment form in the resident's chart was confirmed by both an LVN and the Social Services Director, despite the facility's policy requiring this documentation upon admission.
A resident with Parkinson's, dementia, and incontinence experienced multiple falls due to the facility's failure to identify causative factors and update the care plan with specific interventions. Despite a history of falls and confusion, the care plan lacked measures to address nighttime incontinence and confusion, leading to repeated falls and injuries.
The facility failed to follow its oxygen therapy policy for two residents. One resident received oxygen with an empty humidifier bottle, risking nasal membrane drying. Another resident received more oxygen than prescribed, and empty oxygen tanks were improperly stored in the room. Staff interviews confirmed these deficiencies.
The facility failed to follow proper food handling practices, as observed in the kitchen and resident's refrigerator. Food items were found without labels indicating the date they were opened, and expired bread was present in the dry storage area. Staff acknowledged the risk of bacterial growth and potential foodborne illness due to these deficiencies, which violated the facility's policies on food labeling and storage.
The facility failed to properly dispose of garbage, resulting in two dumpsters being uncovered and overflowing with trash. This was confirmed by the Director of Dining Services, who acknowledged the dumpsters should have been covered to prevent attracting animals. The facility's policy requires garbage containers to be maintained with lids to prevent pest attraction and ensure sanitation.
The facility failed to adhere to infection control practices for several residents. A visitor entered a COVID-19 isolation room without proper PPE, and staff did not ensure nasal cannula tubing was stored correctly for a resident. Another resident on Enhanced Barrier Precautions was not properly protected by staff during care, and a nebulizer was not stored in a clean bag, increasing infection risk.
A resident with an indwelling catheter did not receive proper catheter care as a nurse failed to cap the drainage tube with a sterile sheath during irrigation, contrary to the facility's policy. The resident, who required substantial assistance and had a history of chronic conditions, was at risk due to this oversight. The facility's policy emphasized maintaining a closed system to prevent contamination, which was not adhered to during the procedure.
A resident with type 2 diabetes was administered an incorrect insulin dose due to a transcription error, and the nurse failed to document the administration properly. Additionally, there was no documented evidence of monitoring for signs of hypoglycemia and hyperglycemia, despite recommendations. This lack of documentation and adherence to policies placed the resident at risk of inappropriate diabetes management.
A resident with functional quadriplegia and severe cognitive impairments was found to have their call light on the floor, out of reach, contrary to the facility's policy requiring call systems to be accessible. This deficiency was observed during staff interviews and record reviews.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to adhere to its Advance Directive policy by not informing and providing written information to a resident regarding their right to formulate an advance directive. This deficiency was identified for one of the two sampled residents, who was admitted with chronic kidney disease and thrombocytopenia. The resident's medical records, including the Face Sheet and Minimum Data Set, indicated fluctuating capacity for decision-making, yet the facility did not ensure the presence of an advance directives acknowledgment form in the resident's chart. During interviews, both a Licensed Vocational Nurse and the Social Services Director confirmed the absence of the required acknowledgment form, which should have been completed and placed in the resident's medical record. The facility's policy, revised in March 2024, mandates that social services staff inform residents about their rights concerning advance directives upon admission and document this in the medical record. The lack of this documentation could lead to conflicts in executing the resident's healthcare decisions during emergencies.
Failure to Prevent Falls and Update Care Plan
Penalty
Summary
The facility failed to prevent falls for a resident by not identifying the causative factors of the resident's falls and not revising the care plan with new, resident-specific interventions. The resident, who had a history of falls, Parkinson's Disease, dementia, and incontinence, experienced multiple falls over a period of time. Despite these incidents, the care plans from July to September did not include interventions to address the resident's nighttime incontinence and confusion. The resident was found on several occasions sitting on the floor, confused, and wet with urine, indicating a lack of adequate supervision and intervention. The resident's falls were often unwitnessed, and the circumstances surrounding the falls, such as attempting to reach for something or being confused about their surroundings, were not adequately addressed in the care plan. The facility's policy required immediate interventions and care plan updates, which were not consistently implemented. Interviews with facility staff, including the DON, revealed that the resident had a history of falls and unsteady gait, and was incontinent at night. However, there was no documented evidence of interventions to address these issues. The facility's policies on post-fall assessment and falls prevention emphasized the need for immediate interventions and care plan updates, which were not followed, leading to repeated falls and injuries for the resident.
Oxygen Therapy Policy Violations
Penalty
Summary
The facility failed to adhere to its oxygen therapy policy for two residents, leading to potential adverse effects. For Resident 8, the facility did not ensure that the humidifier bottle attached to the oxygen concentrator was dated and filled with water. During an observation, it was noted that Resident 8 was receiving 4 liters of oxygen per minute via nasal cannula with an empty and undated humidifier bottle. This oversight could result in nasal membrane drying, as the humidifier is intended to add moisture to the oxygen flow, preventing such issues. In the case of Resident 37, the facility did not follow the physician's order for oxygen therapy. The resident was observed receiving 4 liters per minute of oxygen via nasal cannula, despite the physician's order specifying 2 liters per minute. Additionally, empty portable oxygen cylinder tanks were stored in the resident's room alongside full tanks, contrary to the facility's policy, which requires empty tanks to be stored separately. This practice poses a risk of oxygen toxicity and potential safety hazards. Interviews with facility staff, including LVNs and the Director of Nursing, confirmed these deficiencies. Staff acknowledged the importance of following physician orders and the facility's policies to prevent harm to residents. The facility's policy on oxygen therapy, revised in July 2022, outlines the proper procedures for administering oxygen and managing equipment, which were not followed in these instances.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which was observed during a survey. In the kitchen, multiple food items inside walk-in refrigerators were found without labels indicating the date they were opened. This included a large container of cranberries, a grocery bag with various food items, and a large pan of breaded meat. The cook was unaware of the origin of the grocery bag and acknowledged that it should not have been in the refrigerator. Additionally, expired bread items were found in the dry storage area, which the Director of Dining Services and the Registered Dietician confirmed should have been discarded to prevent potential health risks. In the resident's refrigerator near the nurse's station, several food items lacked labels indicating the opened date, resident's name, room number, or the date the food was prepared. This included a small container of red sauce and multiple containers of ice cream. Licensed Vocational Nurses expressed concerns about the lack of labeling, emphasizing the risk of bacterial growth and potential foodborne illness. The facility's policies required all prepared foods and foods not in original containers to be covered, labeled, and dated, and foods brought in by family members to be labeled with the resident's name, room number, and date of preparation or opening.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per their policy, which resulted in two out of three dumpsters being uncovered and overflowing with trash. This was observed during a visit to the facility's garbage area, where the Director of Dining Services confirmed the issue, noting that the dumpsters should have been covered to prevent attracting animals. Additionally, empty boxes were found between the dumpsters, and one dumpster's lid was only partially covering it due to the overflow. The facility's policy, reviewed during the investigation, mandates that garbage containers be maintained in good condition with lids to prevent pest attraction and maintain sanitation.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to implement appropriate infection control practices for several residents, as outlined in their policy and procedure. For Resident 199, a visitor entered the resident's room, which was under novel respiratory isolation due to COVID-19, without wearing the required personal protective equipment (PPE) such as a gown, N-95 mask, gloves, and face shield or goggles. The visitor was not educated on the necessity of these precautions, despite the presence of a sign indicating the required PPE. The Infection Preventionist Nurse confirmed the oversight and emphasized the importance of following isolation precautions to prevent the spread of infection. Resident 37's infection control measures were compromised when the nasal cannula tubing was not stored in a bag after use and was observed touching the floor. The facility's policy requires that oxygen tubing be changed if it becomes dirty or contaminated, which includes contact with the floor. Staff interviews revealed a lack of adherence to these protocols, as the nasal cannula was left exposed, increasing the risk of infection. For Resident 24, who was on Enhanced Barrier Precautions due to a gastrostomy tube and colonization with a multidrug-resistant organism, a staff member failed to don a gown before checking the gastrostomy tube placement. This oversight was acknowledged by the staff member, who later corrected the error. Additionally, Resident 19's handheld nebulizer was not stored in a clean bag when not in use, contrary to the facility's policy, which could lead to contamination and respiratory infection. Interviews with staff confirmed the importance of storing such equipment properly to prevent infection.
Failure to Follow Catheter Irrigation Policy
Penalty
Summary
The facility staff failed to adhere to its manual catheter irrigation policy when a Licensed Vocational Nurse (LVN) did not cap the drainage tube of an indwelling catheter with a sterile protective sheath during the irrigation process for a resident. This oversight was observed during a procedure where the LVN cleansed the connection site, disconnected the catheter from the drainage tubing, and placed the tubing on a clean disposable absorbent pad without capping it. The LVN then proceeded to flush the catheter with normal saline and reconnected the tubing without using a sterile sheath, contrary to the facility's policy. The resident involved had a history of benign prostatic hyperplasia, chronic systolic congestive heart failure, and chronic obstructive pulmonary disease, and required substantial assistance with daily activities. The resident's physician had ordered regular flushing of the indwelling catheter due to sediment buildup. The facility's policy, which was not followed, emphasized maintaining a closed urinary drainage system to prevent contamination. Both the Director of Nursing and the Administrator acknowledged that the LVN did not follow the established policy, which could potentially lead to an infection if bacteria entered the drainage tubing.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to accurately and completely document the insulin dose administered to a resident on a specific date. The resident, who had a history of type 2 diabetes and other medical conditions, was given an incorrect dose of insulin according to the sliding scale prescribed by the physician. The Sliding Scale Insulin Administration Record indicated that the resident's blood sugar level was 197, which required 8 units of insulin, but the record showed that 15 units were administered. Additionally, the licensed nurse who administered the insulin did not initial the record, which is against the facility's policy for charting medications. The Director of Nursing (DON) confirmed that a transcription error occurred, and the wrong amount of insulin was recorded. The DON stated that the nurse should have documented 8 units instead of 15 units and should have initialed the record after administering the insulin. This failure to follow the facility's charting guidelines and medication administration policies placed the resident at risk of receiving inappropriate diabetes management and care. Furthermore, the facility staff did not have documented evidence for monitoring the resident for signs and symptoms of hypoglycemia and hyperglycemia, as recommended by the pharmacist and indicated in the resident's care plan. The Medical Doctor (MD) stated that monitoring for these symptoms is a standard nursing practice and does not require a written order. However, the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) suggests that the monitoring was not consistently performed or recorded, which could lead to unmonitored and untreated adverse reactions from insulin therapy.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 24, who was completely immobile due to functional quadriplegia and had severe cognitive impairments. The resident was dependent on staff for all activities of daily living, including eating, personal hygiene, and toileting. During observations, the call light was found on the floor, out of the resident's reach, which was confirmed by both a Certified Nursing Assistant and a Licensed Vocational Nurse. The facility's policy required that call lights be within reach at all times to enable residents to request assistance. The deficiency was identified during a review of the resident's records and through direct observation and interviews with staff. The facility's policy, dated February 2009, clearly stated the necessity of having call systems accessible to residents to ensure they can request help, especially in emergencies. Despite this policy, the call light for Resident 24 was not accessible, which could prevent the resident from calling for assistance when needed.
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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