American River Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Carmichael, California.
- Location
- 3900 Garfield Avenue, Carmichael, California 95608
- CMS Provider Number
- 555450
- Inspections on file
- 31
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at American River Center during CMS and state inspections, most recent first.
Kitchen thermometers were not maintained in good working condition, and weekly calibration was not documented in the log binder. A kitchen staff member, the CDM, and the RD all confirmed that one manual and one digital thermometer were not working properly and that calibration records were missing, despite facility policy requiring weekly testing and calibration for accuracy.
A nurse did not remain with a resident until a ClearLax mixture was fully consumed, leaving part of the dose unfinished, and did not ensure complete ingestion after giving other scheduled meds. In a separate event, an LPN prepared Humalog for a resident with a language barrier, but after the resident pushed his hand away, he treated it as a refusal and made no further attempts, despite staff expectations to use a translation device and try additional strategies.
Improper disposal of medications and retention of discontinued controlled drug: Whole tablets were found in open red sharps containers on 2 med carts, and nursing staff used those containers for dropped or refused non-narcotic doses even though the meds were still retrievable. A discontinued clonazepam bubble pack for a resident with anxiety and insomnia remained in the locked narcotics compartment after the order had been stopped, and the ADON and CP confirmed discontinued meds should not have remained in the cart.
Expired medications were administered to two residents. One resident received expired glaucoma eye drops, including dorzolamide and latanoprost, from a med cart after the discard date, and another resident received an expired fluticasone/salmeterol inhaler for COPD after the manufacturer’s discard date. The LN confirmed the doses were given, and the ADON and CP stated staff were expected to check medication expiration dates.
Medication labeling and storage practices were not followed consistently. Surveyors found expired suppositories, eye drops, and inhalers in stock and on med carts, an Infuvite vial stored on a countertop instead of refrigerated, an insulin pen without a pharmacy label, and multiple inhalers and nebulized solutions opened without open dates or kept outside required foil pouches. The DON, LNs, and CP confirmed the findings and stated staff were expected to label opened meds, follow manufacturer storage directions, and remove expired meds from use.
A resident with bipolar disorder, anxiety, and major depressive disorder had fluoxetine increased from 40 mg to 60 mg for depression manifested by sadness and anger without adequate documented clinical rationale or target behavior monitoring for efficacy. The ADON stated behavior monitoring should have shown increased target behaviors before the psychotropic dose was raised, but the record contained only limited notes of irritability and an overly nonspecific MAR behavior order that only required yes/no documentation.
Unordered bandage wrap used on heel wound. A resident with PVD and a chronic right heel ulcer had a physician order for triad, medi-honey, calcium alginate, and a foam dressing, but no bandage wrap was ordered. During observation, an RN/TN was seen removing and then reapplying the same bandage wrap to the wound. The TN confirmed the wrap was not in the order and said she did not clarify whether it should be used; the ADON stated orders should be clarified to ensure accuracy.
A resident with dementia and a traumatic brain injury, identified as being at risk for elopement, was able to leave the facility unsupervised and undetected for about an hour. The resident's care plan and assessments documented the need for supervision due to cognitive impairment and a history of wandering, but staff did not implement the required supervision as outlined.
The facility failed to store food safely, affecting 96 residents. Observations revealed unlabeled and uncovered food items, including desserts and cheeses, and spoiled tomatoes in the refrigerator. The CDM confirmed these practices were against the facility's policy, posing a risk of foodborne illness.
The facility failed to maintain infection control practices, as a visitor accessed ice unsupervised, and an ice scoop was stored uncovered. Additionally, a CNA did not perform hand hygiene after handling garbage. The Infection Preventionist and Administrator confirmed that only staff should distribute ice, and hand hygiene is crucial to prevent infections.
A facility failed to develop a person-centered care plan for a resident with a UTI and bacteremia. Despite the resident receiving daily Nitrofurantoin Macrocystal as prescribed, there was no care plan in place. The DON and ADON confirmed this oversight, acknowledging potential compromises in nursing care. The facility's policy mandates individualized care plans, which was not followed.
A resident with hemiplegia and thrombosis was not provided with compression stockings as ordered, despite physician instructions for daily use to manage edema. Observations showed the resident's left leg was swollen, and staff confirmed the stockings were not applied. The DON and ADON acknowledged the oversight, which could affect the resident's circulation.
A resident with dementia and a need for personal care assistance did not have her hearing aids applied daily as ordered, despite a physician's order and care plan specifying their use. Observations confirmed the resident was not wearing the aids, and staff interviews revealed non-compliance with the order. The facility's policy on hearing aid care was not followed, resulting in a deficiency.
A resident with multiple sclerosis and quadriplegia was left outside the facility past the agreed time on multiple occasions, unable to contact staff for assistance. Despite having an arrangement to be outside from 9:00 a.m. to 11:00 a.m., the resident was left alone and felt frightened when unable to reach staff. Staff interviews confirmed the arrangement and acknowledged the issue, while the facility's policy emphasized the resident's right to self-determination and communication.
A resident was discharged from the facility without verified home health service arrangements, despite having a disrupted surgical wound requiring specific care. The discharge plan included home health services, but there was no evidence that these were confirmed with the agency. Post-discharge follow-up showed the resident had not been contacted by the home health agency, leading to a lack of necessary wound care. Facility staff confirmed the expectation for social services to ensure these arrangements, which was not met.
A resident with multiple diagnoses, including dementia and osteoporosis, suffered a fracture of unknown origin. Despite the injury being identified, the facility failed to report it to state agencies as required by their policy. The DON confirmed the injury was not reported and acknowledged it could have been a pathological fracture, but no fall was reported.
A resident with multiple diagnoses was left crying and afraid after receiving a cold shower due to an argument between two CNAs about a staffing assignment. The incident highlighted the inappropriate behavior of the CNAs and the impact on the resident's dignity.
A resident with vascular dementia and moderate protein-calorie malnutrition was not readmitted to the facility after hospitalization, despite being eligible for a 7-day bed hold. The facility's Interdisciplinary Team decided against readmission due to unresolved conflicts with the resident's family, violating the resident's rights for readmission.
The facility failed to maintain food safety standards by not properly cleaning the ice machine, allowing rust on food storage racks, and not monitoring freezer temperatures in resident food refrigerators. These deficiencies could lead to food-borne illnesses among residents.
The facility failed to follow therapeutic diets for 14 residents, including those on modified texture, TLC, Renal, and CCD diets, during a lunch meal. The staff did not adhere to the menu, resulting in residents receiving incorrect food items, which could potentially affect their nutritional needs.
The facility failed to document the offering, administration, or refusal of the COVID-19 vaccine for three residents, despite their medical histories and the facility's policy requiring such documentation. The DON confirmed the absence of proper records, and family members reported not receiving recent vaccine offers.
The facility failed to follow infection control standards for two residents. A resident's catheter bag was found lying on the floor, and two CNAs did not wear gowns while providing high-contact care to another resident, contrary to Enhanced Barrier Precautions.
Kitchen Thermometers Not Calibrated Weekly and Not in Working Condition
Penalty
Summary
The facility failed to follow professional standards of food service safety when two kitchen thermometers, one manual and one digital, were not in good working condition. During a concurrent observation, interview, and record review, a kitchen staff member demonstrated how to calibrate the thermometers and identified that the two thermometers were not working properly. The thermometer log binder did not show that the thermometers had been calibrated weekly. During the same review, the Certified Dietary Manager confirmed that weekly thermometer calibration was not documented and that the two thermometers were not in good working condition. The CDM stated that thermometer calibration was important to ensure accurate temperature readings and prevent food borne illness caused by undercooked food. The Registered Dietician stated that kitchen staff were expected to calibrate thermometers weekly and record the readings, and that all thermometers should be in good working condition. The facility policy titled Food Preparation stated that thermometers in use should be tested and calibrated at least once a week for accuracy.
Medication Administration Not Completed or Fully Attempted
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for two residents. For one resident, a medication pass observation showed the nurse prepared eleven medications, including ClearLax mixed in lemonade, and gave the resident the pills and the cup with the mixture. The resident took the pills with sips of the ClearLax mixture, but about half of the solution remained in the cup when the nurse left the room before the resident finished consuming it, leaving the medication in the resident’s hand. The nurse later stated he did not recall leaving the resident with the ClearLax solution half drunk, and the facility policy stated the resident is always observed after administration to ensure the dose was completely ingested. For another resident, the nurse prepared Humalog KwikPen after checking the resident’s blood sugar and entered the room to administer 10 units. When the nurse attempted to lift the resident’s sweater to give the insulin in the abdomen, the resident pushed the nurse’s hand away. The nurse then stated the resident had refused the medication and made no further attempts to administer the insulin. The ADON stated staff were expected to use a translation device when there was a language barrier, that the resident pushing the nurse’s hand away was not considered a refusal, and that the nurse should have made additional attempts using other staff or other strategies. The nurse acknowledged he did not use the translation device and did not make any additional attempts to give the insulin.
Improper Disposal of Medications and Retention of Discontinued Controlled Drug
Penalty
Summary
The facility failed to ensure medications for disposal were rendered unusable and irretrievable when red sharps containers with open lids were used in 2 medication carts to dispose of dropped or refused non-narcotic tablets. During inspection, whole tablets were observed in the sharps containers on Station 1 Medication Cart 2 and Station 2 Medication Cart 2, and nursing staff stated these containers were used for disposal of dropped or refused doses. The Assistant DON confirmed the medications were not non-retrievable using that method, and the Consultant Pharmacist stated non-controlled medications should be disposed of in a designated container with a substance such as coffee grounds, hand sanitizer, or soap so they could not be easily poured out in their original form. The facility also failed to remove discontinued medications from the drug supply in a timely manner when a bubble pack of clonazepam for a resident remained in the locked narcotics compartment after the order had been discontinued in December 2025. The resident’s record showed clonazepam 0.5 mg at bedtime for anxiety manifested by inability to sleep, and the ADON confirmed the order had been discontinued and that discontinued medications should not have remained in the medication cart. The Consultant Pharmacist stated discontinued controlled medications were expected to be given to the DON at the end of the shift, and the facility policy stated medication is destroyed within 90 days from the date it was discontinued.
Expired Medications Administered to Two Residents
Penalty
Summary
The facility failed to ensure two sampled residents were free from significant medication errors when expired medications were administered. For Resident 50, the record showed physician orders for dorzolamide 2% ophthalmic solution and latanoprost 0.005% ophthalmic solution for ocular hypertension and glaucoma. During medication cart inspection, both eye drop bottles were found labeled to discard on 4/1/26, yet the MAR showed Resident 50 received 18 doses of expired dorzolamide and 6 doses of expired latanoprost after that date. The LN confirmed the expired doses were given and stated staff were expected to check expiration dates when preparing medications. For Resident 76, the medication cart contained an opened fluticasone/salmeterol 250/50 mcg inhaler that the manufacturer’s labeling indicated should be discarded one month after opening the foil container. The LN confirmed the inhaler had expired on 3/20/26 and that this was the inhaler used for administration to the resident. The MAR showed Resident 76 received the expired fluticasone/salmeterol twice daily for a total of 37 doses after expiration. The ADON and CP stated staff were expected to check expiration dates, and the CP noted medications may not be fully efficacious beyond their expiration date.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled and stored according to accepted professional principles and manufacturer instructions. During inspection of the medication storage room and medication carts, surveyors found multiple expired hemorrhoidal suppositories, including boxes and loose suppositories with expiration dates of 11/2025 and 2/2025, available in facility stock. A vial of Infuvite with a pharmacy label indicating refrigeration was found on the countertop instead of in the refrigerator. The DON and nursing staff confirmed the expired and improperly stored medications should not have been present in stock or on the cart. Surveyors also found several medications on the carts that were expired, opened without required dates, or not stored in the manufacturer’s protective packaging. These included expired dorzolamide and latanoprost eye drops, an expired fluticasone/salmeterol inhaler, an opened Trelegy Ellipta inhaler with an open date that showed it had passed the discard timeframe, two Anoro Ellipta inhalers and two Trelegy Ellipta inhalers that were opened but unlabeled with an open date, and an opened Advair Diskus inhaler without an open date. LN 1 and LN 2 confirmed these findings and reviewed the manufacturer labeling during the inspection. Additional storage and labeling issues were identified with prescription medications and nebulized solutions. A Humalog KwikPen was found in a clear plastic bag without a pharmacy label. Four arformoterol vials and two ipratropium/albuterol vials were stored outside their foil pouches without dates showing when they were removed from the pouch or brought to room temperature, and a box of dorzolamide/timolol single-use vials had one vial outside the foil pouch. LN 1 confirmed the storage did not match manufacturer instructions. The DON and CP stated staff were expected to label opened medications with open dates, keep bottles clean, follow manufacturer storage directions, and remove expired medications from stock.
Unnecessary Psychotropic Medication Dose Increase Without Adequate Behavior Monitoring
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication when fluoxetine was increased from 40 mg to 60 mg without adequate documented clinical rationale and without target behavior monitoring for efficacy. The resident was admitted with diagnoses including bipolar disorder, anxiety, and major depressive disorder, and the physician’s orders showed fluoxetine prescribed for depression manifested by verbalizations of sadness and anger. During interview and record review, the ADON stated she expected an increase in target behaviors to be documented before a psychotherapeutic medication dose was increased. Review of the resident’s progress notes for the 6 weeks before the dose increase showed only two notes indicating the resident was irritable and irate, both on the same date. The MARs for the prior two months showed the behavior monitoring order was nonspecific and directed staff only to document yes or no, and the ADON stated this made it difficult to monitor and document the resident’s behavior. The MARs indicated the resident exhibited behavior twice on evening shifts during the monitoring period.
Unordered bandage wrap used on heel wound
Penalty
Summary
The facility failed to ensure that one resident’s right lateral heel diabetic wound was treated as ordered when the Treatment Nurse wrapped the wound with a bandage wrap that was not included in the physician’s order. The resident was admitted with peripheral vascular disease and a chronic ulcer of the right heel and midfoot. The physician’s order for the right lateral heel eschar diabetic ulcer directed staff to apply triad to the peri-wound, medi-honey to the immediate wound, calcium alginate, and a foam dressing, but it did not include any bandage wrap. The resident’s revised care plan identified the resident as at risk for skin breakdown related to PVD and the right lateral heel diabetic ulcer and directed staff to provide wound treatment as ordered. Wound surgical consults dated 3/13/26, 3/20/26, 3/27/26, and 4/3/26 described the goal as preventing wound decline and creating a wound healing bed, with treatment including calcium alginate with honey and collagen, and they did not indicate wrapping the wound with a bandage wrap. During observation, the resident was in bed with the right lateral heel wound wrapped with bandage wrap. The Treatment Nurse removed the wrap, cleansed the wound, applied the ordered treatments, and then wrapped the wound again with the same bandage wrap. The Treatment Nurse confirmed the order did not indicate the wound should be wrapped and stated she did not clarify whether to use a bandage wrap after every treatment. The ADON also stated nurses should always clarify physician orders to ensure the treatment was accurate, including the use of bandage wrap.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with dementia and a traumatic brain injury from eloping from the facility. The resident was identified as being at risk for elopement based on an Elopement Evaluation and had a care plan in place that addressed this risk, including a history of wandering and previous elopement at a hospital. The resident's Minimum Data Set assessment indicated impaired cognitive status, and the care plan specifically noted the need for supervision due to alcohol/drug-seeking behavior and elopement risk. Despite these documented risks and care plan interventions, the resident was able to leave the facility unsupervised and undetected. Staff became aware of the resident's absence after being informed by another staff member, and the resident was missing for approximately one hour before being located. Facility policy required adequate supervision for residents at risk of elopement, but this was not implemented as indicated in the resident's care plan. Interviews with facility staff and the administrator confirmed the resident's high risk for elopement and acknowledged that closer supervision should have been provided.
Plan Of Correction
The preparation and/or the execution of this plan of correction do not constitute admission of agreement by the provider of true facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because the provisions of the Federal and State law require it. This Plan of Correction constitutes the facility's credible allegation of compliance. Corrective action accomplished for identified resident(s) affected by the deficient practice: Resident 1 was found and brought back into the facility without incident or injury. Resident placed on 1 on 1 supervision until the wanderguard system for the front door was adjusted with an additional reader on 10/3/2025. How other residents having potential to be affected by the same deficient practice will be identified and what corrective action will be taken: On 10/2/2025, an audit of all residents that triggered at risk for elopement was completed by the Medical Records Director to ensure that they all have appropriate interventions in place. Updates made as identified. Immediate measures and systemic changes put in place to ensure that the deficient practice does not recur: On 10/1/2025 and 10/2/2025, the Director of Staff Development in-serviced CNAs and Licensed Nurses on the elopement policy and procedure and wanderguard devices. A description of the plans and persons responsible for monitoring ongoing performance, and ensuring that the corrective actions are achieved and sustained: The Medical Records Director or designee will conduct an audit for residents triggering as elopement risks weekly to confirm interventions are in place. The results of the audits will be reported to the QAPI Committee meeting monthly for 3 months and then re-evaluated thereafter. Completion Date: 11/4/2025
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, affecting 96 residents who received food from the kitchen. During observations and interviews with the Certified Dietary Manager (CDM), it was confirmed that opened and prepared foods were stored without labeled use-by dates. Specifically, a pan of cinnamon brown sugar blondie dessert and opened packages of processed yellow cheese and sliced cheese were found without any date labels. The CDM acknowledged the importance of labeling food items to track when they were prepared and when they should be used by. Additionally, the facility did not adequately cover or seal opened food packages, which could lead to foodborne illnesses. Observations revealed a pan of prepared dessert and several peanut butter and jelly sandwiches in unsealed bags, as well as a package of hot dogs that were not tightly wrapped. Furthermore, spoiled food was found in the walk-in refrigerator, including two mushy and rotten tomatoes. The CDM confirmed that these practices were not in line with the facility's policy on food receiving and storage, which requires all foods to be covered, labeled, and dated to ensure safe food handling.
Infection Control Deficiencies in Ice Distribution and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by several observations. A visitor was seen accessing and obtaining ice from the nursing unit's ice chest without supervision, which was confirmed by a Certified Nursing Assistant (CNA) and the Director of Staff Development (DSD). The Infection Preventionist (IP) and the Administrator (ADM) both stated that only facility staff should distribute ice, and there was no specific policy written for the usage and distribution of ice from the nursing station ice chest. Additionally, the ice scoop was observed to be stored uncovered on a cart, which was confirmed by both the CNA and the DSD. The IP stated that the ice scoop must be stored covered to prevent exposure to dust or other contaminants. Furthermore, a CNA was observed handling garbage and then handling plastic wrist bands for residents without performing hand hygiene. The ADM confirmed that staff are expected to perform hand hygiene immediately before and after patient care activities. The facility's policy on hand hygiene emphasizes its importance in preventing the spread of infections.
Failure to Develop UTI Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident diagnosed with a urinary tract infection (UTI) and bacteremia. The resident's Admission Record indicated these diagnoses, and the Physician's Orders dated January 6, 2025, prescribed Nitrofurantoin Macrocystal 50 mg to be administered daily for the UTI. The Medication Administration Record confirmed that the medication was administered daily from January 1 through January 10, 2025. However, upon review, it was found that there was no care plan developed specifically for the UTI. During an interview and record review on January 10, 2025, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the absence of a UTI care plan for the resident. The DON acknowledged that nursing care could be compromised without a proper care plan in place. The facility's policy and procedure on comprehensive care plans, dated August 25, 2021, requires an individualized care plan with measurable objectives and timetables to meet the resident's needs, which was not adhered to in this case.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was diagnosed with hemiplegia affecting the left side and acute embolism and thrombosis of the left lower extremity, had compression stockings applied daily as ordered by the physician. The physician's order specified that the compression stockings should be worn during the day and removed at night to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings, and the left lower extremity appeared larger than the right, indicating swelling. Interviews with the resident and staff confirmed that the compression stockings were not offered or applied as required. A Certified Nurse Assistant admitted to not applying the stockings on the observed day. The Director of Nursing and Assistant Director of Nursing reviewed the resident's clinical record and confirmed the physician's order for daily use of compression stockings, acknowledging that failure to comply could compromise the resident's blood circulation. The facility's policy mandates that licensed nurses are responsible for implementing and documenting physician orders, which was not adhered to in this case.
Failure to Apply Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who required hearing aids, had them applied daily as ordered. The resident, who had diagnoses including dementia and a need for assistance with personal care, had a physician's order to apply both hearing aids in the morning and remove them at night. The care plan also specified the need for the resident to wear bilateral hearing aids every morning and remove them every evening. However, during multiple observations over several days, the resident was not wearing her hearing aids as required. Interviews with facility staff, including a Certified Nursing Assistant and a Licensed Nurse, confirmed that the hearing aids were not applied as ordered, and they were not stored in the medication cart as per the physician's order. The Director of Nursing and the Assistant Director of Nursing acknowledged that the order should have been followed and emphasized the importance of the hearing aids for the resident's communication. The facility's policy on hearing aid care, which aims to maintain the resident's hearing at the highest attainable level, was not adhered to, leading to a deficiency in care.
Failure to Accommodate Resident's Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with multiple sclerosis, quadriplegia, and anxiety, who was dependent on staff for self-care and mobility. The resident had an arrangement with the staff to be taken outside daily from 9:00 a.m. to 11:00 a.m. However, on multiple occasions, the resident was left outside past the agreed time and was unable to contact staff for assistance. On one occasion, the resident attempted to call the facility's front desk but received no response, and on another occasion, the resident was left outside until 11:30 a.m. without being able to contact staff, causing the resident to feel frightened. Interviews with staff confirmed the arrangement for the resident to be outside and acknowledged the issue of the resident being unable to contact staff when needed. The Recreations Assistant confirmed that the resident was left alone and unable to contact a CNA for assistance. The Director of Nursing stated that the resident was able to communicate her needs and preferences, including the times she wanted to be outside and return inside. The facility's policy on Resident's Rights emphasized the resident's right to self-determination and communication with people and services, which was not upheld in this instance.
Failure to Ensure Safe Discharge and Continuity of Care
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was discharged home without verified home health service arrangements. The resident, who had been admitted with cellulitis, a disrupted surgical wound, and required nonsurgical wound dressing changes, was discharged with a plan for home health services including physical therapy, occupational therapy, and skilled nursing services. However, there was no documented evidence that the facility's social services or nursing staff confirmed these arrangements with the home health agency prior to the resident's discharge. The resident's discharge plan indicated that home health services were to start shortly after discharge, with specific instructions for wound care, including the use of a wound vac to be changed every 72 hours. Despite these plans, the resident's post-discharge follow-up revealed that the home health agency had not been in contact, and the resident had left several voicemails without response. This lack of coordination resulted in the resident not receiving the necessary continuity of care for his wound. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, Unit Manager, and Administrator, confirmed that there was an expectation for social services to follow up with the home health agency to ensure services were scheduled to start prior to discharge. The facility's policies required social services to coordinate resident referrals with outside agencies, but this was not done in this case, leading to a failure in ensuring the resident's continuity of care upon discharge.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for a resident, which decreased the potential to protect the resident from a possible allegation of abuse and ensure a safe environment during the investigation. The resident, a female with multiple diagnoses including unspecified dementia, Alzheimer's Disease, osteoporosis, a history of falls, and muscle weakness, was readmitted to the facility. On a specific date, the resident complained of left forearm pain, and an x-ray revealed an acute or possibly subacute fracture of the distal radial diaphysis and a deformity of the distal ulna consistent with a wrist fracture. Despite the injury being identified, the Director of Nursing (DON) confirmed that the fracture was an injury of unknown origin as no fall was reported. The DON acknowledged that the fracture could have been a pathological fracture and conducted an investigation to determine the cause. However, the facility did not report the injury to the appropriate state agencies as required by their policy, which mandates that all injuries of unknown source be promptly reported. The facility's policy also requires a written report of the findings of the investigation to be provided to the appropriate agencies within five working days of the incident.
Failure to Maintain Resident Dignity During Shower
Penalty
Summary
The facility failed to maintain dignity for a resident when two CNAs had an argument regarding a staffing assignment while providing a shower to the resident. The resident, who had multiple diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, dysarthria, aphasia, muscle weakness, and major depressive disorder, was left crying and feeling afraid after receiving a cold shower. The incident occurred when CNA 1 placed the resident in the shower chair and turned on the water to warm up. CNA 1 was then approached by CNA 2, who stated that the assignment had changed. While the CNAs argued about the assignment, the resident was left in the shower with cold water, leading to the resident crying and feeling afraid. The incident was documented in a Report of Suspected Dependent Adult/Elder Abuse and an Investigative Summary Report. During interviews, the resident confirmed that he cried because the water was cold and expressed fear that it might happen again. The Director of Nursing, Social Services Director, and Administrator acknowledged the inappropriate behavior of the CNAs and the impact on the resident. The facility's policies on Resident Rights and Dignity were reviewed, indicating that residents should be treated with kindness, respect, and dignity, and that staff should communicate professionally and outside the hearing range of residents.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to follow its own policy for readmission when a resident was not permitted to return after hospitalization, despite being eligible for a 7-day bed hold. The resident, who had vascular dementia and moderate protein-calorie malnutrition, was transferred to a General Acute Care Hospital (GACH) at the request of his daughter due to concerns about worsening oral candidiasis and poor care at the facility. Despite multiple attempts by the hospital's Case Manager to readmit the resident, the facility repeatedly responded that they were unable to accept the patient. Interviews with the Admissions Director, Director of Nursing (DON), and Administrator confirmed that the resident was eligible for readmission under the facility's bed hold policy. However, the Interdisciplinary Team (IDT) decided not to readmit the resident due to unresolved conflicts between the family and facility staff. This decision was made despite the facility's policy, which prioritizes readmission for residents discharged to the hospital or on therapeutic leave. The facility's actions resulted in a violation of the resident's rights for readmission.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. During an initial kitchen tour, the ice machine was found to have significant black and brown stains with scratches on the bottom of the evaporator unit. The Maintenance Supervisor confirmed that despite regular cleaning, the stains did not come off, and the scratches were old. The Registered Dietitian noted that the scratches could harbor microorganisms, potentially contaminating the ice. Additionally, the walk-in freezer and refrigerator had food storage metal racks with rust, which was confirmed by the Food and Nutrition Service Director. The rust was noted in a previous inspection but had not been addressed yet. The FDA Food Code requires food-contact surfaces to be smooth and free of imperfections to prevent microorganism attachment and biofilm formation, which can release pathogens to food. Furthermore, the temperature of the freezer sections of the resident's food refrigerators located in nurse stations one and two were not monitored. The Assistant Director of Nurses confirmed that there were no temperature monitor logs for these freezers, and the Director of Staff Developer admitted to not monitoring the freezer temperatures despite being aware of the policy requiring daily monitoring. This lack of monitoring could lead to improper food storage temperatures, increasing the risk of food-borne illnesses among the residents.
Failure to Follow Therapeutic Diets
Penalty
Summary
The facility failed to ensure that the menu was being followed for therapeutic diets during lunch on 3/20/24. Seven residents on modified texture diets (Dysphagia mechanical soft and Dysphagia advance) did not receive the required gravy for their meat entree, contrary to the facility's diet guide sheet. Additionally, two residents on a Therapeutic Lifestyle Change (TLC) diet received gravy on their pork chop, which was not in accordance with their dietary requirements. Furthermore, three residents on Renal and CCD/Renal diets received cake instead of the prescribed cookie for dessert and gravy on their pork chop, which was not compliant with their dietary needs. Lastly, two residents on a CCD diet received sweet potato instead of mashed potato as indicated on the menu. During interviews, the Regional Registered Dietitian and the Registered Dietitian acknowledged that the staff did not follow the menu or spreadsheet when preparing meals, which could potentially affect the nutritional needs of the residents. The facility's job description for the cook emphasizes the importance of adhering to menus and portion control standards, including those for special diets, when preparing and serving meals. The failure to follow these guidelines had the potential to compromise the medical and nutritional status of the 14 residents involved.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to provide documentation for current COVID-19 immunizations for three residents, specifically regarding the offering, administration, or refusal of the vaccine. Resident 7, who has a persistent vegetative state and a history of pneumonia and COVID-19, had no documented current 2023-2024 COVID vaccine information. Similarly, Resident 61, with a diagnosis of cerebral infarct, and Resident 73, with a history of COVID-19, also lacked documentation for the current COVID-19 vaccine. The Director of Nursing (DON) confirmed the absence of documented consents or refusals for these residents during a review of their vaccination records. The DON explained that the previous Infection Preventionist had sent out mass texts to families when vaccines were available, but there was no follow-up to ensure consents were signed. Family members of Residents 61 and 73 confirmed they had not received recent messages offering the COVID-19 vaccine. The facility's policy required that each resident be offered the vaccine and that documentation of education, consent, and administration be maintained in the resident's medical record. The lack of proper documentation and follow-up decreased the facility's potential to prevent or reduce the severity of COVID-19 among its residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control standards for two residents. Resident 204's indwelling catheter bag was observed lying on the floor, contrary to the care plan and facility policy, which stated that catheter bags should be kept off the floor to prevent infection. This was confirmed by a CNA and the DON, who acknowledged that the catheter bag on the floor increased the risk of infection. The facility's policy on catheter care explicitly stated that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. For Resident 7, the facility did not adhere to Enhanced Barrier Precautions (EBP) during high-contact care activities. Two CNAs were observed changing the resident's incontinence brief without wearing gowns, despite a sign indicating that gowns and gloves were required for such activities. One CNA's shirt came into contact with the bed during care. The ADON confirmed that gowns and gloves should be worn during high-contact care to prevent the transmission of infections. The facility's policy on Enhanced Standard/Barrier Precautions emphasized the importance of gown and glove use to prevent the spread of multi-drug resistant organisms.
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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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