Citations in California
Statistics, citations and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
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.
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.
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Compliance trends in California
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in California
- Required licensed nurses to check narcotic pain patch locations every shift so missing patches were identified prior to the next administration date (J - F0760 - CA)
Failure to Initiate Immediate CPR and Provide Adequate BLS and Oxygen Equipment for a Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide proper and effective Basic Life Support (BLS), including immediate CPR, to a resident who was documented as full code. The resident had multiple cardiac-related diagnoses, including diabetes mellitus, congestive heart failure, dementia, atrial fibrillation, and atherosclerotic heart disease, and a POLST indicating that resuscitation/CPR should be attempted with full treatment status. The resident’s care plan identified potential for cardiac distress and directed staff to monitor for symptoms such as dyspnea, shortness of breath, tachycardia, edema, and to promptly contact the physician if symptoms occurred. On the day of the event, the resident had been stable earlier and ate 100% of dinner, but later became weak, had shallow breathing, stopped talking, and became unresponsive. When the change in condition occurred, CNAs observed the resident become unresponsive with eyes rolling back and immediately summoned nursing staff. RN 1 responded and found the resident sitting up at approximately a 70–90 degree angle, unresponsive, with shallow breathing and not verbally responsive, but making noises. RN 1 proceeded to obtain vital signs and reported normal blood pressure, heart rate, respiratory rate, and oxygen saturation initially at 98%, later dropping to 96% and then 89%. Instead of immediately initiating CPR or placing the resident supine on a firm, flat surface with a head-tilt, chin-lift to open the airway, RN 1 left the room to verify code status and retrieve the crash cart. RN 1 stated he did not initiate CPR because the resident made a noise in response to painful stimulation of the ear and he believed this indicated responsiveness. Staff did not initiate chest compressions while the resident remained unresponsive with shallow breathing, and no reassessment of oxygen saturation was documented after oxygen via simple mask was applied. Other licensed staff also failed to initiate BLS measures. LVN 1 reported that when called to the room, the resident was on oxygen via nasal cannula, breathing abnormally with two to three long breaths, and he recognized that 911 needed to be called, but he did not start CPR. LVN 2 stated that the resident was unresponsive and breathing slowly and acknowledged not being aware that ventilation could be provided when a resident is unresponsive and breathing slowly; vital signs she attempted to obtain were not documented. CNA 1 reported that no CPR was initiated by facility staff before EMS arrival. According to the EMS report and the responding Paramedic Captain, paramedics arrived to find the resident supine in bed, unresponsive, pulseless, apneic, and in asystole, with no CPR in progress and no measurable blood pressure, pulse, respirations, or oxygen saturation. The deficiency also included failure to ensure that emergency equipment and oxygen delivery systems were adequate and properly set up for resuscitation. The crash cart contained an oxygen regulator with a maximum output of only 8 L/min, which was insufficient to keep the BVM reservoir bag fully inflated and deliver 100% oxygen as required during resuscitation. The Paramedic Captain reported that the oxygen regulator connected to the resident’s oxygen tank was limited to 8 L/min, and another regulator found in the crash cart was also limited to 8 L/min, necessitating use of EMS’s own regulator to achieve 15 L/min, which delayed delivery of 100% oxygen. The Paramedic Captain also requested a backboard and was informed by RN 1 that the facility did not have one. Additionally, during surveyor observation and interview, RN 1 was unable to determine that the crash cart oxygen tank was empty and could not demonstrate proper connection of the suction tubing to the suction machine, stating he did not know how to determine whether the oxygen tank was empty or how to connect the suction machine. These failures occurred despite facility policies requiring immediate initiation of CPR for unresponsive residents without a DNR and the use of appropriate oxygen administration and emergency procedures. As a result of these findings, surveyors determined that the facility did not initiate immediate CPR for a full-code resident found unresponsive and did not perform continuous, uninterrupted CPR until EMS assumed care. The facility also failed to position the resident flat on a firm surface with airway opened, and failed to ensure availability and proper use of equipment capable of delivering 15 L/min oxygen for BVM use during resuscitation. EMS documentation indicated that no CPR was being performed upon their arrival, and the resident was found in cardiac arrest. The California Department of Public Health determined that the noncompliance constituted Immediate Jeopardy related to failure to ensure CPR was immediately performed on the resident.
Removal Plan
- RN 1 resigned from the facility.
- Staff involved (LVN 1, LVN 2) were removed by the DON from direct patient care until competency was validated.
- Immediate re-education was reinforced by the DON for direct care staff on immediate initiation of CPR, proper positioning on a firm/flat surface, continuous/uninterrupted CPR, crash cart utilization (including oxygen regulators capable of 15 L/min and backboards), and use of oxygen tanks (including how to determine if full or empty).
- Crash cart was checked by the DON and oxygen regulators were replaced to ensure 15 L/min capability; BVM bag and oxygen delivery systems were verified functional; oxygen tanks were ensured full.
- DON and DSD reviewed current certifications of all direct care staff and ensured only staff with validated CPR certification are assigned to residents' care.
- MRD identified residents designated as full code and ensured staff are aware where to find code status in paper medical records and the health record system.
- DON initiated in-service to licensed nurses (RNs/LVNs) and CNAs on the facility CPR emergency procedure policy with emphasis on calling code blue, locating code status, placing resident on firm/flat surface using backboard, head-tilt/chin-lift with oxygen via simple mask, using an oxygen regulator capable of 15 L/min for BVM, and performing continuous/uninterrupted CPR until EMS assumes care.
- Code Blue drills were initiated and will continue for skills check validation via return demonstration of licensed nurses and CNAs.
- A crash cart checklist was developed and implemented; crash cart and oxygen equipment checklist will be checked every shift by the lead licensed staff.
- Room changes will include updating residents' medical records to reflect new room assignment in both the electronic health record and physical medical record.
- A certified CPR instructor provided mandatory re-education and training for all licensed nurses and CNAs with return demonstration conducted.
- DSD/designee will validate that newly hired licensed nurses and CNAs have current valid CPR certification prior to scheduling for direct resident care; no direct care staff will work directly with residents without valid CPR certification.
- DON conducted a 1:1 in-service with LVN 1 and LVN 2 regarding medical emergency response (immediate CPR, proper positioning, continuous/uninterrupted CPR, crash cart utilization including 15 L/min regulators and backboards, and oxygen tank use/verification).
- DSD updated CPR certification status for all current direct care staff and will update monthly; DSD will audit and communicate with staff if CPR certification expires.
- DON/designee will provide a summary of findings for the monthly Quality Assurance Committee (QAC).
Significant Medication Errors Involving Fentanyl Patches and Resident Identification
Penalty
Summary
The deficiency involves multiple significant medication errors related to fentanyl transdermal patch administration and resident identification. One resident with COPD, dependence on renal dialysis, Alzheimer’s disease, memory problems, and severely impaired cognitive skills was found by a hospital to have a fentanyl patch on admission, despite having no physician order for fentanyl and only being prescribed acetaminophen at the facility. The DON reported that an internal investigation determined that on 3/3/26 an LVN assigned as the medication nurse for this resident and another resident applied the other resident’s ordered fentanyl patch to this resident’s chest while providing care. On 3/4/26, the resident experienced a change in condition with increased work of breathing, low oxygen saturation, tachypnea, tachycardia, crackles in bilateral lung fields, and weak cough, leading to emergency transfer to an acute care hospital, where the fentanyl patch without an order was discovered and reported back to the facility. A second resident, admitted with traumatic subarachnoid hemorrhage, a history of falls, a diagnosis of pain, and severe cognitive impairment, was on hospice services and had a physician’s order for a fentanyl transdermal patch every 72 hours for pain and comfort. The DON stated that on 3/3/26 this resident was scheduled to receive a fentanyl patch, but the patch intended for this resident was instead applied to the first resident. The LVN later acknowledged that he had Resident 2’s fentanyl patch with him while changing the first resident’s gastrostomy tube dressing and did not administer the ordered fentanyl patch to the correct resident, resulting in a medication omission. Another LVN reported that on 3/4/26 she was informed the second resident had not received the fentanyl patch on 3/3/26, and a skin check revealed no fentanyl patch on the resident, confirming the omission. A further deficiency occurred during a medication administration observation for the second resident when an LVN prepared a fentanyl transdermal patch and, according to the EMAR, expected to find a previously applied patch on the resident’s right arm that needed removal before applying a new patch. During administration, the LVN applied a new fentanyl patch to the right side of the resident’s chest after failing to locate a patch on the right or left arm and did not perform a full body or skin check to verify whether a prior patch remained in place, despite acknowledging that the purpose of removal was to prevent the resident from receiving too much fentanyl. Additionally, during a separate medication pass for a third resident with chronic pain, type 2 diabetes, and intact cognition, the same LVN administered multiple oral medications, eye drops, and lidocaine patches without verifying the resident’s identity. The resident was not wearing an identification band, and the LVN did not use alternative identification methods such as checking the photograph in the EHR or confirming identity with other staff, contrary to facility policy requiring verification of resident identity before medication administration. Surveyors determined that these failures to correctly identify residents before administering medications, to ensure medications were given only as ordered, to avoid administering one resident’s fentanyl patch to another resident without an order, to ensure an ordered fentanyl patch was not omitted, and to verify removal of a previously applied fentanyl patch before applying a new one constituted significant medication errors. The facility’s own fentanyl drug reference materials described fentanyl as a very strong opioid narcotic with a high potential for fatal overdose due to respiratory depression, and the pharmacy consultant noted that the first resident was opioid naïve and at higher risk for respiratory depression, sedation, and confusion when given fentanyl. The survey team notified the facility of Immediate Jeopardy related to the failure to identify the correct resident prior to administering a fentanyl patch and the failure to verify the location of a previously administered fentanyl patch before applying a new one, which placed the involved residents at risk for serious injury, harm, impairment, or death.
Removal Plan
- Medical Records conducted a sweep of all residents who were receiving narcotic pain patches.
- The Assistant Director of Nursing conducted a visual check to ensure narcotic pain patches were applied as ordered.
- The Medical Records Department conducted a facility-wide sweep for residents' identification bands.
- Residents who did not have an identification band were provided with one containing: name, date of birth, doctor's name, facility address, and facility phone number.
- Licensed nurses are required to check for the location of narcotic pain patches every shift so missing patches are identified prior to the next administration date.
- All licensed nurses were required to attend an in-service prior to administering any medications.
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