Auburn Oaks Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, California.
- Location
- 3400 Bell Road, Auburn, California 95603
- CMS Provider Number
- 555219
- Inspections on file
- 44
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Auburn Oaks Care Center during CMS and state inspections, most recent first.
A resident with a history of subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and documented moderate memory impairment underwent extensive surgical dental extractions without informed consent from the identified Responsible Party (RP). The physician’s orders indicated the resident lacked capacity, and the face sheet listed a family member as RP, yet consent was reportedly obtained from the resident instead. The DON confirmed no RP consent could be located, and a dental hygienist stated they normally contact the RP but were unaware of the RP status and had never spoken with the family member.
A resident with moderate dementia, PTSD, and a history of unsafe wandering was able to leave the facility unsupervised after the removal of a previously ordered wander guard and the resolution of elopement risk in the care plan. The resident was found outside by a family member, and staff were unaware of the absence until notified. The care plan did not reflect the resident's ongoing elopement risk at the time of the incident.
A resident with cognitive impairment and physical limitations was not protected from abuse when another cognitively impaired resident became physically aggressive during a meal, pushing the first resident's plate onto her chest and lap. The incident was witnessed by CNAs and resulted in emotional distress for the affected resident.
A resident sustained injuries during a transfer from bed to shower chair due to improper use of a Hoyer lift by two CNAs. The resident, who required assistance for transfers and was at high risk for falls, fell when the lift tipped over due to incorrect maneuvering and lack of stability. This resulted in a right ankle sprain and back pain, causing the resident to fear future transfers.
A resident with a right ankle sprain was not properly monitored for the use of a postoperative boot, as there were no physician orders or care plans in place. Despite the resident's high fall risk and moderate cognitive impairment, the facility failed to document or evaluate the boot's use, which was confirmed by the ADON and DOR.
Two LVNs at a facility pronounced a resident deceased, which violated the facility's policy and state law as only a physician or RN is authorized to do so. The resident, on hospice care for COPD, was found unresponsive with no signs of life. Interviews confirmed the LVNs acted outside their scope of practice, potentially jeopardizing resident safety.
A resident with cognitive impairments was physically abused by another resident, resulting in a scratch on her face and feelings of unsafety. The incident occurred after a verbal exchange when one resident accidentally bumped into the other's foot, leading to a physical altercation. The facility's policies on abuse prevention and resident-to-resident altercations were not effectively implemented, resulting in a failure to protect the resident from abuse.
A resident was mistakenly given another resident's medications upon discharge, breaching confidentiality. The error occurred because medications for both residents were stored in the same drawer, and staff failed to verify the medications properly. The facility's policy on confidentiality was not followed, and the breach was not reported to the state or the affected resident's family.
A resident was discharged with another resident's medications due to a mix-up by the nursing staff. The error occurred when medications were pulled from a shared drawer without proper verification. The facility's policy for reviewing discharge instructions and medications was not adequately followed, leading to the resident leaving with incorrect medications.
The facility did not complete annual performance evaluations for three CNAs, as required by policy, increasing the risk of poor-quality care. The DSD admitted to not conducting evaluations for 2023-2024, and the DON and ADM confirmed the oversight. These evaluations are crucial for identifying areas for improvement and assessing CNA competency.
The facility failed to properly manage medications and oxygen for several residents, leading to potential health risks. Medications were left unlabeled and undated at the bedside, and oxygen equipment was not maintained or monitored as required. These deficiencies were confirmed by nursing staff, highlighting a lack of adherence to professional standards.
The facility failed to document controlled substance medications accurately for four residents, with discrepancies between the MAR and CDR. Additionally, an opened antibiotic e-kit was not replaced within the required timeframe, risking medication availability. Interviews confirmed the expectation for accurate documentation and timely e-kit replacement, as per facility policy.
A facility failed to document clinical rationale when disagreeing with pharmacy consultant recommendations for a resident's medication regimen. The resident, with multiple diagnoses including Huntington's disease and depression, was on a complex medication regimen. The pharmacy consultant identified potential risks, but the provider disagreed with recommendations without documenting reasons. The facility lacked a policy for reviewing pharmacy consultant reports.
The facility failed to properly store and label medications, leading to expired and improperly stored medications being available for use. Inspections revealed expired medications, loose tablets, and improper storage of medications requiring different administration routes. The DON confirmed the need for separate storage and proper labeling, as per facility policies.
The facility failed to follow professional standards for food service safety, affecting 95 residents. Observations revealed improper food labeling, expired items not discarded, and poor storage conditions for produce and utensils. The RD confirmed these issues, which contradict the facility's policies and FDA guidelines.
The facility failed to maintain proper infection control by not labeling, dating, or changing respiratory equipment weekly for several residents, increasing the risk of respiratory infections. Staff confirmed lapses in following policies for managing oxygen therapy equipment, which were not consistently adhered to, posing potential infection risks.
A facility failed to accurately code the MDS for a resident, indicating discharge to a hospital instead of home, despite documentation showing the correct discharge destination. The MDS Coordinator confirmed the error, and the DON emphasized the need for accurate MDS coding. The resident had multiple diagnoses, including heart failure and difficulty walking.
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with pulmonary edema had no care plan for a respiratory treatment, while another with asthma had expired respiratory equipment and an empty oxygen tank. A third resident with lung cancer received oxygen therapy at a higher rate than prescribed, and their oxygen saturation levels were not monitored. These oversights resulted in care plans not being followed.
The facility failed to assist four residents with activities of daily living, leading to deficiencies in personal hygiene and nutrition. A resident with Huntington's Disease and another with cognitive impairment had long, unclean fingernails despite needing assistance. Another resident with dementia also had unclean nails. Additionally, a resident with spinal stenosis and dysphagia did not receive the required one-to-one assistance during meals, as confirmed by staff and care plans.
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. A resident with lung cancer and COPD received oxygen at a higher rate than prescribed, and monitoring was inconsistent. Another resident with diabetes received insulin despite blood sugar levels being below the ordered threshold. Staff confirmed these discrepancies, highlighting a failure to follow medical orders.
The facility failed to ensure safe water temperatures in resident bathrooms, with four bathrooms having water temperatures exceeding 120 degrees Fahrenheit. Staff confirmed the excessive heat, and residents expressed fear of burns. The facility's policy requires water temperatures to be between 105 and 120 degrees Fahrenheit, but this was not adhered to, posing a risk of scalds or burns.
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. A resident with severe memory impairment was served a regular sandwich instead of a meal that met her dietary needs. Another resident expressed dissatisfaction with being served pasta despite disliking it, and a third resident repeatedly received meals with sauces despite expressing a dislike for them. A fourth resident was served a sandwich for lunch, which did not align with her expectations or preferences.
A resident with a history of UTIs was prescribed Cephalexin without a stop date, contrary to the facility's antibiotic stewardship policy. Staff interviews revealed a lack of clarity and monitoring for the antibiotic's necessity and duration, with no specific orders to monitor for UTIs.
A resident, who was cognitively intact and required assistance with toileting, experienced verbal abuse from a CNA who used profanity and refused to help. The incident was witnessed by another resident and staff, who confirmed the CNA's aggressive behavior. The facility's policies on resident rights and abuse prevention were not followed, leading to a deficiency in care standards.
A resident with chronic conditions self-administered multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The facility's policy required an IDT evaluation for safe self-administration, but no such evaluation was conducted. This oversight led to the resident taking duplicate medications and supplements without professional oversight, raising safety concerns.
Failure to Obtain Informed Consent from Responsible Party for Extensive Dental Extractions
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent from a resident’s Responsible Party (RP) prior to extensive dental extractions. The resident had diagnoses including subarachnoid hemorrhage, cognitive communication deficit, encephalopathy, and long-term use of anticoagulants, and an MDS dated 2/5/26 documented moderate memory impairment. The physician’s orders indicated the resident was not capable, and the nurse practitioner note from 3/31/26 stated the resident was awake but had periods of confusion. The face sheet identified a family member as the RP. Despite this, the resident was scheduled on a dental visit list for surgical extraction with bone removal of multiple teeth, and post-operative documentation showed that oral surgery was completed on 4/7/26. During a telephone interview, the RP stated they were not asked for consent for the extractions and that the facility reported obtaining consent directly from the resident, even though the resident was confused at times. On observation, the resident demonstrated memory problems and was unable to answer all questions posed by the nurse surveyor. The DON confirmed that, based on the face sheet and physician’s order indicating no capacity, the RP should have been contacted for consent and that no consent from the RP for the extraction of 21 teeth could be found. A registered dental hygienist reported that they normally call the RP if there is one but stated they did not realize the RP had changed and had never spoken to the identified RP. When requested, the facility was unable to provide a policy and procedure related to this issue.
Failure to Prevent Elopement for Resident with Dementia and PTSD
Penalty
Summary
A resident with moderate dementia, PTSD, and difficulty walking was admitted to the facility and identified as being at risk for elopement, as documented in the resident's Elopement and Wandering Risk Assessment. The assessment indicated the need for a wander alarm device, and a physician's order for a wander guard was in place. However, the wander guard order was discontinued and the device was removed several months prior to the incident. The resident's care plan was also revised to indicate that the elopement risk and need for a wander guard were resolved, despite the resident's ongoing cognitive impairments and history of unsafe wandering. On the date of the incident, the resident left the facility unsupervised and was found by a family member walking down the street and standing at a traffic light intersection. Facility staff were unaware of the resident's absence until notified by the family member. Upon review, the care plan did not reflect the resident's elopement risk during the period leading up to the incident, and staff confirmed that the resident's elopement was a safety issue due to his dementia and PTSD. The facility's policy required that residents identified as at risk for wandering or elopement have care plans with appropriate interventions to maintain safety, which was not followed in this case.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hemiplegia, dementia, and anxiety disorder was not protected from abuse by another resident. The incident took place in the dining room, where three CNAs were present. During the meal, another resident with severely impaired cognition due to metabolic encephalopathy and Alzheimer's disease became physically aggressive, pushing the first resident's plate onto her chest and lap. The affected resident reported feeling upset by the incident. Staff interviews confirmed that the altercation was witnessed, and the facility's policy states that residents must be protected from abuse by anyone, including other residents. Despite this, the event resulted in a failure to ensure the resident's right to be free from abuse, as required by federal regulations.
Plan Of Correction
Residents were separated immediately at the time of the incident and Resident 21 was removed from the dining room. All residents who have an altercation have the potential to be affected by the same deficient practice. Any residents who have an altercation will be separated immediately and reported accordingly. DSD in-serviced staff on 07/08/25 on Abuse Policy and ways to prevent altercations. DSD to observe the behavior of Resident 12 in the dining room weekly x 4 weeks, monthly x 1 month to ensure no altercations occur and residents feel safe. Any findings out of compliance will be brought to the attention of the Administrator and addressed immediately. All findings will be reported to the QA Committee. Corrective action will be achieved and sustained by 07/24/2025.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to provide safe supervision and assistance during a transfer for a resident, resulting in an accident. The incident occurred when two CNAs were transferring a resident from bed to a shower chair using a Hoyer lift. The CNAs did not follow the proper maneuvering and operation procedures for the lift, leading to the lift tipping over and the resident falling to the ground. This resulted in the resident sustaining a right ankle sprain, back pain, and developing a fear of being moved out of bed using a lift. The resident involved in the incident had been admitted to the facility with diagnoses including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking. The resident's Minimum Data Set indicated moderate cognitive impairment and a dependency on staff for toileting hygiene, transfers, and showering, requiring the assistance of two or more staff members. The resident was also assessed as being at high risk for falls, with a care plan in place to minimize fall risks, including a recommendation for a room change to accommodate a bariatric bed and ease the maneuvering of the Hoyer lift. During the transfer, CNA 1 improperly maneuvered the lift by moving it sideways instead of pivoting it, and CNA 2 was positioned away from the lift, failing to provide adequate support. The lift's legs were not opened or extended, compromising its stability, and the brakes were not used correctly. As a result, the lift tipped over, causing the resident to fall and the lift to land on the resident's right ankle. The incident was compounded by the CNAs not adhering to the facility's policy and procedure for using mechanical lifts, which emphasized the importance of stability and proper handling to prevent accidents.
Failure to Monitor Postoperative Boot Use
Penalty
Summary
The facility failed to provide necessary care and services for a resident who was using a postoperative boot following a fall that resulted in a right ankle sprain. The resident, who was admitted with conditions including morbid obesity, muscle weakness, fibromyalgia, and difficulty walking, was at high risk for falls and had moderate cognitive impairment. After a fall, the resident was diagnosed with a possible avulsion fracture and was discharged from the hospital with a postoperative boot and pain medication. However, the facility did not monitor or evaluate the use of the boot, as there were no physician orders, treatment notes, or care plans in place for its use. During observations and interviews, it was confirmed that the resident was wearing the boot, but there was no documentation or monitoring for skin integrity and circulation, which are essential when using such devices. The Assistant Director of Nursing (ADON) and the Director of Rehabilitation (DOR) acknowledged the lack of orders and care plans for the boot. The facility's policy on safety and supervision of residents emphasizes the need for implementing, documenting, and evaluating interventions, which was not adhered to in this case.
Improper Pronouncement of Death by LVNs
Penalty
Summary
The facility failed to adhere to its policy regarding the pronouncement of death, resulting in a violation of professional standards of quality. Two Licensed Vocational Nurses (LVNs) pronounced a resident deceased, which is outside their scope of practice according to the facility's policy and state law. The resident, who was on hospice care for Chronic Obstructive Pulmonary Disease (COPD), was found unresponsive in bed with no signs of life. The LVNs documented the absence of a pulse and respiratory effort, and subsequently declared the time of death. Interviews with the Registered Nurse (RN), Hospice Clinical Consultant (HCC), and Director of Nursing (DON) confirmed that only a physician or RN is authorized to pronounce death, especially for residents on hospice care. The facility's policy titled "Death of a Resident" explicitly states that a resident may only be declared dead by a licensed physician or RN with physician authorization. The DON verified that the LVNs acted outside their scope of practice, which could potentially jeopardize resident health and safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident grabbed her hands, resulting in a scratch on her face and feelings of unsafety. The incident involved two residents with cognitive impairments. Resident 1, who has a history of cerebral infarction and schizophrenia, was sitting in her wheelchair when Resident 2, diagnosed with postconcussional syndrome and mild cognitive impairment, accidentally bumped into her foot. This led to Resident 1 grabbing Resident 2's wrists and scratching her face. The incident was witnessed by a CNA and a Licensed Nurse (LN 1), who were at the nursing station when they heard yelling from the residents' room. The CNA reached the room first and observed Resident 1 grabbing Resident 2's hands after a verbal exchange. LN 1 intervened by pulling Resident 2's wheelchair back. Both residents had a history of memory problems, and Resident 1 was known for behaviors such as yelling and repetitiveness. The facility's policy on abuse prevention and resident-to-resident altercations emphasizes the need to protect residents from abuse, including physical abuse by other residents. The policy outlines that all altercations should be investigated and reported to the nursing supervisor, director of nursing services, and the administrator. However, the incident highlights a failure in preventing resident-to-resident abuse, as Resident 2 sustained a physical injury and felt unsafe in her room.
Confidentiality Breach Due to Medication Mix-Up
Penalty
Summary
The facility failed to maintain confidentiality for one of its residents when medications belonging to another resident were mistakenly given to an unauthorized recipient. Resident 1, who was admitted with orthopedic aftercare and spinal stenosis, was discharged with medications that included those belonging to Resident 2, who had been admitted with hemiplegia and hemiparesis following a stroke. This error occurred because the medications for both residents were stored in the same drawer, and during the discharge process, Resident 2's medications were inadvertently included with Resident 1's. The error was discovered when Resident 1's family member noticed the mistake after leaving the facility. Interviews with the Director of Nursing (DON) and several Licensed Nurses (LNs) revealed that the medication cart nurse and desk nurse did not adequately verify the medications before discharge. The medication cart nurse mistakenly pulled medications from the wrong drawer, and the desk nurse failed to thoroughly check the contents of the medication bag, leading to the breach of confidentiality. The DON acknowledged the mistake and noted that the confidentiality breach was not reported to the state, and the family of Resident 2 was not informed of the incident. The facility's policy on confidentiality and resident rights emphasizes the protection of personal and medical records, but the policy was not followed in this instance. The facility's failure to adhere to its own procedures resulted in the unauthorized release of Resident 2's confidential information.
Resident Discharged with Wrong Medications
Penalty
Summary
The facility failed to ensure a safe discharge for a resident, who was discharged with another resident's medications. This incident involved two residents, one of whom was discharged with medications belonging to their roommate. The discharged resident had been admitted with orthopedic aftercare needs and was cognitively intact, while the roommate had been admitted with conditions related to a stroke. The error occurred when the medication cart nurse mistakenly pulled the roommate's medications instead of the discharged resident's. The desk nurse briefly reviewed the medications but failed to notice the error, resulting in the wrong medications being sent home with the resident. The facility's Director of Nursing acknowledged the mistake and noted that the medications were not properly verified before discharge. Interviews with staff revealed that the medications for both residents were stored in the same drawer without proper separation, leading to the mix-up. The staff involved admitted to not thoroughly checking the medications before discharge, and the error was only discovered after the resident had left the facility. The facility's policy required that discharge instructions and medications be reviewed with the resident or responsible party, which was not adequately followed in this case.
Failure to Conduct Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for three of five sampled certified nursing assistants (CNAs) in a facility with a census of 95. During interviews and record reviews, it was found that CNAs hired on various dates had no documented evidence of annual performance evaluations being conducted. The Director of Staffing Development (DSD) admitted to not completing any performance evaluations for the year 2023 to 2024. The Director of Nursing (DON) and the Administrator (ADM) confirmed the absence of these evaluations, which are intended to identify areas for improvement in resident care and assess the competency of CNAs. The facility's policy requires that job performance be reviewed and evaluated at least annually, but this was not adhered to, increasing the risk of residents receiving poor-quality care.
Medication and Oxygen Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications and ointments were properly managed and stored for several residents, leading to potential health risks. For Resident 143, medications and ointments were left on the nightstand, unlabeled and undated, which the resident did not recognize. This was confirmed by both a Certified Nursing Assistant (CNA) and a Licensed Nurse (LN), who acknowledged that the medications should not have been left there and were not properly labeled. Resident 144 experienced a similar issue, with medications and hazardous liquids left at the bedside. A medication labeled for another resident was found in Resident 144's room, along with an unlabeled container of mentholatum ointment and a large plastic container of mouthwash. The CNA and LN confirmed that these items should not have been at the bedside and that medications from home should be checked in with a nurse and stored properly. For Resident 36, a medication was not administered completely and was left at the bedside, and an oxygen tank was found empty while in use. The nasal cannula and other equipment were not dated or changed as required, leading to potential infection risks. Additionally, Resident 85's oxygen saturation levels were not monitored as ordered, and the oxygen was administered at an incorrect rate. These failures were confirmed by the nursing staff, who acknowledged the importance of following physician orders and the potential for respiratory distress if not adhered to.
Deficiencies in Controlled Medication Documentation and E-Kit Replacement
Penalty
Summary
The facility failed to ensure accurate documentation and accountability of controlled substance medications for four residents. For Resident 3, a hydrocodone/acetaminophen tablet was removed but not documented on the medication administration record (MAR). Resident 22 received tramadol, but its removal was not recorded on the Controlled Drug Record (CDR). Resident 75 had lorazepam removed, but the administration was not documented on the MAR. For Resident 78, multiple administrations of hydrocodone/acetaminophen were recorded on the MAR, but their removal was not documented on the CDR. Interviews with Licensed Nurse 2 and the Director of Nursing confirmed the expectation that both the CDR and MAR should reflect the administration and removal of controlled medications, as per the facility's policy. Additionally, the facility did not replace an opened antibiotic emergency kit (e-kit) in a timely manner. The e-kit, identified with a red plastic tie indicating it had been opened, contained logs showing medications were removed on several dates. The Assistant Director of Nursing confirmed that nursing staff were expected to request a replacement e-kit immediately after it was opened to ensure availability of medications. The facility's policy stated that opened kits should be replaced within 72 hours, which was not adhered to in this instance.
Failure to Document Clinical Rationale for Medication Decisions
Penalty
Summary
The facility failed to implement a process to ensure that clinical rationale was documented when no changes were made to medications in response to identified irregularities and recommendations by the pharmacy consultant (PC) for a resident. The resident, who was admitted with multiple diagnoses including Huntington's disease, anxiety, insomnia, dementia, high blood pressure, depression, and repeated falls, was on a complex medication regimen. The PC's monthly drug regimen reviews (MRR) identified potential medication-related problems, such as increased risk of central nervous system depression, serotonin syndrome, neuroleptic malignant syndrome, and extrapyramidal symptoms due to the combination of medications prescribed. Despite these identified risks, the provider disagreed with the PC's recommendations to evaluate and possibly adjust the medication regimen, including the dosing of lamotrigine ER and the use of two antidepressants, without documenting the clinical rationale for these decisions. The Director of Nursing (DON) confirmed that the provider marked disagreement with the PC's recommendations on the MRRs but did not provide the necessary clinical rationale. Additionally, the facility was unable to provide a policy and procedure (P&P) addressing the process for reviewing and acting upon the PC's MRRs when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled according to professional standards and the facility's policies and procedures. During an inspection, expired medications, including Skintegrity Hydrogel and EvenCare G3 blood glucose test strips, were found in the Central Supply. Additionally, an open vial of Assure Platinum blood glucose test strips was identified without an open date label, and loose tablets were found in medication carts. Partially used bottles of sterile normal saline and acetic acid irrigation, which are intended for single use, were not discarded after opening, contrary to the manufacturer's instructions. Further inspections revealed that medications requiring different routes of administration were improperly stored together, such as injectable medications and topical patches being stored with oral medications. The Director of Nursing confirmed that medications should have been stored separately based on their administration routes and that all medications provided by the pharmacy should have been labeled with the resident's name. The facility's policies emphasized the importance of maintaining medication storage areas in a clean, safe, and orderly manner, which was not adhered to, leading to the potential for unsafe medication administration and misuse.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting 95 residents who received facility-prepared foods. During an initial kitchen tour, it was observed that proper food labeling was not followed. Items such as coconut flakes, diced onions, and cut celery sticks were found without proper labels indicating the opened or used-by dates. The Registered Dietitian (RD) confirmed these observations and acknowledged that the staff is expected to label food items correctly as per the facility's policy and procedure. Additionally, expired food items were not discarded as required. Expired items such as oat milk, salad dressing packets, chocolate baking chips, pie crust, and soy milk were found in various storage areas. The RD confirmed these findings and stated that expired items should have been discarded immediately. The facility's policy mandates that no food should be kept beyond its expiration date, aligning with the U.S. Food and Drug Administration (FDA) guidelines. The facility also failed to maintain proper storage conditions for produce and utensils. A box of undated bananas with discoloration and leaking fluids was found in the walk-in refrigerator, which the RD and Dietary Manager confirmed should not be served to residents. Furthermore, several wet steam table pans were found stacked in the clean storage area, contrary to the facility's policy and FDA guidelines that require items to be air-dried before storage to prevent microorganism growth.
Inadequate Infection Control in Respiratory Equipment Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper management of respiratory equipment for four residents. Resident 148 had a hand-held nebulizer and a nasal cannula that were unlabeled and undated, with a nebulizer bag that was dated more than a week prior. Resident 36 had an unlabeled and undated nasal cannula and nebulizer machine, with a disconnected nebulizer chamber and an undated oxygen mask, some of which were touching the floor. These items were not changed weekly as required, increasing the risk of respiratory infections. Resident 1's oxygen tubing and face mask were not labeled or dated, contrary to the facility's policy of weekly changes to prevent infections. The care plan for Resident 1 highlighted the risk of infection due to the use of muscle relaxants and a history of COVID-19, yet the necessary precautions were not followed. Similarly, Resident 3's oxygen tubing and face mask were not labeled or dated, and the antimicrobial bag was expired. The physician orders for Resident 3 specified weekly changes of oxygen equipment, which were not adhered to, posing a risk of infection. Interviews with staff, including CNAs and the Director of Nursing, confirmed the lapses in following the facility's policies for infection control. The facility's policies required that oxygen therapy equipment be labeled, dated, and changed weekly, with storage in antimicrobial bags changed monthly. These procedures were not consistently followed, leading to potential risks of respiratory infections among the residents.
Inaccurate MDS Discharge Coding for a Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the current condition of a resident, identified as Resident 92. The deficiency occurred when the discharge MDS inaccurately indicated that the resident was discharged to a short-term general hospital, despite documentation in the resident's Physician Orders, Nurse's Note, and Nurse Practitioner Note indicating that the resident was discharged to home. This discrepancy was confirmed during a record review and interview with the MDS Coordinator, who acknowledged the error and stated that the MDS should have been coded correctly. Resident 92 was admitted to the facility with multiple diagnoses, including heart failure and difficulty in walking. The facility's policy and procedure on resident assessments, which are federally mandated, require that discharge assessments be accurate and conducted by the interdisciplinary team. The Director of Nursing emphasized the expectation for MDS coding to be accurate. The inaccurate MDS submission to CMS resulted from a failure to adhere to these policies, as evidenced by the incorrect discharge status recorded in the MDS.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop or implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident 148, who was admitted with pulmonary edema, muscle weakness, and swallowing difficulty, had a physician's order for a respiratory treatment using Ipratropium-Albuterol Solution. However, there was no care plan developed for this treatment, and the resident was unaware of the purpose of the nebulizer treatment, indicating a lack of communication and documentation. Resident 36, admitted with asthma exacerbation and respiratory failure with hypoxia, had care plans that were not implemented. Observations revealed expired and undated respiratory equipment, such as nasal cannulas and nebulizer masks, which were not replaced as required. Additionally, the resident's oxygen tank was found empty, and staff failed to monitor and replace it, leading to the resident experiencing shortness of breath. These oversights in equipment management and monitoring contributed to the failure in implementing the care plan. Resident 85, diagnosed with lung cancer, pulmonary fibrosis, and COPD, received oxygen therapy at a higher rate than prescribed. The care plan indicated oxygen should be administered at 3L/min, but observations showed it was consistently given at 4L/min. Furthermore, the resident's oxygen saturation levels were not monitored as ordered, and the staff did not adhere to the care plan interventions. These actions and inactions resulted in the care plan not being followed, potentially affecting the resident's health outcomes.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, leading to deficiencies in personal hygiene and nutrition. Resident 83, who has Huntington's Disease, was observed with long fingernails and a thick dark substance underneath them, despite requiring partial/moderate assistance for personal hygiene. Similarly, Resident 44, with cognitive impairment and muscle weakness, had long fingernails with chipped nail polish and a dark substance underneath, even though they needed substantial/maximum assistance with personal hygiene. Resident 20, diagnosed with dementia and lack of coordination, also had long fingernails with a dark substance underneath, despite requiring partial/moderate assistance for personal hygiene. Staff interviews confirmed the lack of nail care and the importance of maintaining clean nails to prevent cross-contamination and bacterial growth. Additionally, the facility failed to provide one-to-one assistance during meals for Resident 29, who has spinal stenosis, dysphagia, and dementia. Despite the care plan indicating the need for one-to-one assistance and encouragement during meals, Resident 29 did not receive the required assistance during a dining observation. The Registered Dietitian and Director of Nursing confirmed the need for one-to-one assistance, as outlined in the resident's care plan and meal ticket. The facility's policies on ADL and nail care emphasize the necessity of providing services to maintain good nutrition, grooming, and personal hygiene, which were not adhered to in these cases.
Failure to Follow Physician's Orders for Oxygen and Insulin Administration
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident 85, who was diagnosed with lung cancer, pulmonary fibrosis, and COPD, was prescribed oxygen therapy at 3 liters per minute to maintain oxygen saturation levels above 90%, with monitoring every shift. However, observations revealed that the resident was receiving oxygen at 4 liters per minute, and the oxygen saturation levels were not consistently monitored as ordered, with some days having only one or two checks instead of every shift. Licensed nurses confirmed the discrepancies in oxygen administration and monitoring. Resident 71, who was readmitted with a diagnosis of diabetes, had a physician's order for Insulin Glargine to be administered with specific parameters: 25 units to be injected unless blood sugar was below 151. Despite this, the medication was administered on two occasions when the resident's blood sugar levels were below the specified threshold, at 110 and 136, respectively. The Director of Nursing confirmed that the insulin was given outside the ordered parameters, and a licensed nurse acknowledged the importance of adhering to insulin orders to prevent rapid drops in blood sugar levels.
Excessive Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the water temperatures in four out of ten residents' bathrooms exceeding 120 degrees Fahrenheit. During observations and interviews conducted on September 30, 2024, it was confirmed that the water temperatures in these bathrooms ranged from 120.2 F to 122.2 F. Certified Nurse Assistants and a Housekeeper verified these temperatures, expressing concerns about the potential for burns or scalds due to the excessively hot water. Residents also expressed fear and caution when using the water, indicating awareness of the hazard. The facility's policy and procedure on water temperatures, dated May 2024, stipulates that water heaters in bathrooms should be set between 105 degrees Fahrenheit and 120 degrees Fahrenheit. However, the observed temperatures exceeded this range, indicating a failure to adhere to the established guidelines. This oversight could potentially place residents at risk of accidental scalds or burns, particularly given the fragility of the residents' skin as noted by the staff.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of four residents, leading to dissatisfaction and potential nutritional risks. Resident 51, who has severe memory impairment and requires a mechanically altered diet, was served a regular sandwich instead of a meal that met her dietary needs. Despite her confusion and the meal ticket indicating a regular diet order, the Infection Preventionist confirmed the meal was not aligned with her preferences. Resident 60, with mild memory impairment and dietary restrictions, expressed dissatisfaction with the meals provided, specifically being served pasta despite disliking it. The meal ticket confirmed her dislikes, yet the meal did not reflect her preferences. The Licensed Nurse acknowledged the oversight but noted that the resident did not communicate her hunger or need for a replacement meal. Resident 82, who is at risk for malnutrition, repeatedly received meals with sauces despite expressing a dislike for them. The Assistant Director of Nursing verified the presence of sauce on the meal and offered a replacement. Similarly, Resident 20, with moderate memory impairment, was served a sandwich for lunch, which did not align with her expectations or the meal ticket indicating her preferences. The Infection Preventionist was unable to explain why both Resident 20 and Resident 51 received the same meal, highlighting a systemic issue in meal preparation and delivery.
Antibiotic Stewardship Guidelines Not Followed
Penalty
Summary
The facility failed to adhere to antibiotic stewardship guidelines for a resident who was prescribed an antibiotic without a specified end date. The resident, who was admitted in 2012 with conditions including diabetes, kidney disease, and a history of urinary tract infections (UTIs), was prescribed Cephalexin 250 mg daily for a UTI. However, the physician's order did not include a stop date for the antibiotic, and there was no documented evidence of monitoring for signs and symptoms of a UTI. Interviews with facility staff, including the Facility Pharmacist and the Director of Nursing, revealed that there was confusion and lack of clarity regarding the necessity and duration of the antibiotic treatment. The Facility Pharmacist expressed concerns about the indefinite use of the antibiotic and the potential for adverse effects such as Clostridium difficile infection. The Director of Nursing confirmed that there were no specific orders to monitor for UTIs and that the antibiotic order had not been reviewed or updated in 2024. The facility's policy on antibiotic stewardship required prescribers to provide a start and stop date or specify the number of days of therapy, which was not followed in this case.
Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was cognitively intact and required substantial assistance with toileting hygiene. The resident had multiple medical conditions, including depression, a history of stroke, and an amputation above the knee. During an interaction, the resident requested assistance from CNA 1, who responded with profanity and refused to help, leaving the resident feeling intimidated and verbally abused. The incident was corroborated by another resident and staff members who witnessed the exchange. A second resident observed CNA 1's inappropriate behavior and noted that CNA 1 returned to the room laughing after the confrontation. Licensed nurses and the Director of Staff Development also confirmed CNA 1's use of foul language and aggressive demeanor, describing him as having a short temper and being easily flustered. The Director of Nursing and the Administrator acknowledged the unprofessional conduct of CNA 1, who was suspended and subsequently terminated for misconduct. The facility's policies on resident rights and abuse prevention emphasize treating residents with respect and protecting them from abuse, including verbal abuse. However, these policies were not adhered to in this instance, resulting in a deficiency in the facility's care standards.
Failure to Monitor Resident's Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident who was taking multiple non-prescription supplements and vitamins without evaluation or monitoring by health professionals. The resident, who had a history of chronic inflammation disorder affecting nerves, diabetes, pain, and hallucinations, was observed with numerous bottles of vitamins and supplements on their bedside table. These included nerve pain supplements, immune boosters, and dietary supplements, none of which were prescribed by a doctor or listed in the physician orders. Additionally, the resident had two medication cups with loose pills, which they reported taking three to four hours after their prescribed medications. The facility's policy required an evaluation by the interdisciplinary team (IDT) to determine if self-administration was clinically appropriate and safe, with documentation in the medical record and care plan. However, there was no such evaluation or documentation for this resident. The Licensed Nurse and Director of Nursing confirmed the lack of evaluation and monitoring, acknowledging the potential safety concerns and medication errors due to the resident's unsupervised self-administration of medications. The facility's failure to adhere to its policy resulted in the resident taking duplicate medications and multiple supplements without professional oversight.
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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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