West Anaheim Medical Center D/p Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Anaheim, California.
- Location
- 3033 W Orange Ave, Anaheim, California 92804
- CMS Provider Number
- 555883
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at West Anaheim Medical Center D/p Snf during CMS and state inspections, most recent first.
GT Feeding and Medication Administration Errors: A resident with GT feeding had the HOB below the ordered elevation while formula was infusing, another resident with a GT also had the HOB below the ordered level during feeding and flushes, a third resident’s enteral feeding bag was labeled with the wrong rate, and an LVN administered a crushed GT medication without mixing it with water first. The DON confirmed the ordered HOB elevation and labeling requirements, and the facility policy required GT medications to be crushed and dissolved with water before administration.
A facility failed to provide ordered respiratory care for four residents. One resident had an opened Yankauer suction device that had not been changed within the ordered timeframe, two residents had Yankauer suction tips left at the bedside without opened dates despite orders to change them daily, and a ventilator-dependent resident had no documented cleaning and disinfecting of the ventilator machine per the manufacturer’s instructions. Staff interviews showed uncertainty and inconsistent practice regarding suction and ventilator equipment care.
Opened sterile supplies and irrigation fluid were found improperly stored in the facility. A bottle of sterile water used for a resident’s Foley catheter flush was left at the bedside after opening, and Medication Cart A contained opened sterile alginate dressings with antimicrobial silver plus an opened sterile Puracol (Collagen) Plus dressing. The DON verified the findings and stated the dressings should remain unopened until use and unused portions should be discarded after use.
Kitchen sanitation and food handling deficiencies were observed during survey. Surveyors found blenders with visible water and food particles, unlabeled and undated food items in the refrigerator, expired food in a freezer, and a staff member’s personal food stored in the walk-in refrigerator. A Maintenance Manager entered the kitchen with uncovered facial hair, cutting boards were heavily discolored, the ice machine had scale and buildup, a Kitchen Aid failed to perform hand hygiene before putting on new gloves after handling trash, and dirt was observed near the kitchen floor drain.
A resident with severely impaired cognitive skills was observed in bed with the upper body exposed while the room curtain was not pulled, allowing visibility from the doorway and hallway. The resident's family member had requested that the resident not be covered or wear a shirt, and facility policy required curtains and draping to provide full visual privacy and dignity. IP verified the observation, and the DON was informed of the findings.
Failure to Care Plan Anticoagulant Use: A resident had an order for Xarelto via GT for DVT prophylaxis, but the comprehensive care plan did not include an individualized plan for the anticoagulant. During record review, an RN confirmed no care plan had been developed for the medication, and the DON verified the finding.
Care plans were not revised to match current orders and care needs for three residents. Two residents who were GT and ventilator dependent had physician orders for HOB elevation to 35 degrees at all times for aspiration precautions, but their care plans still listed different HOB ranges and did not fully reflect the order; one resident was observed with the HOB below the ordered level. Another resident with a trach and ventilator had a care plan for ventilator dependency that did not include cleaning and disinfecting the ventilator per the manufacturer’s manual.
A resident who was bedbound, nonverbal, and mechanically ventilated did not receive a consistently documented individualized activity program aligned with the care plan. The resident’s preferences included watching Korean movies and using a Tobii device for communication, but observations showed the resident lying awake in bed without engagement in activities, and staff confirmed the resident was not participating. Activity notes were missing for multiple days, and the Activity Director confirmed there was no documentation that preferred activities were offered or refused.
A resident with no responsible party had a POLST indicating DNR, comfort-focused treatment, and no invasive or non-invasive mechanical ventilation, but the record showed the resident was receiving mechanical ventilation with active ventilator orders. The IDT/Care Plan Conference documentation only reflected DNR and did not show discussion of the comfort-focused goals or ventilation limits, and the DON verified there was no documentation that the POLST was reviewed with the IDT and Council on Aging representative or clarified with the physician.
Failure to Notify Physician of Significant Weight Changes: A resident with altered nutrition and tube feeding intolerance had repeated significant weight losses and gains, including a 20-lb loss in one month. The care plan and facility policy required physician notification for excessive weight changes, but the record did not show that the physician was notified when the weight changes occurred or that the resident was monitored for the documented change-of-condition periods.
A resident receiving IV cefepime was observed with NS infusing through a right hand IV access, but the record did not show physician orders for the NS IV fluid or for peripheral IV site rotation every 72 hours and as needed. An RN verified the missing orders during interview, and the DON was informed and confirmed the findings.
An LVN failed to follow the MAR instructions for GlycoLax by mixing the powder with pudding instead of water, and another LVN did not administer a scheduled Pro-Stat supplement via GT during a med pass. The DON stated meds should be given per MD orders and within the ordered time window.
Infection control was not followed during medication administration for two residents. An LVN administered GT medication to a resident on enhanced barrier precautions without wearing a gown and did not disinfect the stethoscope before leaving the room. In a separate observation, an RN administered eye ointment to both eyes of another resident without changing gloves and performing hand hygiene between eyes, despite the facility’s policy requiring glove changes and hand hygiene during eye medication administration.
The facility failed to follow proper procedures for enteral feeding and medication administration for two residents. One resident's feeding formula was not labeled with the start time, and another resident's gastric residual was not checked before administering medications through the GT. These actions were contrary to the facility's P&P and posed risks for complications.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as marred cutting boards, improperly stored wet utensils, and damaged kitchenware. The Dietary Director acknowledged these deficiencies, which included dirty utensils and an unsanitary stove hood. These failures posed a risk of cross-contamination and foodborne illnesses to residents.
The facility failed to maintain infection control practices, as staff did not disinfect stethoscopes after resident use and did not follow proper gown and glove protocols between residents. Additionally, linen cart covers were found dirty and stained, indicating lapses in cleanliness. These deficiencies were acknowledged by the facility's DON and IP.
The facility failed to administer pneumococcal vaccines to two residents despite obtaining consent. The medical records lacked documentation of vaccine administration or explanations for the oversight. Infection Preventionists confirmed the vaccines were offered and consents obtained, but not administered.
The facility failed to maintain a clean and homelike environment, as evidenced by stained walls, curtains, and medical equipment in several residents' rooms. The DSD/MDS Coordinator and DON acknowledged that staff should have cleaned these areas promptly and reported stains to EVS staff. However, a communication gap led to the deficiencies, impacting the residents' living conditions.
A facility failed to store medications properly, as two tubes of Zinc Oxide paste were found on a resident's bedside table instead of being locked in the treatment cart. The DSD/MDS Coordinator confirmed this was against the facility's policy, which requires medications to be stored in lockable areas accessible only to authorized personnel.
The facility failed to maintain accurate medical records for two residents, leading to potential care issues. A resident's weekly wound assessment was not documented, and treatments did not match physician orders. Another resident's skin assessment was incomplete upon readmission. These documentation failures indicate non-compliance with facility policies.
A resident reported verbal and physical abuse by a CNA, but the facility failed to immediately remove the CNA from the care assignment, waiting seven hours to take action. This delay was contrary to the facility's policy, which required immediate protective measures. Interviews confirmed the CNA should have been removed immediately.
A facility failed to report an alleged abuse incident involving a CNA and a resident to the CDPH within the required 24-hour timeframe. The resident, who was cognitively intact, sustained a scratch on the left temple, and the family accused the CNA of causing the injury. The CNA reported the injury to an LVN, and the charge nurse overheard the accusation, but the DON was not informed timely, resulting in a five-day delay in reporting.
GT Feeding and Medication Administration Errors
Penalty
Summary
The facility failed to provide appropriate care and services for residents with gastrostomy tubes by not following ordered feeding and medication administration practices for four residents. The report states that the facility did not ensure the head of bed was elevated above 35 degrees while enteral feeding was infusing for two residents, did not ensure one resident’s enteral feeding formula bag was labeled with the correct feeding rate, and did not ensure a crushed medication was mixed with water before being administered via GT for another resident. The facility’s policy for enteral feeding required the head of bed to be elevated at a 30-to-45-degree angle during pump or infusion controller feeding, and the medication administration policy required crushed medications to be mixed with water before GT administration. Resident 3 was GT dependent and had a physician’s order to elevate the head of bed 35 degrees at all times for aspiration precautions. During observation, the resident was found in bed with Jevity 1.2 infusing at 50 ml/hr while the head of bed was measured at 26 degrees, and later observations showed the head of bed at 30 degrees while feeding continued. Resident 4 had a GT and a physician’s order to elevate the head of bed 35 degrees at all times for aspiration precautions. The resident was observed receiving Jevity 1.2 and water flushes via GT while the head of bed was at 30 degrees, and later the head of bed was observed at less than 30 degrees while the water flush was infusing. Resident 12 had an order for tube feeding with [NAME] Farms 1.4 via GT at 35 ml/hr continuously for 24 hours, with an alternate formula allowed at the same rate if needed. The resident was observed receiving [NAME] Farms 1.4 at 35 ml/hr, but the feeding bag was labeled with a rate of 5A instead of the ordered rate. Resident 8 received baclofen via GT, and the LVN was observed crushing the medication, placing it in a medication cup, then pouring it into a syringe and adding water afterward rather than mixing the crushed medication with water before administration. The DON reviewed the findings and acknowledged them.
Respiratory Care and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents who were receiving suctioning and ventilator-related care. For Resident 2, the physician’s orders included oxygen therapy via trach collar, suctioning every two hours and as needed, and changing the Yankauer suction device every 24 hours and as needed. During observation, an opened Yankauer suction device was found at the bedside with a label showing it had been opened on 3/22/26, and the respiratory therapist stated it should have been changed after 24 hours once opened. For Residents 3 and 12, both had care plans and physician’s orders directing that the Yankauer suction be changed daily and as needed. During observation, each resident had an opened Yankauer suction tip stored in the original packaging at the bedside, and neither package was labeled with the opened date. The respiratory therapist stated the Yankauer suction tip should be labeled when opened and changed every shift for infection control purposes, and later discarded the suction tips for both residents. The DON reviewed the records and verified the orders and care plans called for changing the Yankauer suction every 24 hours. For Resident 15, who was admitted with a tracheostomy and ventilator support, the ventilator operator’s manual directed that device parts be cleaned with warm water and soap or mild detergent, rinsed thoroughly, and air dried. The resident’s record showed ventilator settings and respiratory treatment documentation, but there was no documented evidence that the ventilator machine had been cleaned and disinfected per the manufacturer’s instructions. During interviews, respiratory staff were uncertain who was responsible for cleaning the ventilator, and one RT stated the facility did not have a specific regular cleaning and disinfecting process for ventilator machines and instead cleaned them with bleach wipes as needed. The DON was informed and verified these findings.
Improper Storage of Opened Sterile Supplies and Irrigation Fluid
Penalty
Summary
Drugs and biologicals were not stored in a safe manner for one of two medication carts and for one sampled resident. At Resident 3’s bedside table, a bottle of sterile water was observed opened and labeled with the date 3/20/26. The bottle was identified as a sterile, single-dose container with instructions to discard the unused portion. During interview, an LVN stated the sterile water was used to flush Resident 3’s Foley catheter as needed and confirmed the bottle had been opened and labeled, then later stated it should be discarded 24 hours after opening. Medication Cart A also contained opened sterile wound care supplies. During inspection, two opened sterile alginate wound dressings with antimicrobial silver and one opened sterile Puracol (Collagen) Plus wound dressing were observed stored in the cart. The DON verified the findings and stated the sterile dressings should not be opened until ready for use due to infection control purposes, and later stated any remaining unused sterile dressings should be discarded after each use to prevent transmission of microorganisms or infections to the wound bed.
Kitchen sanitation, food storage, and staff hygiene deficiencies
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during observations, interviews, and record review. Surveyors observed two heavy-duty blenders stored with lids on and visible water inside the blenders, and another blender with food particles on the base of the machine. The facility’s policy required food processors or blenders to be cleaned and allowed to air dry, and the FSS acknowledged the findings and stated the blenders would be washed again. Surveyors also observed multiple food storage and labeling issues. In the walk-in refrigerator, sliced carrots were opened in a plastic bag with no label and no date, and a rice bin had no label and no date. A container of ice cream sherbet with an expiration date of 12/2/25 was also found inside the freezer and was removed after being identified by the MDS Coordinator. The report also noted an unlabeled disposable food container in the walk-in refrigerator that the FSS identified as kitchen staff’s personal food and discarded. Additional kitchen sanitation concerns included staff hygiene and equipment condition. A Maintenance Manager was observed in the kitchen with uncovered facial hair while checking the ice machine, despite the facility policy requiring hair restraints. Two white cutting boards were heavily marred with black discoloration, and the inside of the ice machine had dried water scale and whitish to dark buildup around the motor and base. A Kitchen Aid was observed picking up trash from the floor while wearing disposable gloves, then putting on new gloves without performing hand hygiene first. The kitchen floor drainage area also had dirt near the drain, and the DON was informed and verified the findings.
Failure to Provide Privacy and Dignity During Bed Observation
Penalty
Summary
The facility failed to ensure staff provided care and services to promote dignity and respect for Resident 13. The report states the resident's family member preferred that Resident 13 not be covered or wear a shirt, but staff did not ensure the curtain was pulled to provide privacy. On 3/26/26 at 0810 hours, Resident 13 was observed lying in bed with the upper body exposed and a blanket at the waist, visible from the doorway of the room while multiple staff members walked past in the hallway from 0810 to 0816 hours. Facility policy titled Resident Privacy, Dignity, and Confidentiality stated staff will provide privacy for residents and use curtains to provide full visual privacy and dignity during resident care and other requested times, including clothing and draping to prevent unnecessary exposure of body parts. During the observation, IP 2 verified the findings and stated the curtain should have been pulled to provide privacy and dignity when the resident did not have a shirt covering him. The medical record showed the resident had severely impaired cognitive skills for daily decision making, and care plan and nursing note entries reflected the family member's requests regarding not covering the resident with a blanket and not wearing a gown due to excessive perspiration and tachycardia.
Failure to Care Plan Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 16’s use of Xarelto, an anticoagulant medication ordered for DVT prophylaxis. Facility policy stated that a comprehensive care plan must be developed within 14 days and completed no later than seven days after a comprehensive assessment has been completed, with participation from involved disciplines and ongoing reassessment and updates. Medical record review showed that Resident 16 had a physician’s order dated 12/19/25 to administer Xarelto 10 mg via GT at bedtime for DVT prophylaxis, but the resident’s comprehensive care plans did not include an individualized plan addressing the medication. During a concurrent interview and record review on 3/26/26, RN 3 verified that Resident 16 had an order for anticoagulant medication and confirmed there was no care plan developed for Xarelto. RN 3 stated that the licensed nurse formulates a care plan once there is a new condition of the resident. Later that day, the DON was informed and verified the findings.
Care Plans Not Updated for Aspiration Precautions and Ventilator Cleaning
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised to reflect current care needs and interventions for three sampled residents. The facility’s care planning policy stated that a comprehensive care plan must be developed within 14 days and completed no later than seven days after the comprehensive assessment, with ongoing reassessment and updates at least quarterly and upon change of condition. For Resident 3, who was GT and ventilator dependent, the physician ordered the head of the bed elevated to 35 degrees at all times for aspiration precautions, but the care plan still listed interventions to keep the head of bed greater than 30 degrees for respiratory distress and to elevate it 30 to 45 degrees during and after tube feeding. During observation, Resident 3 was in bed on a ventilator receiving Jevity 1.2 via GT, and the head of the bed was observed at 26 degrees. For Resident 4, who had ventilator-dependent respiratory failure and a GT, the physician ordered the head of the bed elevated to 35 degrees at all times for aspiration precautions, but the care plan continued to include interventions for respiratory distress, altered nutrition with tube feeding, and aspiration risk that directed head-of-bed positioning at 30 to 45 degrees rather than reflecting the physician’s order. During observation, Resident 4 was in bed on a ventilator receiving Jevity 1.2 and water via GT, with the head of the bed observed at 30 degrees. For Resident 15, who had a tracheostomy connected to a ventilator machine and oxygen from a concentrator, the care plan for respiratory distress related to ventilator dependency included ventilator management interventions but did not include cleaning and disinfecting the ventilator machine per the manufacturer’s manual.
Failure to Provide and Document Individualized Activities
Penalty
Summary
The facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one resident who was bedbound, nonverbal, and dependent on staff for activities of daily living. The resident’s activity assessment showed a need for encouragement to engage in socialization and identified preferred activities such as watching Korean movies. The care plan documented altered activity participation related to a communication deficit, noted that the resident used a Tobii device for communication, and included goals for the resident to engage in independent leisure activities at least once daily and accept activity contact visits twice weekly, with interventions to provide and encourage preferred activities including music, television or movies, and sensory stimulation. During multiple observations, the resident was found lying awake in bed connected to mechanical ventilation, with eyes open and staring at the ceiling; the television was off, no music was heard, and the resident was not observed participating in any activities. Staff interviews confirmed the resident was not engaged in any activity, and one CNA stated the resident enjoyed watching Netflix on the Tobii device but that a family member typically turned it on because she did not know how to operate it. Review of the activity progress notes showed activities were documented on several dates in March 2026, but there was no documentation that activities were provided on multiple other dates, and the Activity Director confirmed there was no documented evidence that activities were offered on those dates or that refusals were documented. The DON was informed and acknowledged the findings.
POLST Not Fully Reviewed or Reflected in Treatment Orders
Penalty
Summary
The facility failed to ensure Resident 11’s POLST was complete, accurate, and discussed in the IDT meeting when the resident did not have a responsible party. The POLST in the record showed DNR, comfort-focused treatment as the primary goal, and additional orders for no invasive or non-invasive mechanical ventilation, no defibrillation, no chest compressions, and no ACLS drugs. The resident was observed lying in bed and connected to mechanical ventilation via a tracheostomy tube, and the active order set included a physician order for mechanical ventilation with specific ventilator settings and oxygen titration. Review of the IDT/Care Plan Conference documentation showed DNR was selected under the POLST section, but it did not indicate whether the resident’s preferences for comfort-focused treatment or no invasive or non-invasive mechanical ventilation were discussed by the IDT. The MDS/DSD verified the POLST and stated the resident had no responsible party, so the facility IDT team members and representatives from the Council on Aging were making treatment decisions. The DON verified the resident was receiving mechanical ventilation despite the POLST instructions and stated there was no documentation that the POLST preferences were reviewed or discussed with the IDT and Council on Aging representative, and no documented evidence that the physician was contacted to clarify the POLST.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to ensure the physician was notified when Resident 11 had excessive weight changes, including losses of more than 5 pounds in a week and a 20-pound loss in a month. Resident 11 was admitted to the facility and had documented weights showing repeated significant changes, including 153 lbs. on 1/6/26, 146 lbs. on 1/11/26, 138 lbs. on 1/25/26, and 133 lbs. on 2/1/26, followed by a gain to 142 lbs. on 2/10/26 and a loss to 135.6 lbs. on 2/22/26. The facility’s Weight Variance Monitoring policy stated that excessive weight losses or gains were more than 2 lbs. per week or more than 8 lbs. in one month and that physicians would be notified of all excessive losses or gains. Resident 11’s care plan addressed altered nutrition, risk for weight loss, and intolerance to tube feeding, with interventions to monitor weight and notify the physician of unplanned significant weight changes. A later care plan also addressed the resident’s 20-pound weight loss in 30 days and included notifying the physician of significant weight change. The physician’s progress notes showed the resident had lost about 7 lbs. since admission and that the RD was to evaluate the resident, but the record did not show that the weight changes on 1/25/26, 2/1/26, 2/10/26, and 2/22/26 were relayed to the physician. The facility’s change of condition log documented unplanned weekly weight loss on 1/11/26 and 1/25/26, with a treatment and duration of 72 hours, but the medical record did not show physician notification or that the resident was monitored for 72 hours for those changes.
Missing IV Orders for Fluid and Site Maintenance
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one resident reviewed for IV care. Resident 13 was observed in bed with normal saline infusing at 10 mL/hr through a right hand IV access with a transparent dressing dated 3/22/26. The resident also had a physician’s order dated 3/24/26 to receive cefepime 2 grams IVPB every eight hours at 200 mL/hr for 30 minutes. Review of the medical record did not show documented physician’s orders for the normal saline IV fluid or for peripheral IV access site rotation every 72 hours and as needed. During interview, an RN stated that when an IV antibiotic order is received, the nurse informs pharmacy, starts an IV access, and then begins a normal saline bag via the IV pump before administering the antibiotic. The RN reviewed the record and verified that no physician’s orders were obtained for the normal saline IV fluid or for care and maintenance of the IV access site. The DON was informed and verified these findings.
Medication Administration Errors With Oral and GT Orders
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration when two licensed nurses made errors during medication passes. During an observation for one resident, an LVN prepared multiple medications, including GlycoLax 17 grams, and was observed emptying the powder into a cup, adding chocolate pudding, and mixing it with a tongue depressor before administering it. The resident’s active orders allowed oral medications with a small amount of thickened water and permitted crushed medications with pudding, but the MAR instructions for GlycoLax directed that the powder be stirred in 120 to 240 mL of water, juice, soda, coffee, or tea and then administered. The LVN later verified that she did not mix the GlycoLax with water as directed and instead mixed it with pudding. During another medication administration observation, an LVN prepared and administered several medications via gastrostomy tube for a different resident, including docusate sodium, levetiracetam, calcium carbonate, vitamin C, vitamin D3, Culturelle, and metoprolol. The resident’s active orders also included Pro-Stat Sugar Free 30 mL daily via the GT, scheduled for 0900, but the medication was not administered during the observation. The LVN later reviewed the MAR and verified that Pro-Stat was scheduled for 0900 and had not been given. The DON stated that medications should be administered according to physician orders and within one hour before and after the scheduled time.
Infection Control Failures During GT Medication and Eye Ointment Administration
Penalty
Summary
The facility failed to implement its infection control program in accordance with its policies during medication administration observations. Resident 8 was on enhanced barrier precautions and had a GT. During a medication pass, LVN 1 prepared and administered baclofen via the GT while reaching across the resident from the right side of the bed to expose the GT from under the resident’s gown. LVN 1 was not observed wearing a gown during the GT medication administration. After the medication was given, LVN 1 was later observed removing gown and gloves and performing hand hygiene before exiting the room, but the stethoscope used to check GT placement was still around her neck and was not disinfected before leaving the room. LVN 1 confirmed she did not don the gown for the GT medication administration and did not disinfect the stethoscope before exiting the room. The facility also failed to follow its eye ointment administration policy during care for Resident 13. RN 2 used the same tissue to wipe both eyes, then removed gloves, performed hand hygiene, and donned a new pair of gloves before administering ophthalmic ointment. RN 2 applied the ointment to the resident’s right eye and then to the left eye without doffing gloves, performing hand hygiene, and donning new gloves between the two eyes. RN 2 stated the gloves should be changed and hand hygiene performed between eyes, and verified she did not change gloves in between the application of the ointment to both eyes. The DON was informed and acknowledged the findings.
Deficiencies in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper labeling and administration procedures for enteral feeding for two residents. For one resident, the enteral feeding formula was not labeled with the time it was started, contrary to the facility's policy and procedure (P&P). This omission was observed on two separate occasions, and the Licensed Vocational Nurse (LVN) responsible was unable to confirm when the feeding formula was initiated. The Director of Nursing (DON) confirmed that the labeling should include the time to ensure the formula does not exceed the 24-hour usage limit. For another resident, the Registered Nurse (RN) did not check the gastric residual volume before administering medications through the gastrostomy tube (GT), as required by the facility's P&P. The RN confirmed this oversight during an interview. The DON stated that checking the gastric residual is a necessary step before medication administration through the GT. These failures posed a risk for complications related to the use of the GT for both residents.
Sanitary Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by several deficiencies observed during a survey. The cutting boards were found to be heavily marred, discolored, and with deep grooves, making them difficult to clean and sanitize. This condition was acknowledged by the Dietary Director, who stated that the cutting boards should have been replaced. Additionally, kitchen utensils were not air-dried before storage, as required by the facility's policies and the USDA Food Code. Several scoops and utensils were found wet and stored improperly, which was also acknowledged by the Dietary Director. Further observations revealed that many kitchen utensils were in poor condition, with deformations, discolorations, and damages such as cracks and peeling handles. These included mesh strainers, potato mashers, whisks, scoops, basting brushes, and spatulas. The Dietary Director confirmed that these items should have been discarded and not used. Additionally, some utensils were found dirty, with watermarks and crusted food residue, indicating a failure to maintain cleanliness as per the facility's policies and USDA guidelines. The kitchen stove hood was also found to be in an unsanitary condition, with black dirt and grease residue observed. The Food Service Supervisor acknowledged this finding and stated that the janitor was supposed to clean the stove hood every other day. The failure to maintain the sanitary condition of the stove hood could lead to grease and smoke buildup, affecting air circulation. These deficiencies collectively posed a risk of cross-contamination and foodborne illnesses to the residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in Equipment Disinfection and PPE Protocols
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff not disinfecting equipment and not following proper gown and glove protocols. RN 1 and RN 2 both failed to disinfect their stethoscopes after using them on residents and before exiting the residents' rooms. This was confirmed through interviews with the RNs, who acknowledged the oversight and stated that the stethoscopes should have been disinfected to prevent the transmission of organisms between residents. Additionally, CNA 1 did not follow proper gown and glove protocols when moving between residents in the same room. CNA 1 was observed wearing the same gown and gloves while interacting with two different residents' environments, which is against the facility's Enhanced Barrier Precautions. CNA 1 admitted to not changing gloves and gown between residents, acknowledging that they should have been changed to prevent cross-contamination. Furthermore, the facility had issues with the cleanliness of linen cart covers, which were observed to be dirty and stained. The DSD/MDS Coordinator confirmed that the covers should be clean, indicating a lapse in maintaining the cleanliness of equipment used in the facility. These deficiencies were acknowledged by the Director of Nursing and Infection Preventionist during interviews.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to administer pneumococcal vaccines to two residents, despite having obtained consent for the vaccinations. Resident 4 was admitted and readmitted to the facility, and consent for the pneumococcal vaccine was obtained on July 8, 2024. However, there was no documented evidence that the vaccine was administered to Resident 4, nor was there any explanation provided for the failure to administer the vaccine after consent was obtained. Similarly, Resident 19 was admitted to the facility, and consent for the pneumococcal vaccine was obtained on September 30, 2024. Like Resident 4, there was no documented evidence that the vaccine was administered to Resident 19, and no explanation was provided for this oversight. During an interview and medical record review, Infection Preventionists (IPs) 1 and 2 confirmed that the vaccines were offered and consents obtained, but acknowledged that the vaccines were not administered to the residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for several residents, as observed during a survey. Specific deficiencies included brownish stains on the walls of a resident's room, stained curtains in multiple residents' rooms, and feeding formula spills and residue on the floor and medical equipment. These observations were confirmed by interviews with the DSD/MDS Coordinator, who acknowledged that the staff should have cleaned the affected areas promptly. The failure to maintain cleanliness was attributed to a lack of immediate action by the nursing staff and a communication gap with the Environmental Services (EVS) staff. The report highlights that the EVS staff were not informed about the need to clean certain areas, such as the wall in a resident's room, which was stained with enteral feeding formula. Interviews with the LVN and EVS Aide revealed that the responsibility for notifying EVS staff about cleaning needs was not consistently fulfilled. The Director of Nursing (DON) also acknowledged that the residents' rooms and equipment should be cleaned of stains and wiped down, and that all stains should be reported by staff when first observed. This lack of communication and prompt action led to the observed deficiencies in maintaining a clean and homelike environment for the residents.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications, as observed during a survey. Two tubes of Zinc Oxide paste, a medicated cream used to treat or prevent skin irritation, were found on a resident's bedside table. This was contrary to the facility's policy and procedure, which mandates that all medications be stored in lockable areas accessible only to authorized personnel. During an interview and medical record review, the DSD/MDS Coordinator confirmed that the Zinc Oxide paste should have been secured in the treatment cart, verifying the improper storage of the medication.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential care issues. For Resident 12, the facility did not document a weekly wound assessment for a sacral pressure injury on a specific date, despite the facility's policy requiring such documentation. Additionally, the wound treatments administered did not align with the Wound Consultant Physician's orders, and there was no documentation of any clarifications made to these orders. The Director of Nursing (DON) confirmed these discrepancies, noting that the nurse should have documented the wound assessment and any order clarifications. Resident 19's medical records also lacked proper documentation. Upon readmission, the facility failed to document the skin assessment for measuring pressure sores and non-pressure sores, as required by the facility's policy. The Skin Body Check Sheet for Resident 19 showed superficial erythema on the buttocks and mid-spine, but there were no measurements recorded. The Licensed Vocational Nurse (LVN) involved was unable to provide the necessary documentation and confirmed that the assessments were not completed as required. These documentation failures indicate that the facility did not adhere to its own policies and procedures regarding medical record-keeping and wound care management. The lack of accurate documentation for both residents could potentially lead to unmet care needs, as their medical information was not accurately recorded.
Delayed Response to Abuse Allegation
Penalty
Summary
The facility failed to take immediate action to prevent further potential abuse after an allegation of verbal and physical abuse was reported by a resident. The facility's policy and procedure for abuse recognition and reporting required immediate protective measures, such as removing the alleged perpetrator from the resident's care assignment. However, after the resident reported the abuse by a CNA, the CNA was not removed from the assignment until seven hours later, following a call from the Director of Nursing. Interviews with the RN and the Clinical Educator/Acting DON confirmed that the CNA should have been immediately removed from the assignment when the allegations were made.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. An allegation of abuse involving a Certified Nursing Assistant (CNA) and a resident was not reported timely to the California Department of Public Health (CDPH), Licensing and Certification (L&C) Program. The facility's policy requires that all incidents of alleged or suspected abuse be reported to the Department of Health Services within 24 hours. However, the report of suspected abuse was submitted five days after the allegation was made. The incident involved a resident who was cognitively intact and had sustained a scratch on the left temple area. The resident's family accused the CNA of causing the injury. The CNA reported the injury to a Licensed Vocational Nurse (LVN) and stated that the charge nurse overheard the accusation. Despite this, the Director of Nursing (DON), who is the Abuse Coordinator, stated that no allegations of abuse involving the resident were reported to her on the day of the incident. This delay in reporting posed the risk of potential abuse going unreported and uninvestigated.
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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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