We Care Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Hayward, California.
- Location
- 21863 Vallejo Street, Hayward, California 94541
- CMS Provider Number
- 555914
- Inspections on file
- 13
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at We Care Skilled Nursing Facility during CMS and state inspections, most recent first.
The facility did not create or implement individualized care plans for three residents with specific needs: one with a PICC line, another with significant weight loss and low oral intake, and a third with moderate hearing loss. Staff failed to document refusals, hold IDT meetings, or follow established policies for care planning and monitoring, resulting in unmet care needs for these residents.
Three medication administration errors were observed, resulting in a medication error rate of 12 percent. These included a resident receiving Metformin without food, a nurse failing to instruct a resident to press the inner canthus after eye drop administration, and a nurse not checking vital signs before, during, or after a nebulizer treatment. These actions did not follow physician orders, manufacturer guidelines, or facility policy.
The facility did not follow professional food safety standards, as frozen meats were thawed improperly above fresh milk and on food prep counters, and kitchen staff used incorrect test strips to check sanitizer concentrations for dishwashing and sinks. Staff were unable to explain proper testing procedures, and logs showed unclear documentation. Additionally, two kitchen staff did not wear proper hair coverings during food preparation, contrary to facility policy.
A resident with a history of adequate hearing experienced moderate hearing loss after a hospital stay, as documented in assessments and observed by staff. Despite this, no care plan was developed, and standard procedures such as notifying the physician or arranging audiology services were not followed, leaving the resident without needed hearing support.
A resident with chronic kidney disease, diabetes, and frequent urinary incontinence reported painful urination and was observed by a CNA to have foul-smelling urine. Although an LVN notified the physician and was instructed to collect a urine specimen and encourage the resident's compliance, no SBAR was completed, no written order was entered, and no care plan was initiated, resulting in a lack of follow-up and documentation as required by facility policy.
A resident with severe cognitive impairment and multiple health conditions was not adequately monitored or assisted with food and fluid intake, leading to significant weight loss and insufficient hydration. Staff were unaware of the resident's specific hydration needs and failed to implement recommendations from the RD, while required monitoring and care planning for weight loss were not completed.
A resident with a PICC line did not receive dressing changes as ordered, and required monitoring for complications was not performed or documented. There was no record of the resident's refusals for dressing changes or removal, and no care plan or IDT meeting addressed the PICC line care, contrary to facility policy and physician orders.
Two residents experienced unaddressed medication regimen irregularities when the consultant pharmacist failed to identify or follow up on issues during monthly reviews. One resident with ESRD continued to receive contraindicated laxatives despite repeated refusal of a phosphate binder, while another resident's recommended reduction in acetaminophen dosage was not communicated to the physician. Facility policy requiring timely reporting and documentation of medication irregularities was not followed.
A resident with heart failure and atrial fibrillation was prescribed apixaban, a medication with a black box warning, but did not receive the required monitoring for adverse effects such as bleeding. Facility policy and FDA guidance required close monitoring for this medication, but review of the MAR and staff interview confirmed that this monitoring was not performed.
A resident with COPD and difficulty chewing was served dry corn flakes cereal despite being on a mechanical soft, controlled carbohydrate diet and having a documented dislike for cereal. Staff interviews revealed that the wrong cereal was provided due to a request from a CNA, and the dietary manager acknowledged the error. The resident felt disregarded, and the facility's policy requires adherence to prescribed therapeutic diets and resident preferences.
Surveyors found seven expired IV administration sets and one expired PICC stabilizing device stored with ready-to-use supplies in the medication storage room. An LVN confirmed no unexpired IV kits or PICC devices were available, even though a resident could have needed them. The DON stated that monthly audits to remove expired supplies were required, but could not provide documentation that these audits were completed.
A facility failed to re-evaluate the use of Seroquel for a resident admitted from a hospital, as required by their policy. The resident, who had COPD and anxiety behaviors, was prescribed Seroquel for a mood disorder, but the MDS assessment showed no indicators of psychosis or aggressive behavior. Despite a pharmacist's recommendation to consider dose reduction or diagnosis clarification, the medication was continued without re-evaluation. Interviews with staff confirmed the lack of re-evaluation, and the DON acknowledged the oversight.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents with specific needs. One resident was admitted with a peripherally inserted central catheter (PICC) line for cellulitis treatment but did not have a care plan addressing PICC line care. The resident had a history of refusing PICC line removal and dressing changes, yet there was no documentation of these refusals or any interdisciplinary team (IDT) meetings to address the situation. The last dressing change was performed over a month prior, and staff acknowledged that a care plan and IDT involvement were necessary to monitor for complications such as infection. Another resident experienced a significant weight loss of 2.4 pounds in one week, attributed to very low oral intake, consuming only 0-25% of meals. Staff recognized the resident's high risk for malnutrition and the need for assistance with feeding, but there was no care plan developed to address the weight loss or low intake. The facility did not hold IDT meetings or establish goals, benchmarks, or monitoring parameters for this resident, despite policy requirements for multidisciplinary care planning in cases of weight loss or impaired nutrition. A third resident had moderate hearing loss documented in multiple assessments, including the Minimum Data Set (MDS), and staff reported communication difficulties requiring written notes or speaking loudly. Despite these ongoing issues and a change in hearing status following a hospital stay, no comprehensive care plan was initiated to address the resident's hearing impairment. There was also no evidence of follow-up with audiology or investigation into the use of hearing aids, and standard procedures for addressing hearing changes were not implemented.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as three medication errors were observed out of 25 opportunities, resulting in a 12 percent error rate. One incident involved a resident with Type II Diabetes Mellitus who was administered Metformin 850 mg orally without a snack or meal, contrary to the physician's order and manufacturer guidelines, which specify that Metformin should be given with food to prevent gastrointestinal upset. The nurse acknowledged administering the medication without food due to the timing of scheduled meals. Another error occurred when a nurse administered artificial tears to a resident for eye dryness but instructed the resident to rapidly blink after instillation, rather than slowly closing the eyes and pressing the inner canthus as per standard nursing practice and facility policy. Additionally, a resident receiving Ipratropium-Albuterol inhalation treatment did not have vital signs checked before, during, or after the nebulizer treatment, despite physician orders and facility policy requiring these assessments. The nurse confirmed the importance of monitoring vital signs to evaluate the effectiveness of the medication.
Failure to Follow Food Safety Standards in Food Storage, Preparation, and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards of food service safety in several key areas. Observations revealed that frozen meats, including chicken and turkey, were thawed on top of ready-to-drink fresh milk inside a refrigerator due to lack of space, as stated by the Dietary Manager. Additionally, frozen chicken was left to thaw on the food preparation counter before cooking, and kitchen staff confirmed that the chicken was pulled from the freezer and left on the counter for lunch service. These practices were not in accordance with the facility's own policy, which requires thawing meat in a refrigerator on the bottom shelf below ready-to-eat foods or under running potable water. Multiple kitchen staff used incorrect test strips to check sanitizer concentrations for both the three-compartment sink and the dishwasher. Staff used pH test strips, which are intended for checking detergent concentration, instead of the appropriate chlorine or quaternary ammonium test strips for sanitizer concentration. Staff were unable to explain the correct procedures for testing sanitizer levels, and logs showed inconsistent and unclear documentation of sanitizer readings. The posted instructions for quat sanitizer testing were outdated and not aligned with current practices, and the logs had been altered to reflect different concentration ranges without clear rationale. Furthermore, two kitchen staff, including the Dietary Manager, were observed not wearing proper hair coverings during food preparation, contrary to the facility's dress code policy. The policy requires hats that completely cover the hair or hair nets for longer hair, but staff were seen with hair partially or completely uncovered while preparing food. These failures in food storage, preparation, sanitation, and personal hygiene had the potential to result in cross-contamination and food-borne illnesses, as noted in the findings.
Failure to Address Resident's Hearing Loss and Provide Access to Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with a communication deficit received appropriate treatment to maintain hearing ability after a decline in hearing was identified. The resident was initially admitted with adequate hearing, but following a hospital stay and return to the facility, assessments indicated moderate difficulty hearing. Despite this documented change, no comprehensive care plan was initiated to address the resident's hearing loss, and there was no evidence that the facility followed its normal process for addressing such changes, which includes ear flushing, notifying the physician and responsible party, and arranging an audiology appointment. Multiple staff interviews confirmed that the resident had ongoing difficulty hearing, requiring others to speak loudly or write messages to communicate. The Social Services Director acknowledged being aware of the resident's hearing issues but did not follow up on whether the resident had hearing aids or if insurance could cover them, and could not provide documentation of communication with the nursing department regarding the change. Observations showed the resident struggling to participate in conversations and activities due to hearing loss, with no interventions in place to address these needs.
Failure to Follow-Up on Resident's Painful Urination and Initiate Required Documentation
Penalty
Summary
Staff failed to provide appropriate treatment and services to prevent a urinary tract infection for a resident who was frequently incontinent of urine and dependent on staff for toileting hygiene. The resident, who had chronic kidney disease, muscle weakness, and diabetes mellitus, reported experiencing painful urination. The resident's urine was also noted by a CNA to have a strange odor, and this information was communicated to an LVN. The LVN contacted the attending physician, who ordered a urine specimen collection, but the resident refused the procedure. The physician further instructed staff to continue encouraging the resident to comply with the urine collection. Despite these developments, there was no documentation in the clinical record regarding the resident's change in condition, no SBAR was completed, no written physician's order for urine collection was entered, and no care plan was initiated. The facility's policy required the use of SBAR for changes in resident condition and for communication among staff, but this protocol was not followed. As a result, there was no formal follow-up or monitoring of the resident's condition after the initial complaint.
Failure to Monitor and Maintain Adequate Food and Fluid Intake
Penalty
Summary
The facility failed to adequately monitor and assist a resident in maintaining sufficient food and fluid intake, resulting in unaddressed weight loss and insufficient hydration. The resident, who was admitted with multiple diagnoses including urinary tract infection and Parkinson's disease, had a BIMS score indicating severe cognitive impairment and required substantial assistance with eating and drinking. The care plan identified the resident as being at risk for dehydration or electrolyte imbalance due to dementia, but fluid intake records showed consistently low daily consumption, well below the recommended amount by the Registered Dietician (RD). Despite the RD's progress notes highlighting a notable weight loss of 2.4 lbs in one week and recommending a daily fluid intake between 1240ml-1485ml, staff interviews revealed a lack of awareness and follow-through regarding these recommendations. Certified Nurse Assistants and Licensed Vocational Nurses acknowledged the resident's need for direct feeding assistance and encouragement to eat and drink, but were not aware of the specific hydration goals or the extent of the resident's intake. The Director of Nursing was also unaware of the RD's recommendations and the resident's recent weight loss, and admitted that fluid intake was not being adequately maintained or monitored. Further, the Assistant Director of Nursing discontinued weekly weight monitoring by mistake and confirmed that no care plan was developed to address the resident's weight loss, despite the known high risk for malnutrition. Facility policies required monitoring and intervention for inadequate hydration and weight loss, but these were not followed, resulting in the resident's ongoing insufficient intake and unaddressed health risks.
Failure to Provide and Document PICC Line Care and Monitoring
Penalty
Summary
A resident admitted with cellulitis of both lower limbs had a peripherally inserted central catheter (PICC) in place, with physician orders for the PICC line dressing to be changed every seven days and as needed. Review of the Medication Administration Record showed that these dressing changes were not performed by a Registered Nurse as ordered. Observation confirmed the presence of the PICC line, and interviews with the Director of Nursing (DON) revealed that the last dressing change was performed in January, despite the ongoing order. The DON stated the resident had refused both PICC line removal and dressing changes multiple times, but there was no documentation of these refusals in the medical record. Further review with the Assistant Director of Nursing (ADON) found no documentation of refusals, no monitoring for PICC line complications, and no evidence that an Interdisciplinary Team (IDT) meeting or care plan addressing PICC line care had been developed. The DON also admitted that required measurements of the external catheter length and arm circumference, which are standard practice for monitoring PICC line placement and complications, were not performed or documented. Facility policies required regular dressing changes, monitoring, and documentation of all care and refusals, but these were not followed for this resident.
Failure to Identify and Address Medication Regimen Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review for two residents, resulting in missed identification and follow-up of medication irregularities. For one resident with end stage renal disease (ESRD), the medication regimen included milk of magnesia and fleet enema, both of which contain substances that should be avoided in renal patients due to the risk of electrolyte imbalance. Despite the resident's repeated refusal of a prescribed phosphate binder, these medications remained part of the bowel regimen, contrary to facility policy and best practices for renal patients. The consultant pharmacist acknowledged that this irregularity was not identified during the monthly review. Additionally, for another resident who transitioned from hospice to custodial care, the consultant pharmacist recommended reducing the daily dose of acetaminophen from 4 grams to 3 grams during a medication regimen review. However, this recommendation was not communicated to the prescribing physician, and no action was taken to adjust the medication order. The assistant director of nursing confirmed that the recommendation had not been followed up, and the consultant pharmacist noted that several recommendations from previous months remained unaddressed. Facility policies required the consultant pharmacist to provide written reports of non-life threatening medication irregularities to the attending physician within 24 hours, with documentation of review and action in the medical record. In both cases, these procedures were not followed, resulting in unaddressed medication regimen irregularities for the affected residents.
Failure to Monitor Resident on Apixaban with Black Box Warning
Penalty
Summary
A resident admitted with heart failure, atrial fibrillation, and mobility difficulties was prescribed apixaban, an anticoagulant with a black box warning (BBW) for significant risks such as bleeding and neurological impairment. The resident's Medication Administration Record (MAR) for two consecutive months was reviewed, and it was found that there was no documented monitoring for adverse effects associated with apixaban, despite facility policy and FDA recommendations requiring close monitoring for BBW medications. During an interview, the Assistant Director of Nursing confirmed that monitoring for adverse effects, such as bleeding, was not performed as indicated in the MAR. The facility's policy specifically required close monitoring for patients on BBW medications, and the manufacturer's insert for apixaban outlined the need for frequent monitoring for signs of bleeding and neurological compromise. The lack of monitoring constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs and that adverse effects were adequately tracked.
Failure to Follow Therapeutic Diet and Food Preferences
Penalty
Summary
The facility failed to follow the prescribed therapeutic diet and food preferences for one resident. The resident, who was admitted with diagnoses including low back pain and chronic obstructive pulmonary disease (COPD), was ordered a controlled carbohydrate diet with mechanical soft texture due to difficulty chewing and swallowing hard foods. Despite clear documentation on the meal ticket indicating the resident's dislikes and dietary restrictions, the resident was served a bowl of dry corn flakes cereal, which she found hard to chew and stated could have caused her to choke. The resident expressed feeling disregarded because her food preferences and therapeutic diet were not followed. Interviews with staff revealed that the certified nursing assistant (CNA) acknowledged the error and attributed it to a mistake by the kitchen staff, who provided the wrong cereal. The dietary manager stated that the dry corn flakes were given because the CNA requested it, despite the resident's documented preferences and dietary needs. The director of nursing confirmed that meal tickets should have been checked before serving and that staff should have verified with a licensed nurse before making changes to the resident's diet. The facility's policy requires therapeutic diets to be prescribed and followed according to the resident's preferences and treatment goals.
Expired IV and PICC Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices by storing seven expired intravenous (IV) administration sets and one expired peripherally inserted central catheter (PICC) stabilizing device in the medication storage room. These expired items were kept alongside other ready-to-use medication administration supplies. During an observation and interview, a licensed vocational nurse confirmed that there were no unexpired IV kits or PICC line stabilizing devices available at the facility, despite having an active resident who could have required these supplies. The Director of Nursing (DON) acknowledged the importance of discarding expired medication administration supplies to maintain sterility and stated that both night shift licensed nurses and the DON were responsible for conducting monthly audits of the medication storage room. However, the DON was unable to provide documentation showing that these audits were being completed. A posted notice in the medication room outlined responsibilities for changing and auditing IV and PICC line supplies, but there was no evidence that these procedures were being followed or documented.
Failure to Re-evaluate Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary drugs when the interdisciplinary team did not re-evaluate the use of Seroquel, an antipsychotic medication, at the time of admission or within two weeks for its appropriateness and indication for use. The resident was admitted from an acute care hospital with a prescription for Seroquel to manage a mood disorder manifested by yelling and hitting. However, the Minimum Data Set (MDS) assessment indicated no potential indicators of psychosis or behavioral symptoms directed towards others. Despite this, the medication was continued without re-evaluation, and the facility did not follow up on the pharmacist's recommendation to consider reducing the dose or clarifying the diagnosis. Interviews with facility staff, including CNAs and LVNs, revealed that the resident exhibited anxiety behaviors related to COPD and called out for help, but there was no documentation of aggressive behaviors that would justify the continued use of Seroquel. The Director of Nursing confirmed that the facility did not re-evaluate the medication use as per their policy, which requires an assessment of antipsychotic medication appropriateness at admission and within two weeks. The facility's policy also mandates that residents transferred from hospitals be evaluated for the appropriateness of antipsychotic medications, which was not adhered to in this case.
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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