Vista Real Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, California.
- Location
- 1665 East Eighth Street, Beaumont, California 92223
- CMS Provider Number
- 555740
- Inspections on file
- 31
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Vista Real Post Acute during CMS and state inspections, most recent first.
A resident with dementia and documented moderate cognitive impairment was assessed as high risk for wandering/elopement, but the care plan only allowed wandering in safe areas and lacked specific interventions to prevent exit from the grounds. Staff had observed the resident expressing a desire to go home, refusing meals, and looking for ways to leave near exit doors, yet the elopement care plan was not revised. While the resident was outside in the garden, the activity assistant remained in the lobby instead of providing close supervision, and the resident climbed over the fence and left the grounds despite staff attempts at redirection, leading to notification of law enforcement.
Multiple cardboard boxes were found on the ground outside the designated recycling container instead of being properly stored inside. The Dietary Supervisor and Registered Dietitian confirmed that facility policy requires daily inspection and cleanliness of the garbage area, and acknowledged that leaving boxes outside the container could attract pests and cause infection control issues.
The facility did not provide required follow-up information or education about advance directives (ADs) to several residents or their representatives, as evidenced by interviews and record reviews. Despite facility policy mandating inquiry and assistance regarding ADs upon admission and during care conferences, documentation showed that residents with and without decision-making capacity were not consistently offered information or resources about ADs, and this was acknowledged by the Social Service Director.
Three dietary staff members did not follow the manufacturer's instructions for testing Quat sanitizer solution, with each dipping the test strip for longer than the required one to two seconds. All staff involved acknowledged the error during interviews, and the Registered Dietitian confirmed the importance of following the correct procedure to ensure proper sanitation.
An Activities Assistant stood over a resident with dementia while providing assistance with liquid nourishment, rather than sitting at eye level as required by facility policy. The resident, who required total assistance with ADLs and was seated in a Geri chair, did not receive meal assistance in a manner that promoted safety, dignity, and respect, as outlined in the facility's procedures.
A LVN did not disinfect a blood pressure machine between uses on multiple residents and used gloves stored in her scrub pocket before administering medication. The facility's infection preventionist confirmed that both actions were against established protocols, which require disinfection of medical devices after each use and obtaining gloves from wall-mounted boxes to prevent contamination.
A resident with a history of schizophrenia and moderate cognitive impairment repeatedly consumed less than 50% of meals, but staff failed to document or communicate these refusals to nursing, the MD, or the RD. The resident was not offered alternative meals, and no care plan was developed to address ongoing meal refusals or weight loss, contrary to facility policy.
A resident with severe cognitive impairment and muscle atrophy was left unattended by a CNA, resulting in a fall and head injury. The resident, on one-on-one monitoring due to elopement behavior, was left alone when the CNA stepped out to get dinner. The facility's policy required continuous supervision for high-risk residents, which was not followed, leading to the incident.
A resident with severe cognitive impairment was found unresponsive and later pronounced dead by hospice. The LPN notified the facility physician and hospice but delayed informing the resident's representative (RP) for approximately 2.5 hours. The facility's policy required immediate notification of the RP, which was not followed, potentially affecting the family's opportunity to say goodbye.
A resident with dementia was physically assaulted by another resident with schizophrenia after staff failed to keep them apart, despite prior knowledge of tension between them. The assaulted resident sustained a facial laceration, highlighting a deficiency in the facility's abuse prevention measures.
A resident with a history of aggressive behavior, diagnosed with dementia and schizoaffective disorder, was not adequately supervised, resulting in an incident where they hit another resident with a plastic plate cover, causing injury. Despite known risks and previous altercations, the resident was not under one-on-one supervision. Staff expressed concerns about safety, and the facility's care plan and policies were not effectively implemented, leading to this deficiency.
The facility failed to ensure dietary staff followed proper procedures, leading to potential nutritional deficiencies. A cook used a slotted spoon instead of a measuring cup for pureed meatloaf, affecting portion accuracy. Additionally, a diet aide served ice cream instead of diet cookies to a resident on a renal controlled carbohydrate diet, risking fluid overload and electrolyte imbalance.
The facility failed to follow prescribed menus, affecting residents on pureed, Controlled Carbohydrate (CCHO), and Mechanical Soft diets. The cook did not adhere to puree recipes, leading to diluted nutrient concentrations for residents on pureed diets. Additionally, biscuits were served instead of wheat rolls to residents on CCHO diets, and biscuits were inappropriately served to residents on Mechanical Soft diets, potentially impacting their nutritional needs and safety.
The facility failed to maintain sanitary food preparation and storage practices, with issues such as grime buildup on the ice maker, wear and tear on the mixer, and black grime on the milk refrigerator's gasket. Open food items were exposed to air, and wet scoops were improperly stored, posing a risk of contamination. The hood vent and ceiling were also unclean, potentially leading to cross-contamination.
The facility failed to implement proper infection control practices when a resident's clean clothing was placed on a commode, and the Activity Director was observed with long artificial nails while providing direct care. Both actions were against the facility's infection control policies, as confirmed by staff interviews and observations.
The facility did not maintain a clean and comfortable environment, as waste was left outside disposal bins, potentially attracting pests. Additionally, damaged window blinds in resident rooms disrupted sleep and increased room temperature. The Maintenance Supervisor and Facility Administrator were aware of these issues but did not take corrective action.
The facility failed to ensure that copies of Advance Directives were available in the medical records for two residents with severe cognitive impairment. Despite having executed ADs, the documents were not accessible in the records, and there was no evidence that information about formulating ADs was provided to the residents or their representatives. The Social Service Director acknowledged the oversight and the facility's policy requirement for AD information to be prominently displayed in medical records.
A resident was transferred to a hospital from a clinic appointment without the facility notifying the resident's representative or the LTC Ombudsman, as required by policy. Staff interviews confirmed the oversight, and the facility's policy mandates such notifications.
A facility failed to transcribe a physician's recommendation for wound treatment into an actual order for a resident with a skin tear. The recommendation to cleanse with normal saline, pat dry, and apply a triple antibiotic was not recorded in the treatment administration record, leading to a gap in communication and care implementation. Interviews with the IP and DON confirmed the oversight, which was against the facility's policy requiring immediate recording of verbal orders.
A resident was found with long, untrimmed fingernails with black residue, indicating a failure in nail care. The CNA acknowledged that the nails should have been trimmed during daily checks. Both an RN and the IP noted the risk of skin breakdown and infection due to the untrimmed nails. The facility's policy requires daily cleaning and regular trimming, which was not followed.
A resident with COPD was administered oxygen at 4 LPM, exceeding the physician's order of 1 to 3 LPM. An LVN acknowledged the error, and the DON confirmed the requirement to follow physician orders. This oversight could lead to ineffective oxygen therapy and respiratory distress.
A resident in the facility was not provided with necessary dental care services, despite being identified as having no natural teeth or dentures upon admission. The resident expressed embarrassment and a need for dentures, but no referral to dental services was made. Facility staff, including the RN, SSD, and DON, acknowledged that a referral should have been initiated, as per the facility's policy.
A resident with specific dietary orders for thin liquids and a 120 ml fluid restriction was given honey-thick liquids and 240 ml of fluid during lunch. The Dietary Supervisor failed to update the meal tray ticket, leading to the resident receiving incorrect liquid consistency and excess fluid, which could potentially cause fluid overload.
The facility failed to maintain an effective pest control program, as house flies were observed in the kitchen and dining hall. Staff acknowledged the presence of flies, which were seen landing on surfaces and near food. The facility's policy aimed to keep the environment pest-free, but the presence of flies contradicted this commitment.
A facility failed to initiate a trauma-informed care plan for a resident with a history of trauma, despite the resident's disclosure of anxiety triggers and a personal history of abuse. The resident, with a complex medical history, was observed using noise-cancelling headphones to manage anxiety. Interviews revealed that the care plan should have included trauma-informed interventions, but the social history assessment was not updated in a timely manner.
A facility failed to provide trauma-informed care to a resident with a history of abuse and traumatic events. The resident, who uses noise-cancelling headphones to manage anxiety, was not assessed for trauma triggers, and no care plan was implemented. Staff interviews revealed a lack of training and awareness regarding trauma-informed care. The facility's policy on trauma-informed care was not followed, as there were no records of required training.
Failure to Supervise High-Risk Wanderer Resulting in Elopement Over Facility Fence
Penalty
Summary
The deficiency involves the facility’s failure to ensure effective supervision and individualized interventions for a resident assessed as high risk for wandering and elopement. The resident, admitted with dementia and documented moderate cognitive impairment, had an elopement/wandering care plan dated September 6, 2025, that identified risk for elopement/exit seeking/wandering related to agitation and altered cognitive status, and noted the resident voiced a desire to leave. The only intervention listed was to allow wandering in safe areas within the facility, and there were no specific interventions to prevent the resident from exiting the facility grounds. An elopement and wandering risk assessment dated December 19, 2025, scored the resident at 10, indicating risk for wandering or elopement. Staff documentation on an eINTERACT SBAR dated January 15, 2026, recorded that staff saw the resident jump over the fence, that available staff followed and attempted to redirect the resident back inside the facility grounds, and that the resident refused and continued walking along a nearby street. Interviews with staff further described actions and inactions leading to the elopement. CNA 1, who was assigned to the resident at the time, stated she was informed by CNA 2 that the resident had jumped over the fence, and that staff attempted to redirect the resident but the resident refused, after which law enforcement was contacted. CNA 2 reported being familiar with the resident, noting the resident had verbalized wanting to go home with his brother, had refused meals, and had been observed about a week prior to the incident walking near exit doors and appearing to look for ways to leave the facility. The Activity Assistant stated she knew the resident was at risk for elopement and required close supervision, and that residents at risk for elopement required close supervision when outside. She reported that she observed the resident sitting in the garden while she remained in the lobby, then saw the resident climb over the fence, and acknowledged she should have been outside supervising the resident. The Registered Nurse Supervisor stated that although the facility’s practice was to revise the elopement risk assessment and care plan when exit-seeking was observed, the resident’s care plan was not revised to add new interventions such as 1:1 supervision while outside. The facility’s wandering and elopement policy required that residents identified at risk have care plans including strategies and interventions to maintain safety.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse when multiple cardboard boxes were observed on the ground outside of the designated recycling container, rather than being stored appropriately inside the container. During an observation of the garbage and refuse storage area, surveyors found these boxes on the ground near the recycling container. The Dietary Supervisor confirmed during an interview that there should not be any debris or cardboard boxes on the ground around the containers and acknowledged that such practices could attract pests and cause infection control issues. The Registered Dietitian also stated that garbage containers should be kept clean and inspected daily to ensure no garbage or cardboard boxes are left on the ground in the surrounding area, in accordance with facility policy. A review of the facility's policy indicated that garbage and trash cans must be inspected daily to ensure no debris is present on the ground or surrounding area, and that the lids are closed.
Failure to Provide Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that seven out of fourteen residents reviewed for Advance Directives (ADs) were provided with follow-up information regarding the formulation of an AD. Multiple residents, including those with the capacity to make decisions and those with fluctuating or no capacity, were either unsure if they had an AD or could not recall being offered information about one. Record reviews for these residents consistently showed either no documentation of an AD or no evidence that information or education about ADs was provided to the resident or their representative. Interviews with the Social Service Director (SSD) revealed that the facility's protocol was to determine the presence of an AD upon admission and to offer resources if one was not present. However, the SSD acknowledged that follow-up with residents or their representatives was not consistently performed, and documentation of such follow-up was lacking. In several cases, the SSD admitted that education and resources regarding ADs were not provided as required, and that quarterly reviews or care conferences did not include documented follow-up on ADs for residents without one. The facility's own policy required that residents be asked about ADs upon admission and that assistance be offered if an AD was not in place, with this information to be prominently displayed in the medical record. Despite this, the survey found that for the seven residents in question, there was no documented evidence that they or their representatives were provided with the necessary information or education about their right to formulate an AD, as required by facility policy and federal regulations.
Dietary Staff Failed to Follow Sanitizer Testing Instructions
Penalty
Summary
Three dietary staff members failed to follow the manufacturer's instructions for testing the Quaternary Ammonium (Quat) sanitizer solution used for sanitizing food contact surfaces and equipment. Observations and interviews revealed that the Dietary Aide dipped the test strip in the solution for 10 seconds, the Cook for eight seconds, and the Dietary Supervisor for five seconds, instead of the required one to two seconds as specified by the manufacturer's instructions. Each staff member acknowledged during interviews that they did not follow the correct procedure and recognized the importance of adhering to the manufacturer's guidelines to ensure proper sanitizer concentration. The Registered Dietitian confirmed that the test strips should be dipped for one to two seconds to ensure proper sanitation, and not following these instructions could compromise disinfection. The review of the USDA Food Code 2022 and related professional references further supported the requirement to use sanitizer solutions according to the manufacturer's directions. The failure to follow these procedures had the potential to create unsafe and unsanitary kitchen conditions.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
A deficiency occurred when an Activities Assistant (AA) assisted a resident with liquid nourishment while standing over the resident, rather than sitting at eye level as required by facility policy. The resident was observed seated in a Geri chair with the head tilted at a 45-degree angle, positioned in the corner of the activities room. The AA was seen standing directly over the resident during the assistance, which did not align with the facility's expectations for promoting safety, dignity, and respect during meal assistance. The resident involved had a diagnosis of dementia without behavioral disturbance and required total assistance with activities of daily living, including meals. The facility's policy and procedure for meal assistance specifically stated that staff should not stand over residents while assisting them with meals, emphasizing the importance of attention to safety, comfort, and dignity. During interviews, the AA acknowledged that he could either sit or stand while assisting, while the DON confirmed that staff are expected to sit at the resident's eye level. This failure to follow policy had the potential to negatively impact the resident's safety, dignity, and respect.
Failure to Follow Infection Control Protocols for Equipment Disinfection and Glove Use
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to clean and disinfect a blood pressure machine before and after use between multiple residents during blood pressure checks. This was observed during a morning medication pass, where the LVN used the same device on three different residents without performing any disinfection. The LVN later acknowledged in an interview that the equipment should have been disinfected between uses. The facility's Infection Preventionist confirmed that the protocol requires disinfection of medical devices after each use, and the facility's policy also specifies cleaning and wiping the sphygmomanometer and cuff with antiseptic. Additionally, the same LVN was observed donning gloves that had been stored in her scrub pocket prior to administering medication to a resident. In an interview, the LVN stated she believed it was acceptable to use gloves stored in her pocket. However, the Infection Preventionist clarified that facility protocol requires staff to obtain gloves from wall-mounted glove boxes and that storing gloves in pockets is not permitted due to contamination risks. The facility's policy on glove use outlines the importance of using gloves to prevent the spread of infection and specifies when gloves should be used.
Failure to Communicate and Address Resident Meal Refusals and Low Intake
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who consistently consumed less than 50% of meals on multiple occasions. Despite repeated low meal intakes documented throughout March, there was no evidence that these occurrences were communicated to nursing staff, the physician, or the registered dietitian. The resident, who was alert and able to make decisions, reported dissatisfaction with the food, lack of alternatives, and ongoing weight loss. Observations confirmed that the resident was not offered alternative meals when refusing food, and staff interviews revealed a lack of timely communication and documentation regarding meal refusals. Record reviews showed that the resident had a history of schizophrenia and a moderately impaired cognitive status, but retained the capacity to understand and make decisions. The resident's intake records indicated multiple instances of eating less than 50% of meals, yet there was no documentation that these patterns were reported or addressed by the care team. The facility's own policy required that variations in eating patterns be documented and reported to nursing, the physician, and the dietitian, but this was not followed in the resident's case. Interviews with the DON and RD confirmed they were not made aware of the resident's inadequate intake or meal refusals until after the surveyor's inquiry. There was also no evidence that a care plan was developed to address the resident's meal refusals or to provide interventions to prevent further weight loss. The lack of communication and documentation regarding the resident's nutritional intake represented a failure to follow facility policy and to meet the resident's dietary needs and preferences.
Failure to Provide Continuous Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure continuous supervision and assistance for a resident who was on one-on-one monitoring due to severe cognitive impairment and elopement behavior. The resident, who had been admitted with diagnoses including muscle wasting and atrophy, was left unattended by a CNA who stepped out to retrieve the resident's dinner from the hallway. During this brief absence, the resident fell asleep in a chair, slid out, and sustained a 3 cm laceration and bump on the left forehead. Interviews with the Director of Nursing, an LVN, and the CNA confirmed that the resident required constant supervision to prevent accidents. The CNA acknowledged leaving the resident unattended, which was against the facility's policy for one-on-one monitoring. The facility's policy emphasized the importance of continuous bedside observation for residents at high risk for falls, which was not adhered to in this instance, leading to the resident's fall and injury.
Delayed Notification of Resident's Death to Representative
Penalty
Summary
The facility failed to notify the resident's representative (RP) of a decline in the resident's health status in a timely manner. Resident 1, who had severe cognitive impairment, was found unresponsive, not breathing, and without a heartbeat by LVN 2. The facility physician and hospice were notified, and the hospice nurse pronounced the resident dead. However, the RP was not informed until approximately 2.5 hours later, after the hospice had arrived and pronounced the time of death. During interviews, LVN 2 and the Director of Nursing (DON) confirmed that the RP should have been notified immediately after the resident was assessed as deceased. The facility's policy required immediate notification of the RP in such situations, but this was not followed. The delay in communication potentially deprived the family of the opportunity to be present and say goodbye before the resident's remains were released to the mortuary.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide an environment free of physical abuse for a resident, identified as Resident 2, who was assaulted by another resident, Resident 3. Resident 2, who has dementia and moderate cognitive impairment, was accused by Resident 3 of taking his belongings. Despite being aware of the initial altercation at 6:15 a.m., where Resident 3 was agitated and punched a wall, staff did not effectively intervene to prevent further interaction between the two residents. Later that morning, at 10:55 a.m., Resident 2 was walking towards the dining room when Resident 3, who has schizophrenia and the capacity to understand and make decisions, was with the Activity Director in the hallway. Resident 3 suddenly punched Resident 2 on the right side of the face, causing a laceration and swelling. The staff, including the Activity Director and nursing staff, were aware of the need to keep the residents apart but failed to redirect Resident 2 away from Resident 3, leading to the physical altercation. Interviews with the Registered Nurse, Activity Director, and Director of Nursing confirmed that the staff were instructed to keep the residents apart to prevent an altercation. However, the staff did not take adequate measures to separate the residents, resulting in Resident 2 being injured. The facility's policy on abuse prevention emphasizes the need to protect residents from physical abuse, including from other residents, but this was not adhered to in this incident.
Inadequate Supervision Leads to Resident Assault
Penalty
Summary
The facility failed to provide effective supervision for a resident with a history of aggressive behavior, resulting in an incident where this resident hit another resident with a plastic plate cover, causing a bruise and swelling. The aggressive resident, diagnosed with dementia and schizoaffective disorder, had a documented history of fluctuating decision-making capacity and previous altercations with staff and other residents. Despite these known risks, the resident was not under one-on-one supervision at the time of the incident. Interviews with staff revealed that the aggressive resident's behavior had been escalating, and staff members expressed concerns about their safety and the safety of other residents. The resident had previously assaulted a CNA with a fork and made verbal threats to staff and residents. The facility's care plan for the resident included increased supervision and safety measures, but these were not adequately implemented, as evidenced by the incident in the dining room. The Director of Nursing and other staff members acknowledged that the supervision provided was insufficient to prevent the incident. The facility's policy on behavioral assessment and intervention emphasized the need for immediate safety strategies to protect residents and staff, but these measures were not effectively executed, leading to the deficiency.
Deficiencies in Dietary Service and Meal Preparation
Penalty
Summary
The facility failed to ensure that dietary staff were able to carry out the functions of food and nutrition services safely and effectively. During a lunch service, a cook used a slotted spoon instead of a measuring cup to portion pureed meatloaf, failing to follow the standardized recipe. This action had the potential to affect the nutritional needs of four residents who received pureed meat, as the portion size was not accurately measured. The Registered Dietitian confirmed that not measuring the meatloaf portion could impact the nutritional values of the prepared pureed meat. Additionally, a diet aide served ice cream instead of diet cookies to a resident with a physician-ordered renal controlled carbohydrate diet. This error was observed during the lunch meal plating service. The resident's meal tray ticket indicated a requirement for diet cookies, but the diet aide did not follow the Cooks spreadsheet, which guides dietary staff on food items and therapeutic diets. The Registered Dietitian noted that serving ice cream could lead to fluid overload and negatively affect the resident's electrolyte levels due to the high levels of phosphorus and potassium in dairy products.
Menu Non-Compliance and Nutritional Deficiencies
Penalty
Summary
The facility failed to ensure that menus were followed and resident nutritional needs were met during meal preparation and service. On July 8, 2024, the cook did not adhere to the puree recipes when preparing pureed diets for residents with physician-ordered pureed diets. The cook used a slotted spoon to scoop meatloaf without measuring, added excessive beef broth, and did not refer to the recipe, resulting in a diluted consistency. Similar deviations occurred with the preparation of pureed biscuits and vegetables, where the cook did not follow the recipes, leading to a diluted concentration of nutrients. This failure affected four residents on pureed diets, potentially compromising their nutritional intake. Additionally, the facility did not follow the menu for residents on Controlled Carbohydrate (CCHO) diets. During the lunch service, the cook served biscuits instead of the prescribed wheat rolls to all residents, including those on CCHO diets. The Registered Dietitian confirmed that the menu required wheat rolls to help control blood sugar levels for diabetic residents. This oversight affected twelve residents with CCHO diet orders, potentially impacting their blood sugar management. Furthermore, the facility served biscuits to residents on Mechanical Soft diets, contrary to the menu guidelines. The cook served biscuits to all residents, including those on Mechanical Soft diets, which are not supposed to include hard crusts like biscuits. This action affected fourteen residents with Mechanical Soft diet orders, potentially causing difficulties in chewing and swallowing. The Registered Dietitian confirmed that biscuits were inappropriate for these residents, as they could pose a risk to those with chewing or swallowing limitations.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. The ice maker was found to have a buildup of grime, which was confirmed by the Dietary Supervisor (DS) and Maintenance Assistant (MA) during an inspection. The Registered Dietitian (RD) later confirmed that the ice maker should be kept clean to prevent contamination. Additionally, the stationary mixer in the kitchen was observed to have wear and tear, with exposed brown grime, making it difficult to clean. The RD stated that the mixer needed to be replaced due to its unsmooth surface. Further observations revealed that the milk refrigerator's gasket had black grime buildup, which the DS admitted was missed during cleaning. The RD emphasized the importance of cleaning the gasket to prevent cross-contamination. Several pieces of kitchen equipment, including storage shelves and the base of a can opener, were found to have brown grime, indicating a lack of proper sanitation. Open food items were also found exposed to the air in the reach-in freezer, which the DS acknowledged should have been sealed to prevent freezer burn and contamination. Additional issues included wet serving scoops and a plastic container being improperly stored with dry items, which could lead to bacterial growth. The hood vent above the stove was covered with grease and dust, and the ceiling above the steam table had black debris, which the DS identified as dust. The RD confirmed that these areas should be kept clean to prevent cross-contamination. These deficiencies in food safety and sanitation practices posed a risk of foodborne illness to the residents receiving food from the kitchen.
Infection Control Deficiencies: Improper Clothing Storage and Artificial Nails
Penalty
Summary
The facility failed to implement proper infection control practices in two observed instances. In the first instance, a resident's clean clothing, including a pair of black shoes and blue pants, was found placed on top of a commode. This was confirmed through observations and interviews with the resident, a CNA, an RN, and the Infection Preventionist (IP), all of whom acknowledged that clothing should be stored in designated clean areas to prevent contamination and potential infection. The Director of Nursing (DON) also emphasized the importance of CNAs conducting rounds to identify and rectify such infection control issues. In the second instance, the Activity Director (AD) was observed with long artificial nails while providing direct care to residents, which is against the facility's policy. The AD admitted to having artificial nails and was unaware of the policy prohibiting them for direct care staff. The IP and DON confirmed that long artificial nails could pose an infection risk, as they may damage residents' skin and lead to infections. The facility's policy clearly states that direct care staff should maintain short, natural fingernails, and artificial nails are prohibited, especially for those caring for severely ill or immunocompromised residents.
Facility Fails to Maintain Cleanliness and Comfort
Penalty
Summary
The facility failed to maintain a safe and clean environment by not containing waste in closed containers and not providing a homelike environment for residents. Observations revealed multiple discarded medical equipment and non-medical materials surrounding the outside disposal bins, which had the potential to attract insects and rodents. The Maintenance Supervisor (MS) acknowledged awareness of the debris for nine months, and both the Facility Administrator (FA) and Infection Preventionist (IP) confirmed that waste should be properly disposed of in designated bins to prevent pest infestation. The facility's policies on waste disposal and pest control were not adhered to, as garbage and trash were allowed to accumulate outside the designated areas. Additionally, the facility failed to maintain window blinds in resident rooms, affecting the comfort of three residents. Damaged blinds in the rooms of Residents 30, 42, and 43 led to issues such as disrupted sleep and increased room temperature due to uncontrolled sunlight. The MS and FA were aware of the damaged blinds and acknowledged the need for replacement or repair. The facility's maintenance policy requires the maintenance department to keep the building in good repair, which was not followed in this instance.
Failure to Ensure Availability of Advance Directives in Medical Records
Penalty
Summary
The facility failed to ensure that copies of Advance Directives (AD) were available in the medical records for two residents, Residents 4 and 5, who were reviewed for Advance Directives. Resident 5, who was admitted to the facility and had severe cognitive impairment with a BIMS score of 4, had executed an AD as indicated by an acknowledgment form. However, there was no documented evidence of the AD being available in the resident's medical record. During an interview, the Social Service Director (SSD) confirmed that Resident 5's AD should have been accessible to staff and physicians but was not. Similarly, Resident 4, who also had severe cognitive impairment with a BIMS score of 3, had an acknowledgment form indicating an executed AD. However, the AD was not available in the medical record, and there was no evidence that the resident or their representative was provided information about formulating an AD. The SSD acknowledged the responsibility to ensure the availability of ADs in the records and admitted that assistance with the AD should have been offered during a quarterly review with the resident's representative. The facility's policy requires that information about an AD be prominently displayed in the medical record, which was not adhered to in these cases.
Failure to Notify Resident Representative and Ombudsman of Transfer
Penalty
Summary
The facility failed to notify the resident representative and the Office of the State Long-Term Care Ombudsman about the transfer of a resident, identified as Resident 57, to a hospital. This deficiency was identified during a review of closed records, where it was found that there was no documented evidence of a transfer/discharge notice being sent to the resident's representative or the LTC Ombudsman. Resident 57 had been admitted to the facility with a diagnosis that included anxiety disorder. The transfer occurred when the resident was sent to a hospital from a scheduled clinic appointment, and the facility did not follow the required notification procedures. Interviews with facility staff, including the Director of Medical Records, the Director of Nursing, and a Licensed Vocational Nurse, confirmed that the notification process was not followed. The Director of Medical Records acknowledged that a letter should have been sent to both the resident's representative and the LTC Ombudsman. The Director of Nursing and the Licensed Vocational Nurse also confirmed that no notification letter was sent, despite the facility's policy requiring such notifications. The facility's policy, dated October 2022, mandates that transfer or discharge notifications be provided to the resident and their representative, as well as to the LTC Ombudsman, as soon as practicable.
Failure to Transcribe Physician's Wound Treatment Recommendation
Penalty
Summary
The facility failed to ensure that a physician's recommendation for wound treatment was transcribed into an actual physician order for a resident. This oversight was identified during a review of the resident's records, which revealed that the physician's recommendation to cleanse a skin tear with normal saline, pat dry, and apply a triple antibiotic was not transcribed into the resident's physician orders for June and July 2024. The resident, who was admitted with diagnoses including wheelchair dependency and severe debility, had a documented skin tear on the right hand, but the recommended treatment was not recorded in the treatment administration record. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the physician's recommendation was not transcribed into an order and, consequently, was not followed. The facility's policy requires that verbal orders be recorded immediately in the resident's chart, including the prescriber's last name, credentials, date, and time of the order. The failure to transcribe and implement the physician's recommendation resulted in a gap in communication and affected the implementation of the recommended care.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for one of the residents, identified as Resident 42. During an observation and interview, Resident 42 was found to have long, untrimmed fingernails with black residue underneath. The resident expressed that their nails were dirty and needed trimming. A Certified Nurse Assistant (CNA) confirmed the condition of the resident's nails and acknowledged that they should have been trimmed during daily body checks. A Registered Nurse (RN) and the Infection Preventionist (IP) also noted the long, untrimmed nails and highlighted the risk of skin breakdown and infection if the resident were to scratch themselves. The facility's policy on nail care, dated February 2018, mandates daily cleaning and regular trimming to prevent accidental scratching and injury, which was not adhered to in this case.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to the physician's order for oxygen administration for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident, who was admitted with COPD, had a physician's order to receive oxygen therapy via nasal cannula at a rate of 1 to 3 liters per minute (LPM) to maintain oxygen saturation levels at or above 90%. However, during an observation, it was noted that the resident was receiving oxygen at a rate of 4 LPM, which exceeded the prescribed limit. Licensed Vocational Nurse (LVN) 3 acknowledged the discrepancy, stating that the resident should not have been administered oxygen above 3 LPM due to the risk of the resident being unable to breathe independently. The Director of Nursing (DON) confirmed that nursing staff are required to follow physician orders for oxygen therapy, and the facility's policy on oxygen administration mandates verifying and adhering to physician orders. This oversight had the potential to result in ineffective oxygen therapy and respiratory distress for the resident.
Failure to Provide Dental Care Services
Penalty
Summary
The facility failed to provide necessary dental care services for a resident, identified as Resident 55, who was observed to have missing upper and lower teeth. During an interview, Resident 55 expressed the need for dentures and reported not having seen a dentist since admission to the facility. The resident also mentioned feeling embarrassed and unable to smile due to the lack of teeth, and stated that a licensed nurse had been informed of these dental issues but no assistance was provided. Upon review of Resident 55's records, it was noted that the resident was admitted with a diagnosis of anxiety and was identified as having no natural teeth or dentures. A physician's order for a dental consult was dated June 23, 2024, but no referral was made. Interviews with the Registered Nurse, Social Service Director, and Director of Nursing confirmed that the resident should have been referred to dental services upon admission. The facility's policy indicated that social services were responsible for making dental appointments, but this procedure was not followed for Resident 55.
Failure to Follow Physician Diet Orders
Penalty
Summary
The facility failed to adhere to physician orders for a resident during a dining observation. The resident, who had a physician order for thin liquids, was mistakenly given honey-thick apple juice during lunch. This error occurred because the Dietary Supervisor did not update the meal tray ticket to reflect the current physician order, as the resident had previously been on thickened liquids. The Registered Dietitian confirmed that physician orders need to be followed and expressed concern that the resident could be discouraged from drinking due to receiving the incorrect liquid consistency. Additionally, the resident, who was on a 120 ml fluid restriction for lunch due to undergoing dialysis, was served 240 ml of fluid. This occurred because the resident was given ice cream instead of diet cookies, which added an extra 120 ml of fluid to their intake. The Dietary Supervisor acknowledged the mistake, noting that the ice cream was considered a fluid and could potentially lead to fluid overload. The Registered Dietitian confirmed that the resident was only supposed to receive 120 ml of fluid during lunch according to the physician order, and the facility's policy indicated that fluid restrictions are ordered to treat conditions like renal failure.
Pest Control Deficiency in Kitchen and Dining Hall
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen and dining hall, as evidenced by the presence of house flies. On July 8, 2024, during an observation and interview with the Dietary Supervisor, two house flies were seen flying in the kitchen, with one landing near the handwashing station. The Dietary Supervisor acknowledged the presence of flies and mentioned that dietary staff had noticed them a month prior, resorting to shooing them away or using a fly swatter. Later that day, a Dietary Aide observed a house fly landing on a cleaned cutting board surface. Further observations on July 9, 2024, revealed house flies in the dining hall, with one resident swatting a fly away from their food. An Activity Assistant noted that flies enter the dining hall when residents go outside to smoke. A Certified Nurse Assistant confirmed the presence of flies and expressed concern about the potential for cross-contamination and foodborne illnesses. The Registered Dietitian emphasized that no pests should be in the kitchen due to the risk of cross-contamination. The facility's policy on pest control, which was reviewed, indicated a commitment to maintaining a pest-free environment, yet the presence of flies contradicted this policy.
Failure to Initiate Trauma-Informed Care Plan
Penalty
Summary
The facility failed to initiate a comprehensive care plan for a resident with a documented history of trauma, which was identified during a social history assessment. The resident, who has a complex medical history including diabetes, breast cancer with metastasis, bipolar disorder, and anxiety disorder, was observed using noise-cancelling headphones to manage anxiety triggered by loud noises. Despite the resident's disclosure of a personal history of abusive relationships and the presence of trauma, no care plan was developed to address these needs. Interviews with the Director of Nursing and the Social Worker revealed that the resident's care plan should have included trauma-informed care interventions, such as assessing for triggers. However, the Social Worker indicated that the resident's social history assessment would not be updated until the next quarterly assessment. The facility's policy on trauma-informed care requires the interdisciplinary team to care plan for PTSD risks and to identify past trauma, but this was not implemented for the resident in question.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident with a history of abusive relationships and exposure to numerous traumatic events. The resident, who uses noise-cancelling headphones to manage anxiety triggered by loud noises, was not assessed for trauma triggers, and no care plan addressing their history of trauma was implemented. Interviews with staff, including a CNA and LVN, revealed a lack of awareness and training on trauma-informed care, with staff not taking any specific actions for residents with a history of abuse. The Social Worker indicated that the responsibility for assessing triggers and implementing a care plan lies with the RN or DON, but this was not done for the resident in question. The resident's Social History Assessment indicated exposure to various traumatic events and a history of substance use disorders, yet the care plans did not address these issues. The facility's policy on trauma-informed care, which includes in-service training and the use of a Significant Life Events Checklist, was not followed, as there were no records of such training from May 2023 to May 2024. The DON acknowledged that the resident had not disclosed a history of abuse until a specific incident occurred, highlighting a gap in the facility's approach to trauma-informed care and the need for proper assessment and care planning for residents with trauma histories.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
