Brighton Place San Diego
Inspection history, citations, penalties and survey trends for this long-term care facility in San Diego, California.
- Location
- 1350 N. Euclid Avenue, San Diego, California 92105
- CMS Provider Number
- 055795
- Inspections on file
- 47
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Brighton Place San Diego during CMS and state inspections, most recent first.
A resident with anxiety disorder who required assistance with personal care alleged that a CNA attempted to slap her during a bed bath, causing a broken imitation fingernail when she raised her hand to protect herself. The resident reported the incident to an LN the same night and later discussed it with an SSA, who relayed the allegation to the ADM. Documentation reflected the resident’s agitation and verbal threats to report the CNA during care, and the ADM acknowledged being informed of the allegation by both the LN and SSA. Despite a facility policy requiring the ADM or designee to notify CDPH within two hours of any abuse allegation without serious bodily injury, the SOC 341 report was not submitted until two days after the incident, well beyond the required reporting timeframe.
The facility did not report a COVID-19 outbreak to CDPH L&C as required, despite multiple residents and a CNA testing positive. Additionally, a resident's family member was observed assisting with care in a contact precautions room without wearing PPE, contrary to facility policy. Staff confirmed the visitor had not previously reported any PPE allergies, and the facility's infection control policy required PPE use for all visitors in such situations.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
Two residents with complex medical needs were discharged without documented, person-centered discharge care plans. Interviews with nursing staff and the DON confirmed that such plans are required upon admission to ensure coordinated and goal-oriented discharges, but records showed no evidence of their development or implementation, contrary to facility policy.
Two residents were discharged without proper discharge care plans, as required by facility policy. One had a history of stroke and the other had dementia. Staff interviews confirmed that the discharge care plans were either not updated or not created, despite the responsibility lying with social services and the DON.
A resident's responsible party, seeking access to medical records for a resident with dementia, experienced a delay when the request was not communicated promptly to the Medical Records Director. Although the Admissions Coordinator and DON were aware of the request, the records were not provided within the facility's required two-business-day timeframe due to internal communication lapses.
The facility failed to maintain sanitary conditions in resident bathrooms, as reported by multiple residents and confirmed through observations. Bathrooms had feces on walls and around toilets, remaining uncleaned for extended periods, contrary to facility policies.
The facility did not ensure food temperatures were checked before serving on two days, as the Food Temperature Log was blank for breakfast and lunch. The Dietary Supervisor noted that two staff members were responsible for recording the temperatures but failed to do so, with one staff member unable to recall the reason. This failure increased the risk of food-borne illness.
The facility failed to ensure dietary staff were trained to properly test kitchen sanitizer, increasing the risk of food-borne illness. Cook 1 incorrectly tested the sanitizer, and Dietary Aide 2 was unaware of the procedure, lacking completed initial competencies. The Dietary Supervisor confirmed the need for all staff to know the procedure, and a review showed no evidence of training for Dietary Aide 2.
The facility failed to ensure proper food storage and handling, as expired food was not discarded, opened food items were unlabeled, and a dietary aide did not cover facial hair, increasing the risk of food-borne illness.
The facility failed to follow infection control policies, leading to potential cross-contamination and infection spread. A resident's oxygen supplies were improperly stored, and the facility lacked an infection surveillance tracker, hindering effective contact tracing during a COVID-19 outbreak. Additionally, staff and visitor screenings were inadequate, compromising infection control efforts.
A facility was found to have two rooms occupied by six residents each, exceeding the regulatory limit of four residents per room. The Administrator confirmed that the facility did not have any current waivers to allow for this increased capacity, with the last waiver being from 2012. This situation could potentially lead to overcrowding and affect the quality of care.
The facility failed to notify the LTC Ombudsman about the transfer of two residents to an acute care hospital, violating regulations. One resident was transferred due to an abnormal heart rate, and another for low hemoglobin levels. Staff were unaware of the requirement to notify the Ombudsman, leading to a deficiency in following the facility's policy on transfer and discharge notifications.
A resident with Alzheimer's disease eloped from the facility due to a failure to conduct a comprehensive elopement assessment. Despite known risks of wandering, the facility's elopement risk binder was outdated, and procedures were not effectively implemented, allowing the resident to leave the premises and be found at a nearby church.
The facility failed to accurately code the MDS for three residents, resulting in the transmission of incorrect health status information. A resident's fall was not documented, another resident's fall was omitted from the MDS, and a third resident's resolved pneumonia was inaccurately listed as active. The MDSN and DON acknowledged these oversights, highlighting the importance of accurate MDS coding for care planning.
A resident with psychosis and depression was admitted to a facility with an inaccurate PASRR screening that failed to reflect their mental health needs and medication. The MDSN and DON acknowledged the error, which was contrary to the facility's policy requiring accurate PASRR updates.
The facility failed to implement person-centered care plans for residents, leading to deficiencies in care. A resident with chronic kidney disease was served inappropriate meals, another resident on hospice lacked a hospice care plan, and a resident with Alzheimer's had inadequate elopement prevention measures. These issues highlight gaps in the facility's care planning process.
A resident with COPD was at risk of developing pressure injuries due to an improperly set low air loss mattress. The mattress was configured for a weight of 400 pounds, while the resident weighed 233.4 pounds. Staff interviews confirmed the incorrect setting could lead to pressure injuries, as the mattress would be too firm. The facility failed to adjust the mattress according to the resident's weight, as required by the mattress manual.
A resident with Chronic Kidney Disease Stage 4 was not provided meals according to his dietary preferences and needs, as the facility failed to follow the meal tray card instructions. Despite having a dietary evaluation indicating specific dislikes and restrictions, the resident was served inappropriate foods, such as oranges and potatoes. The dietary staff and Licensed Nurse acknowledged the oversight, and the Director of Nursing emphasized the importance of honoring meal preferences to prevent complications like weight loss.
A resident with cognitive deficits and limited hand use received a meal not prepared in the required chopped form, despite the meal ticket indicating so. Staff interviews revealed a failure in the meal verification process, as acknowledged by the DON, which did not align with the facility's policy to provide meals consistent with residents' needs and physician's orders.
The facility failed to follow its smoking policy for two residents, leading to a deficiency in managing smoking and tobacco use. One resident with diabetes mellitus did not have quarterly smoking assessments completed, missing two assessments. Another resident with severe cognitive deficits also missed a quarterly assessment. The facility's policy required assessments upon admission, quarterly, annually, and upon any change in condition, which was not adhered to, potentially compromising resident safety.
A facility failed to monitor and document urine output for a resident with a urinary catheter, contrary to its policy. The resident, admitted with a dysfunctional bladder, had no urine output measurements recorded, as confirmed by a CNA who stated they were not instructed to do so. Interviews with an LN and the DON revealed that the facility's policy required such monitoring, but it was not followed, leading to a lack of documentation in the resident's clinical record.
A resident who had a liver transplant did not receive their prescribed anti-rejection medication, tacrolimus, as ordered. The MAR showed missed doses due to the medication not being on hand or pending delivery, with some instances lacking documentation. Interviews confirmed the facility's failure to ensure the medication was available, despite the pharmacy supplying it, increasing the risk of organ rejection.
A resident with a colostomy did not receive proper care due to the facility's failure to develop a baseline care plan, obtain a physician order, and document treatments in the TAR. The Treatment Nurse changed the colostomy bag daily without recording these actions, and the Director of Nursing confirmed the lack of necessary documentation and planning.
A resident with the capacity to make medical decisions eloped from the facility after going out on pass with a family member. The facility failed to document the resident's departure and return, and the out on pass logbook was incomplete. An LPN did not clarify the duration of the out on pass order with the physician, and the resident's condition was not assessed upon return. The facility's policy required a physician's order and documentation of the resident's status before and after the pass, which were not followed.
The facility failed to conduct reference checks prior to hiring a CNA, which had the potential to increase the risk of abuse for residents. A resident reported an incident of physical abuse involving the CNA, who was subsequently suspended. A review of the CNA's personnel file revealed that no reference checks were conducted prior to hire, contrary to the facility's policy.
The facility failed to provide consistent dialysis access care and complete dialysis communication forms for three residents. This included not removing dialysis dressings within the required 4-6 hours and missing pre and post-dialysis assessments, leading to potential complications.
Failure to Timely Report Alleged Abuse to CDPH
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident 1 to the California Department of Public Health (CDPH) within two hours of the initial allegation. Resident 1, who had an anxiety disorder and required assistance with personal care, reported that during an evening bed bath on 3/4/26, a CNA attempted to slap her when she objected to how her gluteal area was being cleaned. Resident 1 stated she raised her hand to protect her face and her imitation fingernail on the right pinky broke. She reported the incident that night to a licensed nurse at about 10 P.M., and the following day discussed the incident with the Social Services Assistant (SSA). The SSA overheard Resident 1 describing that the CNA was not following her instructions on how to clean her, and that when Resident 1 raised her hand, the CNA hit her and broke her nail. The Behavior Note by Licensed Nurse 1 on 3/4/26 documented Resident 1 making threatening verbal statements toward a CNA during care, speaking in a raised voice, appearing agitated, and stating, "You are not doing the right thing and I will report you," with the supervisor notified. The Administrator (ADM) acknowledged being informed of the incident by the licensed nurse on the night of 3/4/26 and again by the SSA on 3/5/26 at about 4 P.M., but did not report the alleged abuse to CDPH within the required two-hour timeframe. The SOC 341 report was not sent until 3/6/26 at 3:59 P.M., despite the facility’s abuse-reporting policy stating that the Administrator or designee will notify CDPH by telephone within two hours of an allegation of abuse with no serious bodily injury. The ADM stated that the expectation was to report any alleged abuse to CDPH within two hours of the allegation being made and recognized the importance of this requirement.
Failure to Report COVID-19 Outbreak and Ensure Visitor PPE Compliance
Penalty
Summary
The facility failed to implement required infection control practices in two key areas. First, the facility did not report a COVID-19 outbreak to the California Department of Public Health Licensing and Certification (CDPH L&C) as required by their own policy, despite having multiple residents and a staff member test positive for COVID-19 over a specified period. The Director of Nursing (DON) believed the Infection Preventionist had reported the outbreak, but did not verify this, and the Administrator later confirmed the outbreak was only reported to the local county, not to CDPH L&C. The facility's policy clearly stated that outbreaks meeting certain criteria must be reported to CDPH L&C. Second, the facility did not ensure that a resident's family member was educated on and compliant with infection control practices, specifically the use of personal protective equipment (PPE) while assisting a resident on contact precautions. During an observation, the family member was present in the resident's room and assisting with meals without wearing PPE, despite signage and facility policy requiring its use. The family member stated she was allergic to the gown and had not previously reported this issue. Staff confirmed that visitors were expected to wear PPE to prevent the spread of infection, and the facility's policy required donning gowns and gloves upon entry to rooms under contact precautions.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Person-Centered Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered discharge care plans for two residents during their stay, as identified through interviews and record reviews. One resident, admitted with Alzheimer's disease, was discharged to another facility for supervised care in a secured unit, but there was no documented evidence of a discharge care plan being created or followed. Similarly, another resident with encephalopathy was discharged to a board and care facility for a lower level of care, yet no discharge care plan was documented in the clinical record. Interviews with nursing staff and the Director of Nursing confirmed that discharge care plans are expected to be developed upon admission to ensure staff are aware of residents' discharge wishes and to facilitate coordinated, goal-oriented discharges. The absence of these care plans meant that staff were not informed of the residents' goals or wishes regarding discharge, and there was no organized or collaborative approach to preparing for their transitions. Facility policy requires comprehensive, person-centered, interdisciplinary care planning, but this was not followed in these cases.
Failure to Develop and Update Discharge Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that discharge care plans were developed and updated for two residents who were discharged from the facility. One resident, admitted with a history of stroke, was discharged without an updated discharge care plan. Another resident, admitted with dementia, was discharged without any evidence of a discharge care plan being developed. These deficiencies were identified through clinical record reviews and staff interviews. Interviews with the Social Service Director and Social Services Assistant confirmed that they were responsible for developing and updating discharge care plans but did not do so for these residents. The Director of Nursing also acknowledged that discharge care plans should have been developed to meet the residents' needs. The facility's policy requires social services staff to prepare discharge summaries and post-discharge plans of care in coordination with the interdisciplinary team, which was not followed in these cases.
Delay in Providing Resident Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records within two business days of the request, as required by its own policy. The responsible party for a resident with dementia requested copies of the resident's medical records by emailing the Admissions Coordinator, who then forwarded the request to the DON. The DON acknowledged receiving the request and speaking with the responsible party on the same day. However, the Medical Records Director was not informed of the request until eight business days later, at which point the records were provided. The delay in communication between staff members resulted in the responsible party not being able to review the resident's records in a timely manner. The facility's policy clearly states that copies of medical records should be provided within two working days after receiving a written request, but this was not followed due to the breakdown in internal notification procedures.
Unsanitary Bathroom Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain resident bathrooms in a sanitary condition, as observed in four of the 16 sampled bathrooms. Resident 144 reported that their bathroom had feces on the walls and at the base of the toilet, which had not been cleaned since their admission 48 days prior. Similarly, Resident 56 described their bathroom as dirty, with feces around the toilet for more than a week. Observations confirmed the presence of brown material at the base of the toilet and streaks of brown liquid on the walls and back of the toilet. Further observations revealed that another bathroom had brown material at the base of the toilet. Resident 60 expressed concerns about the cleanliness of their bathroom, and Resident 55 also noted that their bathroom was not clean enough. A subsequent observation with the Housekeeping Supervisor confirmed that the brown spots remained uncleaned three days after the initial observation. The facility's policies on maintaining a clean and homelike environment were not adhered to, as the bathrooms were not cleaned thoroughly with disinfectants as required.
Failure to Record Food Temperatures
Penalty
Summary
The facility failed to ensure that food temperatures were checked before serving to residents on two sampled days, the 10th and 11th of January 2025. This oversight was identified during a record review of the Food Temperature Log, which was found to be blank for breakfast and lunch on these days. During an interview, the Dietary Supervisor indicated that two staff members were responsible for recording the temperatures on these days but failed to do so. One of the staff members, when interviewed, could not recall why the log was not filled out, suggesting it may have been forgotten. The facility's policy requires that food temperatures be recorded at the beginning of the tray line process, but this procedure was not followed, placing residents at an increased risk of food-borne illness.
Inadequate Training of Dietary Staff on Sanitizer Testing
Penalty
Summary
The facility failed to ensure that dietary staff were adequately trained to test the strength of kitchen sanitizer, which increased the risk of food-borne illness. During an observation, Cook 1 demonstrated improper testing of the quaternary sanitizer by holding the test strip in the liquid for only four seconds, despite stating that it should be held for ten seconds. The container for the test strips clearly instructed to immerse the strip for ten seconds, indicating a lack of adherence to proper procedures. Additionally, Dietary Aide 2 admitted to not knowing how to test the sanitizer and had not completed his initial competencies, which should have been done within 90 days of his hiring. The Dietary Supervisor confirmed that all kitchen staff should know how to test the sanitizer and subsequently instructed Dietary Aide 2 on the correct procedure. A review of Dietary Aide 2's employee file revealed no evidence of orientation or training specific to his role, highlighting a gap in the facility's training and competency verification process.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, which increased the risk of food-borne illness for residents. During an inspection, it was observed that a container of dill pickle relish in the walk-in refrigerator was past its use-by date and had not been discarded. Both a staff member and the Dietary Supervisor acknowledged that the expired relish should have been thrown out. Additionally, the facility's policy on food storage and handling lacked specific guidance on handling pickled foods or general guidance on use-by dates. Further observations revealed that several food items in the walk-in refrigerator were opened but not labeled with use-by dates, including bags of shredded cheese and lettuce, and a container of what appeared to be applesauce. The staff member noted that these items should have been labeled and stored in reusable containers, but there were no containers available. The facility's policy required all opened food to be labeled with the date they were opened. Additionally, a dietary aide was observed preparing meals without covering his facial hair, contrary to the facility's infection control policy, which required all dietary staff to wear beard nets if they had facial hair.
Infection Control Deficiencies in Oxygen Storage and COVID-19 Management
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures, leading to potential cross-contamination and infection spread. Resident 72's oxygen supplies were improperly stored, with unlabeled tubing left on the floor and the concentrator placed on the roommate's side of the room. This improper storage was observed multiple times, and staff confirmed that such practices could lead to confusion and cross-contamination, as the supplies were not clearly identified or stored in a sanitary manner. Additionally, the facility lacked an infection surveillance tracker, which hindered effective contact tracing during a COVID-19 outbreak. The Infection Preventionist confirmed that no surveillance data was available for 2024 and January 2025, and contact tracing was not conducted after the first COVID-19 case was identified. This oversight was critical, as it prevented the facility from identifying and isolating potential cases promptly, thereby increasing the risk of further transmission among residents and staff. Furthermore, the facility did not properly screen staff and visitors during the COVID-19 outbreak. Screening for staff began late, and visitor logs were incomplete, with missing information on symptoms and dates. This lack of thorough screening compromised the facility's ability to control the spread of infection, as individuals who might have been symptomatic or exposed were not adequately monitored or restricted from entering the facility.
Overcrowding in Resident Rooms
Penalty
Summary
The facility failed to comply with regulations limiting the number of residents per room, as observed during a tour on January 12, 2025. Two rooms were found to be occupied by six residents each, exceeding the maximum allowed capacity of four residents per room. During interviews and record reviews with the Administrator, it was revealed that the facility's Client Accommodations Analysis incorrectly indicated a capacity for six residents in these rooms. The Administrator acknowledged that the facility did not possess any current waivers to exceed the room capacity limit, with the last waiver dating back to 2012. This discrepancy could potentially lead to overcrowding and compromise the quality of care for the residents in these rooms.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman about the transfer of two residents to an acute care hospital, which is a requirement for ensuring residents' rights to appeal and receive advocacy. Resident 6, who had a history of cerebrovascular accident, was transferred due to an abnormal heart rate. The Social Services Director stated that nurses were responsible for notifying the Ombudsman for hospital transfers, but the Licensed Nurse involved was unaware of this requirement and only notified the medical doctor and family members. Similarly, Resident 72, with a history of cerebral infarction, was transferred to an acute hospital for low hemoglobin levels. The Licensed Nurse responsible for this transfer also did not notify the Ombudsman, as they were not aware of the requirement. The Medical Records Director mentioned that in her previous role, she was responsible for sending such notifications but had not been instructed to do so at the current facility. Interviews with the Director of Nursing revealed that it was expected that the Ombudsman be notified for hospital transfers, as they serve as patient advocates. However, the facility's policy and procedure on transfer and discharge notifications were not followed, leading to the deficiency. The policy required that the Ombudsman be notified as soon as practicable in cases of urgent medical needs requiring immediate transfer.
Failure to Conduct Comprehensive Elopement Assessment
Penalty
Summary
The facility failed to complete a comprehensive elopement assessment for a resident diagnosed with Alzheimer's disease, leading to the resident's elopement. The resident, who had a history of forgetfulness and wandering, was admitted on 12/27/24. Despite the known risks, the facility did not update the elopement and wander risk binder since June, and the resident was able to leave the facility on 1/2/25, setting off an alarm and climbing over a fence. The resident was found at a nearby church and returned to the facility. Interviews with staff revealed that the facility had procedures for assessing elopement risks and notifying relevant parties if a resident eloped, but these procedures were not effectively implemented. The Licensed Vocational Nurse mentioned that the binder for elopement and wander risk residents was outdated, and the Director of Nursing stated that assessments were conducted on admission, but there was no indication that a wander guard was implemented for this resident. The lack of timely and comprehensive assessment and updating of risk information contributed to the resident's ability to elope.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to the transmission of inaccurate health status information to the federal database. Resident 72 experienced an unwitnessed fall while attempting to self-toilet, which was not accurately captured in the MDS. The MDS Nurse (MDSN) acknowledged the oversight during a joint record review and interview, noting that the fall should have been documented in the MDS dated after the incident. The Director of Nursing (DON) emphasized the importance of accurate MDS coding for care coordination and planning. Resident 29, who was admitted with a degenerative disease of the nervous system, was found on the floor in their room, but this fall was not reflected in the subsequent MDS assessment. The MDSN admitted that the MDS assessment completed after the fall did not include this incident, which should have been documented to ensure accurate patient care guidance. The DON reiterated the necessity of updating the MDS to reflect such incidents for proper care planning. Resident 23's MDS inaccurately listed pneumonia as an active diagnosis despite the condition having resolved. The MDSN confirmed that pneumonia was diagnosed in December of the previous year and should not have been documented in subsequent MDS assessments. The facility's policy on the RAI process and diagnosis list emphasizes the need for accurate coding and documentation of resolved diagnoses, which was not adhered to in this case.
Inaccurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening Resident Review (PASRR) for a resident diagnosed with psychosis and depression. The resident was admitted with a history of mental illness and was prescribed aripiprazole, an antipsychotic medication, upon discharge from the hospital. However, the PASRR screening conducted prior to admission inaccurately indicated that the resident did not have a serious mental illness and was not on psychotropic medications. This discrepancy was identified during a review of the resident's medical records and interviews with facility staff. The Minimum Data Set Nurse (MDSN) acknowledged that the PASRR was not accurate and should have been corrected to reflect the resident's mental health needs. The Director of Nursing (DON) also confirmed that the PASRR should have included the resident's diagnosis of psychosis and the use of psychotropic medication. The facility's policy requires updates to the PASRR to be completed according to Minimum Data Set guidelines, but this was not adhered to in this case, potentially impacting the resident's mental health care.
Deficiencies in Person-Centered Care Planning
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for several residents, leading to deficiencies in their care. Resident 84, who has chronic kidney disease, was consistently served meals that did not align with his dietary preferences and restrictions. Despite having a documented dislike for certain foods and a need for a renal diet, the facility staff served him meals containing items like oranges and potatoes, which are not suitable for his condition. The dietary preferences were not included in his care plan, leading to repeated instances of inappropriate meal service. Resident 9, who was admitted to hospice care due to end-stage heart failure, did not have a hospice care plan included in their records. This omission meant that the care provided was not aligned with the resident's current health status and needs. The lack of a hospice care plan was acknowledged by the Director of Nursing, indicating a gap in the facility's care planning process. Resident 198, diagnosed with Alzheimer's disease, had a history of wandering and elopement risk, which was not adequately addressed in their care plan. Despite previous incidents and documentation indicating the resident's tendency to wander, the facility's care plan was not individualized to prevent future occurrences. The resident was not listed in the facility's elopement risk binder, and the care plan did not reflect the necessary interventions to manage the resident's behavior effectively.
Improper Mattress Setting for Resident at Risk of Pressure Injuries
Penalty
Summary
The facility failed to ensure proper interventions for skin breakdown prevention for a resident, identified as Resident 47, who was at risk of developing pressure injuries. Resident 47 was admitted with chronic obstructive pulmonary disease and was prescribed a bariatric low air loss mattress to prevent skin breakdown. However, during an observation, it was noted that the mattress was set to static mode and configured for a resident weighing 400 pounds, while Resident 47's actual weight was 233.4 pounds. This discrepancy in the mattress setting was confirmed through interviews with a Certified Nurse Assistant and a Licensed Nurse, both of whom acknowledged that the incorrect setting could lead to the development of pressure injuries due to the mattress being too firm. Further interviews with the Director of Nursing corroborated the importance of having the mattress set correctly to ensure the resident received the full benefit of the low air loss mattress, which is designed to prevent pressure injuries. A review of the mattress manual indicated that the pressure setting should be adjusted according to the patient's weight and height, which was not adhered to in this case. This oversight had the potential to compromise Resident 47's skin integrity and increase the risk of pressure injury development.
Failure to Honor Resident's Dietary Preferences and Needs
Penalty
Summary
The facility failed to ensure that the meal preferences and nutritional needs of Resident 84, who has Chronic Kidney Disease Stage 4, were met. The resident's meal tray card, which guides staff on what to serve, was not followed, leading to the resident being served foods that were not suitable for his condition. Despite having a dietary evaluation that indicated specific dislikes and dietary restrictions, the resident was served meals containing items such as oranges and potatoes, which are high in potassium and not recommended for kidney patients. Observations and interviews revealed that Resident 84 expressed dissatisfaction with the meals provided, stating that they were not appropriate for his kidney condition and included items on his dislikes list. The dietary staff, including the Dietary Supervisor, acknowledged that the resident's preferences were not honored and that the meal tray card should have been checked to ensure compliance with the resident's dietary needs. The Licensed Nurse also confirmed that the resident's meal preferences should have been respected and that the menu should have been adjusted to provide nutritionally adequate substitutes. The Director of Nursing stated that the expectation was for the dietary staff to honor the resident's meal preferences and that failure to do so could lead to complications such as weight loss. The facility's policy indicated that meals should be consistent with resident preferences and physician's orders, and suitable substitutes should be provided if a preferred item is not available. However, this policy was not followed, resulting in the deficiency.
Failure to Provide Food in Appropriate Form for Resident
Penalty
Summary
The facility failed to prepare food in a form that met the needs of Resident 27, who was admitted with diagnoses including cerebral infarction and end-stage renal disease. The resident had moderate cognitive deficits and limited use of hands, requiring adaptive devices for eating. Despite the meal ticket indicating chopped meat, the resident received a quarter-inch slice of meat, which he was unable to eat due to his inability to use a knife and fork in combination. This discrepancy was observed during a lunchtime meal delivery. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that there were procedures in place to check meal orders against meal tickets to ensure accuracy. However, the DON admitted to checking the meal tag, which incorrectly stated chopped meat, and acknowledged the error. The facility's policy required meals to be consistent with residents' preferences and physician's orders, but this was not adhered to in the case of Resident 27, potentially leading to unintended weight loss and medical complications.
Failure to Follow Smoking Policy for Residents
Penalty
Summary
The facility failed to adhere to its smoking policy for two residents, leading to a deficiency in the management of smoking and tobacco use. Resident 18, who was readmitted with a history of diabetes mellitus, had a smoking assessment that was not updated quarterly as required. The last assessment was completed on 4/29/24, and two subsequent quarterly assessments were missed. This oversight was acknowledged by the MDS nurse, who emphasized the importance of regular assessments to ensure the resident's safety and update the care plan accordingly. The Director of Nursing also confirmed the necessity of timely assessments to accommodate any changes in the resident's condition. Similarly, Resident 40, who also had a history of diabetes mellitus and severe cognitive deficits, did not have a smoking assessment completed for the October 2024 quarter. The last assessment for this resident was conducted on 7/22/24. The MDS nurse and the Director of Nursing both highlighted the importance of these assessments to monitor the resident's ability to smoke safely and to update the care plan as needed. The facility's policy required smoking assessments to be conducted upon admission, quarterly, annually, and upon any change in condition, which was not followed in these cases. The deficiency in following the smoking policy for both residents had the potential to lead to accidents and injuries. The facility's failure to conduct timely smoking assessments and update care plans as per their policy was identified through observations, interviews, and record reviews. This lapse in protocol could have compromised the safety and well-being of the residents involved, as regular assessments are crucial for evaluating the residents' current health status and ensuring appropriate safety measures are in place.
Failure to Monitor and Document Urine Output for Resident with Urinary Catheter
Penalty
Summary
The facility staff failed to monitor and document urine output for a resident with a urinary catheter, as per the facility's policy. This deficiency was identified during an unannounced visit following a complaint related to resident assessment. The resident in question was admitted with a urinary catheter due to a dysfunctional bladder. Despite the facility's policy requiring the monitoring and documentation of urine output for residents with urinary catheters, the staff did not measure or record the urine output for this resident. A Certified Nursing Assistant (CNA) confirmed that they only documented whether the resident was continent or incontinent, without measuring urine output, as they were not instructed to do so. Further interviews with a Licensed Nurse (LN) and the Director of Nursing (DON) revealed that the facility's policy was indeed to monitor and document urine output for residents with urinary catheters. However, there was no documentation of the resident's urine output in the clinical record, and the staff did not follow the policy. The DON confirmed that CNAs should have been checking and documenting the urine output when emptying the urinary catheter to ensure the resident was voiding properly. The facility's policy on indwelling catheters, revised in 2014, also indicated that output recording should occur in accordance with intake and output recording procedures.
Failure to Administer Anti-Rejection Medication as Prescribed
Penalty
Summary
The facility failed to ensure proper medication administration for a resident who had undergone a liver transplant. The resident was prescribed tacrolimus, an anti-rejection medication, to be administered twice daily via a gastrostomy tube. However, the medication administration record (MAR) revealed multiple instances where the medication was not administered as ordered. Specifically, there were entries indicating that the medication was not on hand or pending delivery, and on some occasions, there were no notes explaining the missed doses. Interviews with licensed nurses and the Director of Nursing (DON) confirmed that the facility did not have the medication on hand at times, despite the DON verifying that the pharmacy had supplied the medication. The lack of documentation and failure to administer the medication as prescribed increased the risk of organ rejection for the resident. The facility's policy required medications to be administered as ordered by the attending physician, highlighting a significant lapse in adherence to this policy.
Failure to Provide Proper Colostomy Care and Documentation
Penalty
Summary
The facility failed to provide necessary colostomy care and treatment for a resident who required such services. Upon admission, the resident did not have a baseline care plan developed, which is essential for ensuring proper care. Additionally, there was no physician order obtained for the colostomy care, and the treatments provided were not documented in the resident's Treatment Administration Record (TAR). This lack of documentation and planning led to inconsistencies in the care provided by licensed nurses, as evidenced by the absence of records for colostomy bag changes and skin condition monitoring. Interviews with the Treatment Nurse and the Director of Nursing revealed that the colostomy bag was changed daily, sometimes twice per shift, but these actions were not recorded in the TAR. The Treatment Nurse admitted to not signing the TAR for each treatment and acknowledged the absence of a baseline care plan. The Director of Nursing confirmed that the baseline care plan should have been created upon admission and that the TAR should accurately reflect the care provided. The facility's policies emphasize the importance of documenting treatments and monitoring the stoma and surrounding skin, which were not adhered to in this case.
Failure to Prevent Resident Elopement and Incomplete Documentation
Penalty
Summary
The facility failed to implement measures to prevent a resident from eloping and did not provide adequate monitoring for the resident. The incident involved a resident who had the mental capacity to make medical decisions and was admitted to the facility on an unspecified date. On 5/28/24, the resident went out on pass with a family member, but there was no documentation in the nursing notes indicating the resident's departure or return. The facility's out on pass logbook was incomplete, lacking details such as the licensed nurse who signed the resident out, the expected return time, and the condition of the resident upon return. Licensed Nurse (LN) 2 failed to clarify the duration of the out on pass order with the attending physician, which contributed to the lack of proper documentation and monitoring. LN 1, who was passing medications at the time, did not complete the necessary documentation in the resident's clinical record or assess the resident's condition upon return. The Director of Nursing (DON) confirmed that there should have been a physician's order and documentation indicating the resident was assessed before leaving and upon returning to ensure their safety. The facility's policy, revised in January 2016, required a physician's order specifying the length of time a resident may be on pass and mandated that a licensed nurse assess the resident's physical and mental status before and after the pass. The policy also required documentation of the time the resident left and returned, the name of the accompanying person, and the resident's condition upon return. These procedures were not followed, leading to the resident's elopement and the potential compromise of their health, safety, and well-being.
Failure to Conduct Reference Checks Prior to Hiring CNA
Penalty
Summary
The facility failed to conduct reference checks prior to hiring a certified nursing assistant (CNA), which had the potential to increase the risk of abuse for residents. Resident 1, who was admitted with diagnoses including schizoaffective disorder and anxiety disorder, reported an incident of physical abuse involving a CNA. The resident stated that the CNA pulled off her clothes and pushed her against the side rails, although no bruises were noted. The CNA was subsequently suspended. A review of the CNA's personnel file revealed that no reference checks were conducted prior to hire, which was confirmed by the facility administrator. The facility's policy required at least two reference checks from previous or current employers prior to hiring, but this procedure was not followed in this case.
Inconsistent Dialysis Care and Documentation
Penalty
Summary
The facility failed to consistently provide appropriate dialysis access care for Resident 1, who was readmitted with end-stage renal disease and dependence on dialysis. Despite the care plan interventions indicating the need to monitor and document any signs of infection at the access site, the facility did not remove the dialysis dressing within the required 4-6 hours after treatment. This was confirmed through interviews with the resident, a licensed nurse, the hemodialysis nurse, and the assistant director of nursing, all of whom acknowledged the importance of timely dressing removal to prevent clotting and infection. Additionally, the facility's policy on dialysis management was not followed, as it required daily assessment and documentation of the access site care, which was not done for Resident 1 on multiple occasions, including a missed post-dialysis assessment on 3/21/24. The facility also failed to complete the dialysis communication form consistently for three residents, including Resident 1, Resident 2, and Resident 3. For Resident 2, there was a missed dialysis assessment on 3/2/24, with no follow-up documentation from the facility's licensed nurses. Similarly, for Resident 3, there was a missed dialysis assessment on 3/23/24, again with no follow-up documentation. The assistant director of nursing confirmed that the expectation was for licensed nurses to follow up on the residents' treatment at the dialysis center and check for any new orders from the doctors. The facility's policy on dialysis management, which required pre and post-dialysis evaluations by licensed nurses and proper documentation of dialysis treatment and post-dialysis weight, was not adhered to. This lack of compliance with the facility's own policies and procedures resulted in missed assessments and inadequate care for residents dependent on dialysis, potentially leading to complications such as clotting and infection at the dialysis access sites.
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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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