Balboa Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 3520 Fourth Avenue, San Diego, California 92103
- CMS Provider Number
- 056105
- Inspections on file
- 37
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Balboa Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with depression and COPD, who was cognitively intact per a recent MDS, reported to hospital staff that he had been physically assaulted by facility staff. The hospital notified the Department, prompting an unannounced survey. The DON later stated she had received information that the resident reported being physically assaulted but did not take any action or report the allegation to the Department, despite facility policy requiring investigation and reporting of abuse allegations within federally mandated time frames.
Surveyors found that the facility administered antibiotics for suspected UTIs without adequate clinical indication, assessment, or monitoring. One resident with a suprapubic catheter and immunodeficiency received multiple antibiotics for UTI treatment and prophylaxis despite an infection screening showing no symptoms, no documented diagnosis supporting prophylaxis, no stop date for a prophylactic agent, and no documented monitoring of UTI symptoms or side effects. Another resident with DM and moderate cognitive deficits was started on Ciprofloxacin for confusion and a positive urine culture, even though confusion alone did not meet McGeer criteria for UTI and the facility’s Infection Screening Evaluation was not completed, with no documentation of symptom or side-effect monitoring during therapy.
The facility failed to follow its antibiotic stewardship and infection screening processes for three residents treated for suspected or documented UTIs. One resident with quadriplegia, immunodeficiency, and a suprapubic catheter received multiple antibiotics, including Macrobid, Levofloxacin, and Methenamine Hippurate, without documented monitoring of UTI symptoms or side effects, and with prophylactic therapy ordered despite a negative infection screening and no defined stop date. A second resident with Parkinson’s disease and moderate cognitive deficits was started on Cefuroxime Axetil for dysuria and a urinalysis showing many bacteria, but no Infection Screening Evaluation was completed before therapy and only one late progress note documented UTI symptom monitoring. A third resident with diabetes and moderate cognitive deficits was prescribed Ciprofloxacin for confusion and a positive urine culture, even though confusion alone did not meet McGeer criteria for UTI, and no Infection Screening Evaluation or ongoing symptom monitoring was documented during treatment.
Surveyors found that the facility failed to protect PHI when EBP lists containing resident names, room numbers, and reasons for EBP were posted on shower room mirrors on multiple floors. CNAs, nurses, the QAN, the IP, and the DON all acknowledged that residents’ private information should not be displayed in public areas where anyone entering could view it. Facility policies on residents’ rights and PHI required that unauthorized release or disclosure of resident information be prohibited and that PHI use be limited to the minimum necessary, but these requirements were not followed in this instance.
The facility failed to maintain a safe, clean, and homelike environment when multiple resident rooms experienced significant water intrusion from leaking ceilings and walls during rain, resulting in flooded bathrooms and wet floors that required extensive towel use. Several residents with conditions such as fractures, CKD, COPD, CHF, neuropathy, RA, fibromyalgia, and depression reported that their bathrooms and walls leaked, that floors were very wet, and that the situation was not homelike and could be dangerous. Observations confirmed water damage, including wet ceiling spots and bubbling paint, while review of the maintenance binder showed no entries documenting these leaks or repairs. Although staff described a process of reporting leaks via phone or Teams and documenting them in a maintenance log, the DOM and a maintenance worker acknowledged that no such documentation existed for the affected rooms, despite a facility policy requiring a safe, clean, and orderly homelike environment.
A resident with Alzheimer's disease and a history of behavioral disturbances, including hitting and yelling at staff and other residents, was not properly assessed or care planned for these behaviors. Staff observed and reported the behaviors, but the MDS did not reflect them, and there was no care plan in place prior to documented altercations. Facility policy required behavioral assessment and care planning, which was not followed.
A resident with chronic pain did not receive prescribed pain medication in a timely manner after requesting it multiple times during the night. The delay occurred because the assigned medication nurse was on break without passing on the medication cart keys, and another nurse failed to communicate the resident's request when the medication nurse returned. This resulted in the resident experiencing unnecessary pain due to a breakdown in staff communication and medication administration procedures.
A resident with a history of independent ambulation left the facility without staff knowledge, failing to sign out or notify anyone. The resident was last seen using the elevator, and staff only realized the absence after a search. The facility has multiple entrances, with the front entrance open during the day and the back entrance locked. Staff interviews indicated that the resident was considered independent, and the receptionist relied on nurses to communicate supervision needs. There were multiple elopements in recent months, and this incident occurred during a weekend with reduced staffing.
A resident with a history of hemiplegia, hemiparesis, visual impairment, and prior falls was allowed to smoke outside the facility without staff supervision, despite assessments and a care plan requiring supervision due to poor safety awareness. Facility staff confirmed there was no designated smoking area, no scheduled smoking times, and no formal smoking supervision program in place, resulting in unsupervised smoking contrary to documented care needs.
The facility did not have a full-time DON to oversee and manage nursing services, as confirmed by staff interviews and record review. The QA nurse, who was the former DON, indicated that the facility was still in the process of hiring for the position, and a consultant was not present during the initial investigation. This resulted in a lack of designated leadership for clinical care and care planning for all residents.
A resident with a history of falls, substance abuse, and smoking left the facility unsupervised at night and was missing for about 14 hours before being found with injuries from a wheelchair fall. Staff did not promptly report the resident's absence or initiate a search, and care plan interventions for supervision were not followed. The facility lacked a policy to ensure supervision during smoking, contributing to the resident's elopement and injury.
Staff did not follow the prepared menu or serve correct portion sizes for residents on mechanical soft, ground meat, and pureed diets, using smaller scoops than required for BBQ chicken. This affected multiple residents and was confirmed by dietary staff, the RD, DON, and Administrator, all of whom stated the importance of adhering to menu guidelines and portion sizes.
A resident with ALS and total dependence for eating was repeatedly left with their meal tray out of reach and had to wait for extended periods before being fed, while observing their roommate being fed first. Staff interviews and observations confirmed inconsistent and delayed feeding practices, resulting in a lack of a dignified dining experience as required by facility policy.
The facility failed to ensure accurate completion of MDS assessments for two residents. One resident's discharge destination was incorrectly documented as a hospital instead of home, despite supporting documentation and staff awareness of the actual discharge. Another resident's MDS did not reflect a completed PASRR Level II, even though state records confirmed it. Staff interviews confirmed these inaccuracies and a lack of verification in the MDS process.
A resident with severe cognitive impairment, dysphagia, and a history of stroke was not supervised during meals as required by their care plan. Staff delivered meals and left the resident unsupervised, despite documentation and clinical recommendations for supervision to ensure safe swallowing. Staff interviews revealed a lack of awareness or adherence to the supervision requirement.
Staff did not provide required one-on-one supervision during meals for a resident with severe cognitive impairment and dysphagia, despite clear physician orders and care plan documentation. The resident was repeatedly observed eating alone, and interviews revealed staff were either unaware of or did not adhere to the supervision requirement.
A resident with moderate cognitive impairment and a history of muscle weakness and back pain experienced ongoing pain from an ingrown and mycotic toenail due to delayed podiatry care. Despite repeated complaints and a facility policy requiring prompt podiatry referrals, the resident remained on a waiting list and was not seen by the podiatrist in a timely manner, resulting in continued pain and an overgrown, thick toenail.
A resident with a history of suicidal ideation and Major Depressive Disorder was not adequately monitored, despite recommendations for close supervision. The resident was able to harm herself by ingesting medications and cutting her wrist with a butter knife due to a lack of communication and implementation of safety measures by the facility staff.
A resident with a history of major depressive disorder and suicidal ideation was not properly monitored due to a lack of communication and care planning at the facility. Despite being assessed as at moderate to high risk for suicide, staff were unaware of the resident's condition and access to medications, leading to a self-harm incident involving an overdose and wrist cutting.
A resident with bipolar disorder physically assaulted another resident, resulting in injury and fear. Despite having a care plan to monitor and intervene in such behaviors, the DON was unaware of the interventions, leading to a failure in protecting the assaulted resident. Previous incidents involving the aggressive resident were reported but not addressed, highlighting a deficiency in implementing the facility's abuse and neglect policy.
A facility failed to notify a resident's responsible party about skin issues and a change of condition. The resident, with severe cognitive impairment, had multiple skin issues identified during an assessment. A nurse did not notify the responsible party due to not knowing who they were. Another nurse documented a change of condition but did not follow up after an unsuccessful call attempt to the responsible party. The DON acknowledged the oversight, noting the absence of a notification policy.
A resident with severe cognitive impairment, bacteremia, and diabetes did not receive consistent skin care and IV antibiotics as ordered by the physician. The facility's records showed multiple missed applications of topical treatments for skin conditions and missed doses of critical antibiotics. The Director of Nursing confirmed that licensed nurses were expected to follow physician orders and document medication administration, but the facility's practices did not align with its medication administration policy.
A facility failed to ensure timely signing of a skin evaluation form by an LN, resulting in an incomplete medical record for a resident. The LN conducted a skin assessment upon the resident's admission, identifying several skin conditions, but did not sign the evaluation forms until months later. Interviews revealed the LN was unsure of the delay, and the DON confirmed the expectation for timely documentation, though no specific policy was in place.
A resident's medical record inaccurately indicated that an LVN administered IV antibiotics, when in fact, an RN did so using the LVN's password due to a malfunctioning password. This led to incorrect documentation in the MAR, as the RN failed to report the issue to the DON.
Failure to Report Allegation of Physical Abuse to Authorities
Penalty
Summary
Facility staff failed to timely report an allegation of physical abuse involving one of three sampled residents, identified as Resident 1. Resident 1 had been admitted with diagnoses including depression and COPD, and an MDS dated 4/2/26 documented a BIMS score of 15, indicating intact cognition. On 4/14/26 at 6:48 P.M., the Department received a complaint from a hospital staff member stating that Resident 1, who had come from the facility, reported being physically assaulted by a staff member at the SNF. On 4/22/26 at 9:55 A.M., surveyors conducted an unannounced visit to investigate this abuse allegation. During an interview on 4/22/26 at 4:19 P.M., the DON stated that on 4/17/26 she received a report that Resident 1 had told hospital staff he was physically assaulted. The DON acknowledged that she did not take any action with this information and did not report the allegation to the Department. She further indicated that it was important to report allegations of abuse to keep residents safe and to start the investigation timely, which was not done in this case. A review of the facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated April 2021 showed that the facility was required to investigate and report any allegations within time frames required by federal requirements, which did not occur for Resident 1.
Unnecessary Antibiotic Use Without Proper UTI Assessment or Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs, specifically related to antibiotic use for suspected urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool and infection surveillance list as part of its infection prevention and antibiotic stewardship program. On one occasion, this resident had an Infection Screening Evaluation score of 50 with acute dysuria, and a urine culture showing Gram positive cocci with a colony count of 50,000–90,000, leading to a physician order for Macrobid for a UTI. However, there was no supporting documentation that staff monitored UTI symptoms or side effects during the antibiotic course, despite the expectation that such monitoring occur during antibiotic therapy. On a later occasion for the same resident, an Infection Screening Evaluation completed on a different date showed a score of zero, indicating no symptoms of infection. The prior urine culture still showed Gram positive cocci with a colony count of 50,000–90,000, yet the resident was prescribed Levofloxacin for a UTI and Methenamine Hippurate for infection prophylaxis. The Methenamine Hippurate order did not include a documented diagnosis that clearly supported infection prophylaxis and did not include a stop date. Again, there was no documentation of monitoring for UTI symptoms or side effects during the course of these antibiotics. The Infection Prevention (IP) nurse later acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order required clarification and a defined duration. Another resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and that confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting the antibiotic, and there was no documented monitoring of UTI symptoms or side effects during the antibiotic course. The DON and facility policy indicated that staff were expected to follow appropriate clinical criteria, including McGeer criteria, and to avoid premature diagnostic conclusions, but these expectations were not met in the cases reviewed, resulting in antibiotics being initiated and continued without adequate indication, evaluation, or monitoring. The facility’s written policy on urinary tract infection/bacteriuria stated that nurses should observe, document, and report signs and symptoms in detail and avoid premature diagnostic conclusions, and that physicians should carefully review persistent or recurrent UTIs before prescribing additional antibiotics, justifying any continuation or resumption of antibiotic treatment beyond an initial course. The DON stated that when a new antibiotic order is received, the IP nurse should complete the Infection Screening Evaluation and notify the physician if criteria for antibiotic therapy are not met, and that new onset nonspecific symptoms alone, such as change in mental status or decline in appetite, are not enough to diagnose a UTI. Despite these policies and stated expectations, the survey findings showed that antibiotics were ordered and administered without documented adherence to these criteria, without completion of the Infection Screening Evaluation in at least one case, and without documented monitoring of symptoms and side effects, constituting unnecessary drug use.
Failure to Implement Effective UTI Antibiotic Stewardship and Symptom Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective infection prevention and antibiotic stewardship process for three residents with suspected or documented urinary tract infections (UTIs). For one resident with quadriplegia, immunodeficiency, and a suprapubic catheter, the facility used an Infection Screening Evaluation tool as part of its surveillance program. On 1/12/26, this resident’s screening showed a score of 50 with acute dysuria, and a urine culture from 1/9/26 showed Gram Positive Cocci with a colony count of 50,000–90,000. The physician ordered Macrobid from 1/9/26 through 1/16/26 for UTI treatment, but there was no supporting documentation that nursing staff monitored UTI symptoms or potential side effects during the antibiotic course. For the same resident, an Infection Screening Evaluation completed on 2/11/26 showed a score of zero, indicating no symptoms of infection, yet the resident was prescribed Levofloxacin from 2/10/26 through 2/17/26 for UTI and Methenamine Hippurate for infection prophylaxis without a stop date. The Methenamine Hippurate order did not include a documented diagnosis supporting infection prophylaxis, and again there was no documentation of monitoring for UTI symptoms or side effects while the resident was on these antibiotics. The Infection Prevention (IP) nurse acknowledged that the resident should have been monitored for signs and symptoms of UTI during antibiotic therapy and that the prophylactic antibiotic order lacked a defined duration and clear diagnostic basis. A second resident with Parkinson’s disease and moderate cognitive deficits complained of dysuria on 2/2/26 and had a urinalysis on 2/3/26 showing many bacteria. The resident, who was incontinent and did not have a urinary catheter, was prescribed Cefuroxime Axetil for seven days beginning 2/4/26 for a suspected UTI. However, the facility did not complete an Infection Screening Evaluation prior to starting the antibiotic to determine if McGeer criteria for UTI were met. During the antibiotic course, only one progress note dated 2/10/26 documented monitoring of UTI symptoms, stating the resident continued on antibiotics for UTI with no complaint of bladder discomfort, and no consistent monitoring of UTI symptoms was documented. A third resident with diabetes mellitus and moderate cognitive deficits was prescribed Ciprofloxacin from 2/8/26 through 2/15/26 for a suspected UTI based on confusion and a urinalysis with a colony count greater than 100,000 E. coli. The IP nurse stated that, according to McGeer criteria, residents without an indwelling catheter must exhibit two or more clinical symptoms in addition to a positive culture to support a UTI diagnosis, and confusion alone did not meet the diagnostic criteria for initiating antibiotic therapy. For this resident, the Infection Screening Evaluation was not completed prior to starting antibiotics, and there was no documented monitoring of UTI symptoms while on treatment. Across all three residents, the facility’s documented practices did not align with its Antibiotic Stewardship policy, which required complete antibiotic orders including duration and the use of clinical criteria and evaluation tools before and during antibiotic therapy.
Failure to Protect PHI by Posting EBP Lists in Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ Protected Health Information (PHI) by posting detailed Enhanced Barrier Precautions (EBP) lists in multiple shower rooms. Surveyors observed that on the 2nd, 3rd, and 4th floors, documents titled "2nd Floor EBP," "3rd Floor EBP," and "4th Floor EBP" were posted on shower room mirrors at the entrances. These documents contained resident names, room numbers, and the reasons for EBP for a total of 59 residents out of 194. The lists were used to remind staff which residents required personal protective equipment (PPE) such as gowns, gloves, masks, and face shields during showers. During interviews conducted at the time of the observations, multiple CNAs confirmed that the posted lists were used as reminders for staff about which residents were on EBP and what PPE was needed when providing showers. CNA staff on each of the three floors acknowledged that the lists contained residents’ private information and that such information should not be posted in public areas where anyone entering the shower room could read it. One CNA indicated that they believed the Infection Preventionist (IP) had hung the lists. Additional interviews with licensed nurses, RNs, the Quality Assurance Nurse (QAN), the IP, and the Director of Nursing (DON) further established that facility staff understood that residents’ private information should not be posted in public areas and should be protected. The DON stated that PHI should not be posted in a public area like a shower room and emphasized that PHI should be kept in a secured area to prevent disclosure to the public. Review of facility policies on Residents’ Rights and Protected Health Information showed that unauthorized release, access, or disclosure of resident information is prohibited and that personnel are responsible for managing and protecting PHI, limiting its use or disclosure to the minimum necessary. Despite these policies, the facility allowed PHI to be posted openly in shower rooms, resulting in the cited deficiency.
Unaddressed Ceiling and Wall Leaks Created Non-Homelike Resident Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment by not identifying and repairing leaking ceilings and walls in multiple resident rooms on the fourth floor. During a facility tour on 1/2/26, the Director of Maintenance (DOM) reported that the only leak he had been informed of was in the third-floor dining room and that it had been addressed by resealing a sliding glass door. However, observations and resident interviews revealed that rooms 417, 421, and 425 had experienced significant water intrusion during recent rain, with visible water damage to ceilings and walls and reports of flooded bathrooms and floors. The DOM stated he was not aware of the damage in these areas. Resident 3, who had a history including right femur fracture, fall, atrial fibrillation, and chronic kidney disease and a BIMS score of 11 (moderate cognitive impairment), reported that her bathroom floor had been very wet the previous night and that staff had to place many towels to absorb the water. Observation of her bathroom showed water damage on the ceiling with wet spots and towels on the floor, and she stated that the flooding and water damage were not homelike. Resident 4, with diagnoses including neuropathy, rheumatoid arthritis, and fibromyalgia and a BIMS score of 12 (moderate cognitive impairment), similarly reported that her bathroom had flooded the previous night and that staff had placed many towels to soak up the water. Her bathroom showed water damage and bubbling paint on the ceiling, and she stated that the water on the floor was dangerous and not homelike. Resident 5, with acute kidney failure, rheumatoid arthritis, and depression and a BIMS score of 15 (intact cognition), reported that her roommate’s wall had leaked a lot the previous night and that staff had put down many towels to absorb the water; she stated that the leaking wall was not homelike and could have been dangerous if someone slipped. Resident 16, with a history of fall, COPD, and CHF and a BIMS score of 11 (moderate cognitive impairment), reported that there had been a lot of water on the bathroom floor the previous week, that staff had placed big towels from the wall to the toilet to the door, and that no one could use the bathroom; she stated that the leaking ceilings and flood were not homelike. Staff interviews (RNs and CNAs) consistently described their immediate response to leaks as moving residents if needed, placing towels to control water, and contacting maintenance by phone or Teams and documenting in a maintenance binder, and they all acknowledged that leaking ceilings, flooded bathrooms, and water-damaged walls were not homelike and could present slipping hazards. Review of the fourth-floor maintenance binder on 1/2/26 and 1/9/26 showed no entries documenting the leaks or repairs for rooms 417, 421, or 425, despite staff and resident reports of flooding and water damage. The DOM and a maintenance worker stated that staff were expected to report leaks via phone or Teams and to document them in the maintenance binder, and that repairs should also be documented there so that completion could be tracked. Both the DOM and the Administrator acknowledged that leaking ceilings and water-damaged walls were not homelike and that the facility should be aware of and immediately repair such issues. The facility’s “Homelike Environment” policy stated that residents are to be provided with a safe, clean, homelike environment, including a clean, sanitary, and orderly environment, which was not maintained in the affected rooms due to the unaddressed leaks and resulting water damage.
Failure to Identify and Address Resident Behavioral Disturbances
Penalty
Summary
The facility failed to identify and address a resident's behavioral disturbances, specifically incidents of hitting and yelling at staff and other residents. Observations, interviews, and record reviews revealed that the resident, who had diagnoses including late-onset Alzheimer's disease and cerebral infarction, exhibited behaviors such as wandering, entering other residents' rooms, yelling, and attempting to hit others with her cane. Despite these behaviors being observed and reported by staff, there was no care plan in place addressing these issues prior to a documented altercation. The Minimum Data Set (MDS) assessment completed for the resident did not reflect any behavioral symptoms, and the social service assistant responsible for the MDS did not interview staff or have knowledge of the resident's behaviors. Further review showed that behavior monitoring was only ordered for a short period after an altercation occurred, and there was no ongoing monitoring or comprehensive assessment of the resident's behavioral symptoms prior to the incidents. The facility's policy required staff to evaluate behavioral symptoms as part of the comprehensive assessment and to develop a care plan accordingly, but this was not done in this case. Interviews with staff confirmed that the resident's behaviors should have been identified and care planned to ensure appropriate care and safety.
Failure to Timely Administer Pain Medication Due to Staff Communication Breakdown
Penalty
Summary
A resident with diagnoses including right trochanteric bursitis, type 2 diabetes, and chronic pain syndrome was admitted to the facility and had physician orders for pain management, including Hydrocodone-acetaminophen for moderate pain and Oxycodone for severe pain. On a specific night, the resident reported experiencing severe pain around 2 A.M. and requested pain medication multiple times but did not receive any at that time. The electronic Medication Administration Record confirmed that no pain medication was administered during the period in question. Interviews with nursing staff revealed that the nurse assigned to the resident was on break and did not hand over the medication cart keys, preventing another nurse from accessing and administering the medication. Additionally, the nurse who was aware of the resident's pain request forgot to inform the assigned medication nurse upon their return. As a result, the resident's pain was not addressed in a timely manner, and the opportunity to provide pain relief was missed during the overnight hours.
Resident Elopement Due to Inadequate Supervision and Exit Monitoring
Penalty
Summary
A resident with a known history of independently ambulating throughout the facility and using the elevator was able to leave the building without staff awareness. The resident was last seen around lunchtime using the elevator, and staff later discovered the resident was missing after a facility-wide search. The resident did not inform staff, did not sign out, and left without a physician's order. The facility has three entrances/exits, with the front entrance/exit open from 8 A.M. to 8 P.M., and some residents are allowed in the lobby area near this entrance. The back entrance/exit was reported to be locked. Interviews with staff revealed that the resident was considered independent and frequently roamed the building. The receptionist stated that they would be informed by a licensed nurse if a resident required supervision. The facility experienced three elopements in the past six months, with two occurring in the same month as this incident. The elopement occurred on a weekend when staffing was lower, and no staff member witnessed the resident leaving the building.
Failure to Supervise Resident Smoking According to Assessment and Care Plan
Penalty
Summary
The facility failed to provide required supervision for a resident who smoked, as indicated by the resident's care plan and smoking assessment. The resident, who had a history of hemiplegia and hemiparesis affecting the left side of the body, as well as visual impairment and a history of falls, was assessed as needing supervision while smoking due to poor safety awareness. Despite these documented needs, the resident was allowed to smoke outside the facility premises without staff supervision, as confirmed by interviews with the resident, another resident, and the Activities Director. The facility did not have a designated smoking area or scheduled smoking times, and residents were left to find their own places to smoke outside the facility perimeter. Record review and staff interviews further revealed that the facility lacked a formal smoking program or process for supervising residents who smoke, and the current smoking policy did not address staff supervision for resident smoking safety. The Activities Director and QA nurse both acknowledged that supervision was not consistently provided, and that the facility was still in the process of developing a smoking program. The lack of supervision was contrary to the resident's care plan and assessment, which specifically required supervision to prevent smoking-related injuries.
Absence of Full-Time DON for Nursing Services Oversight
Penalty
Summary
The facility failed to ensure the presence of a full-time Director of Nursing (DON) to manage and oversee nursing services, as required by policy. During a complaint investigation, the Administrator confirmed that there was no DON in place and that the Quality Assurance (QA) nurse would provide assistance during the investigation. Multiple staff interviews, including with a licensed nurse and the Director of Staff Development (DSD), confirmed that the facility did not have a full-time DON at the time. The QA nurse, who was the former DON, stated that the facility was still in the process of hiring a new DON and that a consultant was available but not present during the initial investigation. A review of the facility's policy indicated that the DON is required to be employed full-time (40 hours per week) and is responsible for developing and updating nursing service objectives and overseeing standards of nursing practice. The absence of a full-time DON meant that there was no designated individual to oversee clinical care, care planning, and coordination for the safety and well-being of the facility's 188 residents. This lack of leadership and oversight was directly observed and confirmed through staff interviews and record review.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
A resident with a history of unsteadiness, substance abuse, and smoking was able to leave the facility unsupervised late at night. The resident was not located by staff for approximately 14 hours and was later found with injuries, including abrasions to the face and a swollen, scraped knee, after falling from a wheelchair while away from the facility. The resident reported being lost and unable to find the way back, and required medical evaluation and wound care upon return. The facility's records indicated that the resident was at moderate to high risk for falls, but the fall risk assessments did not account for the antihypertensive medication the resident had been taking, which could have increased the risk. The care plans for substance abuse and smoking included interventions such as assessing the risk of leaving the facility without notification and providing supervision while smoking. However, these interventions were not effectively implemented, as the resident was not accompanied outside and was able to leave the premises without staff awareness. Staff interviews revealed that the licensed nurse on duty was aware the resident had left but did not report the incident until shift change, following advice from a senior nurse to wait until morning to notify the DON and police. There was no immediate search or notification to security or supervisors during the night, and the facility was unable to provide a policy ensuring supervision of residents while smoking. These actions and inactions resulted in the resident's elopement and subsequent injury.
Failure to Follow Menu and Serve Correct Portion Sizes for Modified Diets
Penalty
Summary
The facility failed to follow the prepared menu and serve the correct portion sizes for residents on mechanical soft, ground meat, and pureed diets. Specifically, for a planned lunch meal, staff served mechanical soft BBQ chicken and pureed BBQ chicken using a #12 scoop (2.67 oz) instead of the required #10 scoop (3.2 oz) for mechanical soft and #8 scoop (4 oz) for pureed, as indicated on the facility's Spring Cycle Menus. This deviation affected 30 residents on mechanical soft or ground meat diets and 21 residents on pureed diets. The facility's policy required that menus be followed, and any deviations be recorded and archived, but this was not done in these instances. Interviews with dietary staff, the Dietary Director, the Registered Dietitian, the DON, and the Administrator confirmed that the expectation was to follow the menu and serve the correct portion sizes to ensure residents received adequate nutrition and the nutrients ordered by physicians. The staff member responsible for serving the meals acknowledged using the incorrect scoop sizes and confirmed the discrepancy after reviewing the menu. The deficiency was identified through observation, interview, and review of facility documents and policies.
Failure to Provide Dignified Dining Experience for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with amyotrophic lateral sclerosis (ALS), dysphagia, contractures, and muscle wasting, who was dependent on staff for eating, was not provided a dignified dining experience. The resident's meal tray was repeatedly delivered to their room and placed out of reach, leaving the resident unable to access their food. On multiple occasions, the resident had to wait for extended periods before being fed, while observing their roommate being fed first. The resident expressed dissatisfaction with having to wait and watching their meal sit out of reach. Staff interviews confirmed that the resident was typically fed by a restorative nursing assistant (RNA) after meal trays were delivered, but there was inconsistency in the timing of feeding. The facility's policies required that residents receive assistance with meals in a manner that meets their individual needs and promotes dignity. However, observations and staff statements revealed that the resident was not fed promptly after meal delivery, and both the Director of Nursing and Administrator acknowledged that residents should be fed at the same time for a dignified experience, which was not occurring in this case.
Inaccurate MDS Assessments for Discharge Destination and PASRR Status
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For one resident with a history of multiple rib fractures, falls, and dementia, the discharge MDS incorrectly documented the discharge destination as a short-term general hospital, when in fact the resident was discharged home with family and home health services. The error was attributed to the Social Services Director (SSD) confusing the resident's discharge location, despite progress notes and care plans indicating the correct destination. The MDS Coordinator and SSD both confirmed the discrepancy during interviews, and the Administrator and Director of Nursing (DON) acknowledged the expectation for accuracy in MDS documentation. For another resident with a history of major depressive disorder, psychotic disorder, bipolar disorder, and generalized anxiety disorder, the annual MDS failed to accurately reflect the resident's Preadmission Screening and Resident Review (PASRR) Level II status, despite documentation from the state confirming its completion. The MDS Coordinator stated that the staff member responsible for the PASRR section did not ensure the information was accurate, and the SSD was unaware of the resident's PASRR Level II status. Both the SSD and DON confirmed the inaccuracy in the MDS coding during interviews.
Failure to Follow Care Plan for Meal Supervision of Resident with Dysphagia
Penalty
Summary
The facility failed to follow the care plan for a resident with a history of hemiplegia, hemiparesis following a stroke, dysphagia, and functional quadriplegia. The resident had severe cognitive impairment and required supervision or touching assistance with eating, as documented in the Minimum Data Set and care plan. The care plan specifically indicated the need for supervision during meals due to moderate oropharyngeal dysphagia, which impeded safe swallowing. Facility policy also required that residents receive meal assistance according to their individual needs. Multiple observations revealed that the resident was left unsupervised during meal times, both at breakfast and lunch, despite the care plan's requirements. Staff interviews indicated a lack of awareness or adherence to the supervision requirement, with one CNA stating he was unaware of the need for supervision and another leaving the resident unsupervised to answer a call light. The Speech Language Pathologist confirmed the necessity for supervision throughout the entire meal to ensure safe eating practices. The administrator acknowledged that clinical recommendations must be followed, and failure to do so could have led to adverse outcomes.
Failure to Provide Required Meal Supervision for Resident with Dysphagia
Penalty
Summary
Staff failed to follow a physician's order requiring one-on-one supervision during meals for a resident with a history of hemiplegia, hemiparesis, dysphagia, and functional quadriplegia. The resident, who had severe cognitive impairment and required supervision or assistance with eating, was observed consuming meals alone in their room on multiple occasions. Despite clear documentation in the resident's care plan, Kardex, and tray tickets specifying the need for supervision, staff did not remain with the resident during meal times. Interviews with CNAs revealed a lack of awareness or adherence to the supervision requirement, with one CNA stating they were unaware of the need for supervision and another leaving the resident unsupervised to answer a call light. The Speech Language Pathologist confirmed the necessity for supervision throughout the entire meal to ensure safe eating practices. Facility leadership acknowledged that clinical recommendations and orders must be followed, and failure to do so could have led to adverse outcomes.
Failure to Provide Timely Podiatry Services for Resident with Foot Pain
Penalty
Summary
The facility failed to provide timely podiatry services for a resident who required foot care due to mycotic toenails and an ingrown toenail. The resident, who had a history of muscle weakness and back pain and demonstrated moderate cognitive impairment, was admitted with an order for podiatry evaluation and treatment every 90 days and as needed. Despite a referral to podiatry shortly after admission and repeated complaints of pain from the resident, the podiatrist did not see the resident in a timely manner. Observations revealed the resident's toenail was significantly overgrown and thick, and the resident reported ongoing pain that was not relieved by medication. Staff interviews confirmed that the resident had been requesting podiatry care and experiencing pain for at least one and a half weeks. The facility's policy required prompt assistance in arranging podiatry appointments, including urgent visits if needed. However, the resident remained on the waiting list for podiatry services, and the podiatrist had not responded to the urgent need prior to the scheduled visit. The delay in providing podiatry care resulted in the resident continuing to experience pain and discomfort related to their foot condition.
Failure to Monitor Resident with Suicidal Ideation
Penalty
Summary
The facility failed to protect a resident with suicidal ideation from harm due to inadequate supervision and communication among staff. The resident, who had a history of suicidal tendencies and was at risk of self-harm, was not properly monitored despite multiple recommendations from nurse practitioners. These recommendations included close monitoring and ensuring the resident did not have access to medications or potential weapons. However, the staff did not implement these measures, leading to the resident's ability to harm herself. The resident, who had been diagnosed with Major Depressive Disorder and had a history of overdosing on medications, was found attempting self-harm by cutting her wrist with a butter knife and ingesting a large quantity of metformin pills. Despite the nurse practitioners' assessments indicating the resident was at moderate to high risk for suicide, the facility staff were unaware of these assessments and did not communicate the need for close monitoring. This lack of communication and failure to follow through on the recommended safety measures allowed the resident to access medications and a butter knife, which she used in her suicide attempt. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's suicidal ideation and the necessary monitoring protocols. The Director of Nursing was not informed of the nurse practitioners' recommendations, and the staff did not conduct thorough checks of the resident's belongings, which allowed her to retain medications from home. The facility's policies on resident safety and comprehensive care planning were not effectively implemented, contributing to the resident's opportunity to harm herself.
Failure to Develop Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to communicate and develop a baseline care plan for a resident with suicidal ideation, leading to a serious incident. The resident, who was readmitted to the facility with hemiplegia and hemiparesis, had a history of major depressive disorder and was assessed multiple times by nurse practitioners for suicidal risk. Despite being identified as at moderate to high risk for suicide, with recommendations for close monitoring, the facility staff did not implement a care plan or communicate the resident's needs effectively. On several occasions, nurse practitioners documented the resident's suicidal ideation and the need for close monitoring, but this information was not communicated to the facility staff. Interviews with various staff members, including licensed nurses and certified nursing assistants, revealed a lack of awareness regarding the resident's suicidal ideation and the need for monitoring. The staff were unaware of the resident's access to medications and a butter knife, which the resident used in a self-harm attempt. The incident culminated in the resident attempting self-harm by ingesting a large number of metformin pills and cutting her wrist with a butter knife. The facility's failure to develop a care plan and ensure communication among staff members about the resident's suicidal ideation and risk factors contributed to this critical event. The Director of Nursing acknowledged that the message from the nurse practitioner regarding the resident's risk was not communicated, and a care plan was not developed to ensure the resident's safety.
Failure to Prevent Resident-to-Resident Assault
Penalty
Summary
The facility failed to prevent an incident of physical assault between two residents, resulting in a deficiency. Resident 1, who has a diagnosis of bipolar disorder, physically assaulted Resident 2 by striking him on the left cheek. This incident was observed by a staff member and reported to the State Agency. Despite having a care plan in place to monitor and intervene in episodes of bipolar disorder, the Director of Nursing was unaware of the interventions listed in Resident 1's care plan. This lack of awareness and intervention contributed to the failure to protect Resident 2 from harm. Resident 2, who has a diagnosis of displaced fractures of the 6th and 7th vertebrae, expressed feeling unsafe following the assault and reported previous incidents involving Resident 1 that were not addressed by the staff. The facility's policy on abuse and neglect, which includes identifying risk factors for abuse, was not effectively implemented, as evidenced by the repeated incidents and the lack of appropriate staff response to Resident 2's concerns. The failure to act on these risk factors and previous reports of problematic behavior led to the deficiency in protecting residents from abuse.
Failure to Notify Responsible Party of Resident's Condition
Penalty
Summary
The facility failed to ensure timely notification of a resident's responsible party regarding the resident's skin issues and change of condition. The resident, who was admitted with diagnoses including bacteremia and diabetes, had severe cognitive impairment as indicated by a Minimum Data Set score of six out of 15. During a skin assessment conducted by a licensed nurse, multiple skin issues were identified, including abrasions and rashes. However, the nurse did not notify the responsible party because she was unaware of who the responsible party was. Additionally, another licensed nurse documented a change of condition for the resident but failed to successfully contact the responsible party. The nurse noted an attempt to call the responsible party, but there was no documentation of a follow-up call to inform them of the resident's new diagnosis and medication orders. The Director of Nursing acknowledged that the responsible party should have been informed of the resident's health status, but the facility lacked a policy regarding responsible party notification.
Failure to Administer Prescribed Treatments and Medications
Penalty
Summary
The facility failed to consistently provide skin care and administer intravenous (IV) antibiotics as ordered by the physician for a resident with severe cognitive impairment, bacteremia, and diabetes. The resident's treatment administration record (TAR) showed multiple instances where prescribed topical treatments for various skin conditions were not applied. These included Bacitracin ointment for a cut on the right eyebrow, Vitamins A & D ointment for abrasions on the left elbow and forearm, Hydrocortisone cream for rashes on the abdomen, chest, and back, and Miconazole nitrate powder for moisture-associated skin damage in the groin and perianal areas. The omissions occurred on several dates in January 2022, indicating a pattern of non-compliance with physician orders. Additionally, the facility failed to administer IV antibiotics as prescribed for the resident's bacteremia. The medication administration record (MAR) revealed missed doses of Ampicillin Sodium and Ceftriaxone Sodium on multiple occasions in January and February 2022. These antibiotics were crucial for treating the resident's bloodstream infection, and the missed doses could have compromised the effectiveness of the treatment. The Director of Nursing (DON) confirmed that licensed nurses (LNs) were expected to follow physician orders and document medication administration in the electronic MAR. The facility's policy on administering medication, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed. The policy also requires that topical medications be recorded on the resident's treatment record and that the individual administering the medication initials the MAR after each administration. The repeated failures to adhere to these policies and physician orders highlight significant deficiencies in the facility's medication administration practices.
Failure to Timely Sign Skin Evaluation Forms
Penalty
Summary
The facility failed to ensure that a Licensed Nurse (LN) signed a resident's initial skin evaluation in a timely manner, which resulted in an incomplete medical record for the resident. The deficiency was identified during an unannounced onsite visit related to complaints about quality of care. The resident in question was admitted to the facility and later discharged in early 2022. During the admission, the LN conducted a skin assessment and identified several skin conditions, including abrasions and rashes. However, the LN did not sign the evaluation forms until several months later, in April 2022, which was not in accordance with the expected practice of signing forms upon completion of assessments. Interviews conducted with the LN and the Director of Nursing (DON) revealed that the LN was unsure why the forms were not signed at the time of the assessment, despite having documented the skin issues and taken photographs. The DON confirmed that the facility expected timely completion of medical records but did not have a specific policy in place regarding this. This lack of timely documentation led to the deficiency noted in the resident's medical record.
Inaccurate Medical Record Documentation Due to Password Sharing
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident who was admitted with osteomyelitis of the backbone. The deficiency occurred when the Medication Administration Record (MAR) for the resident indicated that an LVN had administered intravenous (IV) antibiotics, which was not in accordance with accepted professional standards. Upon review, it was found that the LVN did not administer the IV medication, and the signatures on the MAR were incorrect. The error was traced back to an RN who, due to a malfunctioning password, used the LVN's password to document the administration of the IV antibiotics. The RN admitted to administering the medication but failed to report the password issue to the Director of Nursing (DON) to obtain a new password. This action led to inaccurate documentation in the resident's medical record, as the MAR is a legal document that requires precise and truthful entries.
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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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