Capital Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Sacramento, California.
- Location
- 6821 24th Street, Sacramento, California 95822
- CMS Provider Number
- 555442
- Inspections on file
- 67
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Capital Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program when multiple live and trapped roaches and spiders were observed in the rooms of two cognitively intact residents. One resident, admitted for surgical aftercare, had live and trapped pests in her room and reported that bugs were found there often, expressing that she felt hurt and uncomfortable. Another resident with essential HTN reported a roach crawling onto her foot while she was in bed and stated she felt uncomfortable. An activities assistant confirmed the observed pests, an LN verified pest presence via photographs and described the situation as unsanitary with potential for allergic reactions, and the DON stated that rooms were expected to be clean and free of pests despite a written pest control P&P intended to keep the building free of insects and rodents.
A resident receiving aftercare following joint replacement surgery, with moderate cognitive impairment, underwent wound care while lying in bed with steri-strips to the thigh. An LN placed wound care supplies directly on the bed without creating a separate clean and dirty area and did not perform hand hygiene between multiple glove changes. The LN acknowledged not having a separate clean and dirty section, while the IP and DON stated that facility policy and expectations require hand hygiene before and after glove changes, sanitizing equipment after use, and establishing a clean field during wound care.
A resident with intact memory and a history of orthopedic issues and post-amputation aftercare was standing at another resident’s doorway conversing when a cognitively impaired resident with vascular dementia and behavioral disturbance approached, became angry, verbally threatened to hurt him and “kick [his] butt,” and slapped his right hand. Another resident with intact memory and central cord syndrome, as well as a CNA, witnessed and described the incident, confirming that the aggressive resident raised a hand, cursed, and struck the other resident. The Administrator acknowledged residents’ right to be free from abuse, and facility policy states residents must be free from abuse, neglect, misappropriation, exploitation, corporal punishment, involuntary seclusion, and retaliation.
A resident with dementia, schizophrenia, seizures, and severely impaired decision-making, who required extensive assistance with ADLs and mobility, experienced multiple falls over a short period without the facility identifying, implementing, and consistently documenting new fall-prevention interventions. After an initial fall with documented forehead discoloration, the care plan inaccurately recorded no injury and was only updated to include short-term monitoring, with no new fall-prevention measures and no investigation by the DON. Subsequent falls included an unwitnessed fall and a witnessed bed fall with loss of consciousness and a bleeding forehead laceration, confirmed by EMS and ED records, yet the care plan either failed to add truly new interventions or did not reflect those listed on IDT fall forms, and the DON stated there were no injuries despite medical documentation to the contrary. A later bathroom fall, witnessed by the cognitively intact roommate and resulting in an acute right distal clavicle fracture and hospitalization, was again recorded in the care plan as causing no injury, and the DON reported she did not further investigate or interview staff or residents, demonstrating a pattern of inadequate supervision, inconsistent documentation, and failure to reassess and modify fall-prevention strategies after repeated falls and injuries.
A resident with dementia and a history of brain injury was physically abused when a CNA struck them on the head and directed two student witnesses to restrain the resident during care. The students, who had received abuse prevention training, reported the incident after being instructed to hold the resident's arms and legs. Facility leadership confirmed that restraining residents is not permitted and that the CNA admitted to the actions, which violated the facility's abuse prevention policy.
A resident with a history of depression and amputation was struck in the eye by another resident during a hallway argument, following ongoing verbal threats. Staff and other residents confirmed repeated threats and the physical altercation, but leadership was unaware of the ongoing conflict. Both residents had care plans noting aggressive behavior, yet the abuse prevention policy was not effectively implemented.
A resident with spinal cord disease, PTSD, and hearing impairment was subjected to yelling and aggressive gestures by a CNA, causing the resident to feel embarrassed and afraid. Staff failed to use the available whiteboard for communication, and multiple witnesses confirmed the CNA's behavior. The DON acknowledged the incident and lack of follow-up on the resident's psychosocial needs.
Staff did not wear gowns, as required, while providing high-contact care such as transferring, changing briefs, and therapy to three residents on Enhanced Barrier Precautions for MDROs. Despite clear physician orders, posted signage, and facility policy mandating both gloves and gowns for these activities, staff only wore gloves. Both the Infection Preventionist and DON confirmed that gown use was required for these care activities.
A deficiency was identified when an allegation of resident-to-resident abuse, involving threats and reported by a cognitively intact resident and their family, was not reported to the State Survey Agency as required. Although the resident was moved for safety and the incident was communicated internally to the DON and management, the required external reporting was not completed, contrary to both federal regulations and facility policy.
A medication/treatment cart containing prescription medications was found unlocked and unattended in the facility's front lobby, posing a risk of unauthorized access. A licensed nurse confirmed the cart should have been locked, and the DON emphasized the importance of securing medication carts. The facility's policy requires all drugs to be stored in locked compartments.
The facility failed to properly store, handle, and label respiratory equipment for three residents, leading to potential contamination and non-compliance with physician orders. Nebulizer masks and tubing were left uncovered and not changed as required, and oxygen therapy orders were not followed, with equipment lacking necessary labeling for infection control.
The facility failed to ensure safe pharmaceutical services, with hazardous medications lacking warning labels, untimely replacement of Emergency Kits, and improper documentation of medication deliveries and destruction. Additionally, discrepancies in controlled drug records for two residents indicated potential risks of drug diversion.
The facility failed to maintain sanitary conditions for dishwashing, as the low temperature dishwasher's sanitizing solution was below the required 50 ppm. The Dietary Manager confirmed the issue, and records showed no documentation of required testing and recording of the chemical solution per shift, contrary to the facility's policy.
The facility failed to maintain effective infection control practices, including improper cleaning of shared glucometers, a dusty delivery cart for residents' personal items, and inadequate use of protective equipment during care in an Enhanced Barrier Precaution room. These deficiencies increased the risk of cross-contamination and potential exposure to infections.
A computer screen displaying a resident's confidential information was left unattended and unsecured on a treatment cart near the nurse's station and facility lobby, potentially allowing unauthorized access. A Physical Therapy Assistant and the Director of Nursing confirmed this breach of confidentiality, which violated HIPAA regulations and the facility's policies.
A facility failed to maintain a homelike environment for a resident when a significant hole in the wall of the resident's room was observed. The resident, who was cognitively intact and had a history of stroke, hemiplegia, and aphasia, indicated that the hole was bothersome. The facility's administrator confirmed the issue, acknowledging that the wall should have been repaired, in line with the facility's policy to ensure a safe and comfortable environment.
A resident with surgical aftercare and COPD was inaccurately documented in the MDS as discharged to a hospital, despite leaving AMA to go home. The MDS Coordinator Assistant confirmed the error, which contradicted the facility's policy on accurate assessments.
A facility failed to develop a comprehensive care plan for a resident's respiratory care and nebulizer treatment, despite the resident's diagnoses of asthma and other conditions. The resident's MDS indicated moderately impaired cognition and breathing issues, and a physician's order for nebulizer treatment was in place. However, no care plan was developed, as confirmed by a Licensed Nurse and the DON, contrary to the facility's policy on care plan revisions.
The facility failed to perform consistent quality control for glucometers and did not follow proper nursing care practices for a resident with a feeding tube. Glucometer QC records were incomplete, and a nurse did not check feeding tube residuals or elevate the resident's head during medication administration, contrary to orders.
A resident with a G-Tube did not receive care in accordance with physician orders and facility policy. The resident's G-Tube insertion site was observed without the required gauze or abdominal pad, contrary to the physician's order for daily cleansing and covering. This oversight was confirmed by an LN, highlighting a failure to adhere to professional standards and facility procedures.
A resident with a stage 4 pressure ulcer did not receive care consistent with facility policy when a treatment nurse failed to label the dressing with initials and date. Interviews with staff confirmed that labeling is necessary to ensure treatment completion and prevent infection, as per facility policy.
A resident with Type 2 Diabetes and Dysphagia did not receive the correct water flush volume and frequency as per the physician's order. The kangaroo epump was set to deliver 150ml every 6 hours instead of the prescribed 200ml every 4 hours. This discrepancy was confirmed by a nurse and acknowledged by the DON, highlighting a failure to adhere to the facility's policy on feeding tube care.
A resident with cerebral infarction and moderately impaired cognitive function did not have her surgery date clarified by the facility's social services staff, despite reminders from her and her husband. After returning from a physician appointment with a surgical kit prep, the staff failed to follow up with the clinic, leading to a delay in scheduling the surgery.
The facility experienced a medication error rate of 8.11%, exceeding the acceptable 5% threshold. Errors included administering DuoNeb past its recommended use date and improperly crushing medications like enteric-coated aspirin and finasteride without gloves. The DON noted that staff training included following computer prompts and using resources for unfamiliar drugs, but the MAR lacked specific warnings.
The facility failed to ensure safe medication storage practices, with expired, unlabeled, and undated medications found in the medication room and carts. Hazardous drugs lacked proper labeling, and inhalation products were not used within the recommended timeframe. The DON acknowledged these issues, which were contrary to the facility's policy.
A facility failed to accurately document a resident's diagnosis, leading to potential unsafe care. The resident's medical records showed inconsistencies regarding the use of olanzapine, with incorrect indications such as bipolar disorder noted. Interviews with the ADON and DON confirmed these errors, highlighting a failure to adhere to the facility's policy on psychotropic medication documentation.
Two residents in a facility were involved in a verbal and physical altercation. One resident, with a history of shouting racial slurs, provoked another resident, who then slapped him. Despite existing care plans and policies, the facility failed to prevent the incident, as staff did not adequately intervene to manage the residents' behaviors.
The facility failed to secure medications as required, with two bags containing 30-40 bottles and boxes left on an unlocked cabinet in the DON's office. The office door was open, and the DON was absent, while staff and residents were nearby. The DON confirmed the medications should have been locked to prevent unauthorized access.
A resident with chronic respiratory failure had a nasal cannula that was not labeled with an open date and was replaced less frequently than the facility's policy required. The Infection Preventionist confirmed the discrepancy, noting that the tubing should be changed every seven days, not every 28 days as per the resident's order.
A resident with severe cognitive impairment reported being hit twice on the chest by a CNA. The incident was initially not reported to authorities due to perceived inconsistencies in the resident's account. The facility's delay in reporting violated its policy, which mandates immediate reporting of all abuse allegations.
A resident with moderate cognitive impairment and a history of elopement risk managed to leave the facility multiple times in one day. The facility failed to notify the resident's responsible party, physician, or the Department, and did not follow its own elopement policy.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by the presence of multiple live and trapped pests in the rooms of two cognitively intact residents. Resident 1, admitted with a diagnosis including encounter for surgical aftercare and assessed as cognitively intact on an MDS dated 2/5/26, was observed in her room where a live roach was seen on the floor and a live brown spider approximately one inch in length was seen on the sliding door. Additional pests were observed on traps in the same room: two roaches on a trap under the bed, and two one‑inch black spiders and a roach on a trap under a wooden cabinet by the sliding door. During this observation and interview, Resident 1 became angry and stated she felt hurt and uncomfortable having to sleep with pests in her room, and reported that the facility was not clean and that bugs were found in her room often. An Activities Assistant, present during the observation, confirmed the presence of the live spider, the live roach on the floor, and the trapped roaches and spiders in Resident 1’s room. Resident 2, admitted with a diagnosis of essential hypertension and assessed as cognitively intact on an MDS, reported during an interview in her room that a roach had crawled onto her foot while she was in bed and then crawled away in the room on a recent Saturday. Resident 2 stated she felt uncomfortable in the facility. A Licensed Nurse later confirmed the presence of pests in Resident 1’s room via photographic record review and stated that the presence of pests is unsanitary and that a resident could get an allergic reaction from a bug bite if spiders are present, and that pests can make a resident feel uncomfortable with care. The DON stated the expectation is for residents’ rooms to be clean and free of pests. A review of the facility’s pest control policy indicated the facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents, which was not achieved based on the observed and reported pest activity in resident rooms.
Failure to Follow Hand Hygiene and Clean Field Practices During Wound Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during wound care for one of three sampled residents. The resident was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery and had moderate cognitive impairment per an MDS dated 2/16/26. During an observation on 2/26/26 at 10:37 a.m., the resident was lying supine in bed with steri-strips to the left thigh while a licensed nurse performed wound care. The nurse placed wound care supplies directly on the resident’s bed without establishing a separate clean and dirty area, contrary to the facility’s wound care policy that required use of a disposable cloth or paper towel to establish a clean field. During the same observation, the licensed nurse did not perform hand hygiene between glove changes at 10:37 a.m., 10:39 a.m., and 10:41 a.m. The nurse confirmed there was no separate clean and dirty section during the procedure, which increased the potential for the resident to get infections through cross contamination. The Infection Preventionist stated that the expectation was to perform hand hygiene before and after glove changes, sanitize non-dedicated equipment after each use, and maintain separate clean and dirty areas during wound care. The DON similarly stated that staff were expected to perform hand hygiene after each glove change, sanitize equipment after use, and maintain separate clean and dirty areas during wound care, consistent with facility policies on hand hygiene and wound care.
Failure to Protect Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from physical abuse when one resident struck another. Resident 89, who had intact memory and a history of orthopedic issues and aftercare following a surgical amputation, reported that while standing at the doorway of Resident 35’s room and talking with Resident 35, Resident 61 walked straight toward him and slapped his right hand. Resident 89 stated that Resident 61 was angry and verbally threatened to hurt him and “kick [his] butt.” A progress note documented that a CNA present at the time reported Resident 89 extended his hand outward in front of him as Resident 61 was walking down the hallway toward him, and that Resident 61 made contact with and hit Resident 89’s right hand. Resident 61’s record showed diagnoses of cerebral infarction and vascular dementia with behavioral disturbance, and an MDS indicating severe memory problems. Resident 35, who had intact memory and a diagnosis of central cord syndrome at the C4 level, corroborated the incident, stating he witnessed Resident 61 raise his right hand and slap Resident 89’s right hand while angrily yelling that he was going to hurt him and kick his butt. A signed note by CNA 6 further indicated that Resident 89 stretched out his hands and told Resident 61 to go back, after which Resident 61 became angry, started cursing, and hit Resident 89. The Administrator confirmed that residents have the right to be free from any form of abuse, and the facility’s Resident Rights policy stated residents must be free from abuse, neglect, misappropriation, exploitation, corporal punishment, involuntary seclusion, and retaliation.
Failure to Implement and Monitor Effective Fall-Prevention Measures After Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement effective fall-prevention interventions for a cognitively impaired resident with a known history of falls. The resident was admitted with dementia, schizophrenia, and seizures, was nonverbal or minimally verbal, and required extensive assistance with ADLs, including two-person assistance for dressing, bathing, toileting hygiene, and toilet transfers, and one-person assistance for transfers and standing. An MDS dated 1/6/26 documented severely impaired decision-making and that the resident was rarely or never understood. A physician progress note on the same date described the resident as nonverbal, minimally interactive, lacking capacity for informed consent, and having a history of falls, requiring assistance for ADLs, feeding, and mobility. On 1/4/26, the resident experienced a fall in the room after staff heard the roommate yell “Man down!” and found the resident on the floor next to the bed with discoloration to the right forehead. The care plan entry for that fall stated there was an actual fall with no injury, which conflicted with the progress note documenting discoloration to the forehead. The DON acknowledged this discrepancy and stated the progress note could be expanded but reported that no staff or residents were interviewed to investigate the fall and no additional steps were taken to identify, monitor, or prevent future falls. The care plan dated 1/4/26 was updated only to include monitoring and reporting for 72 hours for signs and symptoms such as pain, bruises, or changes in mental status, and did not include any new fall-prevention interventions. An IDT fall review dated 1/6/26 listed “sent to hospital for eval” as a new intervention, which contradicted the medical record that did not show a hospital transfer on 1/4/26. On 1/10/26, the resident had another unwitnessed fall documented in a progress note as having no visible injuries. However, an IDT fall form dated 1/12/26 described a nurse witnessing the resident roll to the right side of the bed, fall out of bed, collide the head with the roommate’s bed, lose consciousness for 20 seconds, and have active bleeding from the right forehead, after which the resident was transferred to the emergency department. Prehospital and ED records from that date documented a one-inch laceration above the right eye and a small right frontal abrasion with wound irrigation and dressing. The IDT fall form dated 1/12/26 listed “fall mats and lower bed” and “transfer to acute” as new interventions, but the care plan did not reflect fall mats, and the fall-prevention interventions added to the care plan on 1/10/26 (anticipating needs, educating the resident about safety, and PT evaluation) were already present in the admission care plan dated 12/31/25. The DON stated the falls on 1/10/26 were reviewed by the IDT after the weekend and that interventions were evaluated when the resident was transferred to the hospital and upon return, but did not identify any other steps taken to identify, monitor, or prevent future falls, and stated the resident had not sustained injuries from the 1/10/26 falls, which conflicted with ED and IDT documentation. On 1/13/26, the resident sustained another fall in the shared bathroom. Staff interviews indicated that a CNA and an LN responded after hearing the roommate scream for help and found the resident on the bathroom floor, confused and with difficulty communicating. The cognitively intact roommate reported seeing the resident standing in the shared bathroom, then tripping and falling forward, hitting his head on the door, then falling backward and hitting the back of his head, followed by shaking on the floor. EMS documentation recorded that staff reported the roommate had heard a loud bang in the bathroom, found the resident on the floor, and that the resident was on blood thinners with a bump to the back of the head and an old bump above the right eye from a prior fall. Hospital trauma and orthopedic records from the subsequent admission documented an acute distal right clavicle fracture with tenderness over the fracture site and a hospitalization from 1/13/26 to 1/17/26 for a fall with a right clavicle fracture and non–weight-bearing status to the right upper extremity. The care plan revised on 1/13/26 indicated no injuries from the 1/13/26 fall, contradicting the hospital records. The DON stated there were no witnesses to the fall and that she did not investigate further or speak with any staff or residents about the fall. Throughout these events, facility policies on falls and comprehensive assessments, which required ongoing evaluation of causes of falls, documentation of appropriate interventions to prevent future falls, and monitoring and documentation of responses to interventions, were not followed as evidenced by the lack of new, implemented, and consistently documented fall-prevention measures after repeated falls and injuries.
Resident Physically Abused and Restrained by CNA During Care
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically abused a resident by striking them on the head and directing two student witnesses to physically restrain the resident during care. The incident was observed by two students who were assisting with the resident's care and later reported the abuse to their instructor and facility staff. The CNA instructed the students to hold the resident's arms and legs, claiming the resident was aggressive, and then proceeded to hit the resident on the forehead with an open hand. The resident involved had a history of traumatic hemorrhage of the cerebrum, dementia, and muscle weakness, and was assessed as having moderate cognitive impairment, requiring additional support for daily living tasks. During the incident, the resident was being changed and was unable to provide an account of the event when later interviewed. Both student witnesses confirmed that they were told by the CNA to restrain the resident, and both expressed discomfort with the situation, stating that they had received abuse prevention training and recognized the actions as inappropriate. Interviews with facility leadership, including the Director of Staff Development (DSD) and Director of Nursing (DON), confirmed that the CNA's actions were reported and that the facility does not have a policy permitting the restraint of residents. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including physical abuse and the use of restraints. Documentation in the CNA's personnel file indicated an admission to restraining the resident during care.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
Facility staff failed to protect a resident from abuse when another resident threw a dessert cup, striking the resident in the right eye during a hostile argument. Multiple staff and residents confirmed that the aggressor had a history of making verbal threats and had previously threatened to physically harm the victim. The incident occurred in a hallway while staff were attempting to separate the two residents during a verbal altercation. The resident who was struck reported feeling unsafe in the facility as a result of these ongoing threats and the physical altercation. Both residents involved had intact cognitive function as indicated by their BIMS scores. The resident who was struck had a history of major depressive disorder and bilateral below-the-knee amputation, while the aggressor had diagnoses including depression, anxiety disorder, and psychoactive substance abuse. Care plans for both residents noted potential for aggressive behavior, but the Director of Nursing and Administrator were unaware of the ongoing tension between the two residents. The facility's abuse prevention policy required staff to report any risks of abuse, but the ongoing threats and altercation were not effectively addressed prior to the incident.
Failure to Ensure Respectful Communication and Dignity for Resident with Hearing Impairment
Penalty
Summary
A resident with spinal cord disease and post-traumatic stress disorder, who was cognitively intact and dependent on staff for emotional, intellectual, physical, and social needs, experienced a lack of respect and dignity from a Certified Nursing Assistant (CNA). The resident, who had difficulty hearing, reported that the CNA entered her room, ignored her question, and then began yelling and waving her arms above her head. The resident expressed feeling embarrassed, afraid, and unable to understand the CNA due to her hearing impairment. Another staff member had to intervene and remove the CNA from the room. Multiple interviews corroborated the resident's account, including statements from another resident, a family member, a licensed nurse, and the Director of Nursing (DON). The family member noted that staff failed to use the available whiteboard to communicate with the resident, despite her hearing difficulties. The licensed nurse confirmed that the CNA was defensive and yelled at the resident when asked to provide assistance. The DON acknowledged awareness of the incident and admitted that the facility did not follow up on the resident's psychosocial or emotional needs. The facility's policy on communication and respect and dignity was requested but not provided.
Plan Of Correction
F557: Respect and Dignity 1. Immediate Corrective Action for the Identified Deficient Practice: The resident(s) involved in the identified incident were immediately assessed to ensure their physical and emotional well-being. Staff members involved were counseled and re-educated on residents' rights related to respect and dignity. 2. Measures to Identify Other Residents Potentially Affected: No other residents were affected by this deficient practice. 3. Systemic Changes to Prevent Recurrence: • All staff will receive in-service training on Residents' Rights, with a focus on respect, dignity, communication, and sensitivity. Ongoing education will be added to the facility's annual training schedule and orientation for all new hires. • Social Services and Department Heads will incorporate random resident interviews into weekly rounds to monitor staff-resident interactions and ensure dignity is preserved. 4. Monitoring to Ensure Sustained Compliance: • The Administrator or designee will conduct monthly audits of resident interactions on all shifts for the next 6 months using a standardized Respect & Dignity Observation Tool. • Any issues identified will be brought to the Quality Assurance and Performance Improvement (QAPI) committee for review and action planning. • Results of the audits and interviews will be tracked, trended, and reviewed at quarterly QAPI meetings. 5. Completion Date: May 18, 2025 F 557
Failure to Use Required PPE During High-Contact Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control practices by not wearing gowns when providing high-contact care to three residents who were on Enhanced Barrier Precautions (EBP) due to multidrug-resistant organism (MDRO) colonization or infection. Observations revealed that staff, including a Certified Occupational Therapy Assistant, a Certified Nursing Assistant, and a Restorative Nursing Assistant, wore gloves but did not don gowns while performing activities such as transferring, changing briefs, and providing therapy or bed mobility assistance. These actions were in direct contradiction to posted EBP signage, physician orders, and the facility's own policy, all of which required both gloves and gowns for high-contact care activities for residents on EBP. The first resident involved had a history of MRSA colonization and was cognitively intact. Despite clear medical orders and posted EBP signage, the therapy staff assisting this resident with daily transfers and exercises consistently wore gloves but never a gown. The second resident, who was severely cognitively impaired and had a history of MDRO in the urine, was observed being transferred and having a brief changed by a CNA who also wore gloves but not a gown. The CNA acknowledged awareness of the requirement but did not comply during the observed care. The third resident, with a history of MRSA wound infection and cellulitis, was assisted by a restorative nursing assistant who transferred the resident's legs and provided bed mobility without wearing a gown, despite the resident's EBP status and relevant physician orders. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that staff were expected to wear both gloves and gowns for high-contact activities with residents on EBP, as indicated by facility policy and CDC guidance. The facility's policy specifically listed activities such as transferring, changing briefs, and providing bed mobility as requiring gown and glove use for residents on EBP.
Plan Of Correction
F880 How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Infection Preventionist (IP) immediately addressed the deficient practices, including in-services and monitoring to ensure that all isolation precautions were being followed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Update: The facility's infection prevention and control policies were reviewed and updated to align with current CDC and CMS guidelines. Staff Education: All staff received mandatory re-education on: • Proper donning and doffing of PPE • Hand hygiene protocols • Room entry/exit infection control practices • Use of transmission-based precautions PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025 PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving one resident to the State Survey Agency as required by federal regulations. The incident involved a resident who reported being threatened by another resident. The resident's family member also contacted the facility, expressing concern and threatening to call emergency services if the situation was not addressed. The facility responded by moving the resident to another room for comfort and safety, and the incident was communicated to the management team and the Director of Nursing (DON). Despite the internal response, the incident was not reported to the State Survey Agency. During interviews, the Administrator acknowledged that the incident should have been reported, and the DON confirmed that the event was not escalated beyond internal management. The facility's own policy and the signed employee attestation required prompt reporting of any reasonable suspicion of abuse to the appropriate authorities, but this protocol was not followed in this case. Both residents involved were cognitively intact at the time of the incident, as indicated by their BIMS scores. The failure to report the allegation of abuse, as required by both federal regulation and facility policy, was confirmed through record review and staff interviews. The deficiency was identified during a review of documentation and interviews with facility leadership, who admitted the reporting process was not completed as required.
Plan Of Correction
How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Training: The facility's Abuse Prevention and Reporting Policy was reviewed with a focus on the reporting timeline (within 2 hours for abuse involving serious bodily injury, and within 24 hours for all other allegations). Staff Re-Education: All staff—including licensed nurses, CNAs, and department heads—were in-serviced on mandatory reporting obligations per F609 and the internal reporting protocol. Chain of Reporting Tools: Abuse reporting binders were reviewed for accuracy. How does the facility plan to monitor its performance to make sure solutions are sustained? The Administrator or designee will audit all incident reports and grievances weekly for 12 weeks to ensure any allegation of abuse, neglect, or mistreatment is properly reported within regulatory timelines. Results of audits will be reviewed quarterly during the QAPI meeting and corrective actions taken if patterns are noted. Completion Date: May 8, 2025 F 609 F 609
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
The facility failed to ensure the security of medications for a census of 118 residents when a medication/treatment cart was found unlocked and unattended in the front lobby. During an observation, the cart was seen against the wall with prescription medications inside, posing a risk of unauthorized access. A licensed nurse confirmed the cart was unlocked and acknowledged that it should always be locked when not in use. The Director of Nursing also stated that all medication and treatment carts with prescribed medications should be locked when unattended for safety. The facility's policy and procedure on medication storage, dated March 1, 2023, mandates that all drugs and biologicals be stored in locked compartments.
Deficiencies in Respiratory Care and Equipment Handling
Penalty
Summary
The facility failed to ensure proper storage, handling, labeling, and delivery of respiratory care and equipment for three residents. Resident 105's nebulizer mask and tubing set were left uncovered on the bedside drawer and were not changed after 72 hours, contrary to the facility's policy. This oversight was confirmed by a licensed nurse who acknowledged the equipment should be placed in a bag when not in use and changed every 72 hours to prevent contamination and ensure infection control. Similarly, Resident 23's nebulizer mask and tubing set were also left uncovered on the bedside drawer. The resident confirmed the equipment was last used the previous day, and a CNA admitted they were not informed about the need to store the equipment in a bag. The facility's infection preventionist and director of nursing both stated that the equipment should be stored in an antimicrobial bag and changed weekly, highlighting a discrepancy between practice and policy. For Resident 88, the physician's order for oxygen therapy was not followed, as the oxygen flow rate was set at 4 liters per minute instead of the prescribed 2 liters per minute. Additionally, the nasal cannula and humidifier bottle were not labeled with the date of first use, which is necessary for infection control and timely replacement. This was confirmed by both a licensed nurse and the infection preventionist, who emphasized the importance of labeling to ensure regular changes of the equipment.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to ensure safe pharmaceutical services for its residents, as evidenced by several deficiencies observed during a survey. Hazardous medications were stored in medication carts without appropriate warning labels, leading to unsafe handling by nursing staff. For instance, a nurse was observed crushing finasteride, a hazardous medication, with bare hands due to the absence of handling instructions on the medication label and the Medication Administration Record (MAR). Additionally, other hazardous medications like Valproic Acid and Anastrozole were found without proper hazardous labeling, which could have prompted the use of personal protective equipment (PPE) by the staff. The facility also failed to manage its Emergency Kits (Ekit) properly. Both oral and injectable medication Ekits were found opened and not replaced in a timely manner, as required by the facility's policy. The staff did not notify the pharmacy to replace the kits within the stipulated 72 hours after use, which could potentially delay urgent medication needs for residents. Furthermore, the facility did not maintain proper accountability for medication deliveries, as delivery manifests were not signed by licensed staff, and there was no clear process for verifying medication deliveries against the manifest. There were also significant issues with the documentation and destruction of medications. Non-controlled prescription drugs were not consistently co-signed by two licensed staff during destruction, and the controlled drug destruction log lacked a clear chain of custody and final destruction information. Additionally, discrepancies were found in the documentation of controlled drug use for two residents. The Controlled Drug Record (CDR) and MAR did not reconcile, indicating potential inaccuracies in medication administration records, which could lead to drug diversion. These documentation lapses were confirmed by the Director of Nursing and the Consultant Pharmacist, highlighting a lack of accountability and potential risk of medication theft.
Failure to Maintain Sanitary Conditions in Dishwashing
Penalty
Summary
The facility failed to ensure that dishes and utensils were cleaned in a sanitary condition, which had the potential for foodborne illnesses. During an interview with the Dietary Manager (DM), it was confirmed that the facility used a low temperature dishwasher. An observation revealed that the dishwasher had a yellow sign indicating it was a Low Temperature Dishwasher. When the Dietary Aide (DA) 1 checked the dishwasher's sanitizing solution using a chlorine test strip, it showed less than 10 parts per million (ppm), which was below the required 50 ppm. The DM confirmed that the chemical strip should have indicated a dark purple color, representing 50 ppm. Further investigation into the facility's records showed that there was no documentation of the dishwasher's chemical solution being tested and recorded at least once per shift, as required. The facility's policy and procedure titled "Dishwasher Policy" dated 3/1/23 stated that dishes and utensils must be cleaned under sanitary conditions with adequate dishwasher temperatures. For low temperature dishwashers, the sanitizing solution should be 50 ppm hypochlorite (chlorine) on the dish surface in the final rinse. The policy also required that chemical solutions be maintained at the correct concentration based on periodic testing, at least once per shift, and results should be recorded. However, these procedures were not followed, leading to the deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper cleaning and sanitization of shared glucometers. Licensed Nurse (LN) 6 was observed using an alcohol prep pad instead of the required Medline Micro-Kill Germicidal Wipes to clean a shared glucometer after use. This practice was against the facility's policy and the manufacturer's instructions, which specified the use of germicidal wipes to prevent the transmission of blood-borne pathogens. The Infection Preventionist and the Director of Nursing (DON) both confirmed that alcohol wipes were not appropriate for disinfecting glucometers, highlighting a concern for potential cross-contamination. Another deficiency involved the cleanliness of the residents' personal items delivery cart. During an observation, the cart was found to have a thick layer of dust on its tray, which was confirmed by both the Laundry Staff and Central Supply. The Laundry Supervisor acknowledged that the cart should be cleaned daily to prevent contamination of clean clothes. The facility's policy emphasized the importance of handling and transporting clean linen in a manner that prevents contamination, yet this was not adhered to, posing a risk of exposing residents to dust and germs. Additionally, the facility did not follow safe infection prevention practices during care provided to Resident 82, who required tube feeding and medication administration in a room marked as Enhanced Barrier Precaution (EBP). LN 6 administered medication without wearing a protective gown, despite the room's EBP status requiring gown and glove use for high-contact activities. The DON confirmed that staff should adhere to guidelines for using protective equipment in such situations. These failures collectively increased the risk of cross-contamination and potential exposure to infections among residents, staff, and visitors.
Failure to Secure Resident's Confidential Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, as observed during a survey. A computer screen displaying a resident's photo, complete name, medical record number, current room and bed number, gender, date of birth, age, attending physician, and other pertinent personal and medical information was left unsecured and unattended on top of a treatment cart near the nurse's station and facility lobby. This lapse in security was witnessed by multiple staff and residents passing by, and the computer screen was facing the facility lobby, making the information easily accessible to unauthorized individuals. During an interview, a Physical Therapy Assistant confirmed the observation and acknowledged that the computer should have been closed or covered to protect the resident's confidential information. The Director of Nursing also confirmed that leaving the resident's personal and medical records unattended constituted a violation of HIPAA regulations. The facility's policy and procedure documents, dated 7/1/23 and 6/1/24, respectively, emphasize the importance of maintaining the confidentiality of residents' personal and medical records, highlighting the facility's failure to adhere to its own policies.
Facility Fails to Maintain Homelike Environment Due to Wall Damage
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for a resident when a hole was observed in the wall of the resident's room. The resident, who was admitted to the facility with diagnoses including a stroke, hemiplegia, and aphasia, was found to be cognitively intact with a Brief Interview for Mental Status score of 14 out of 15. During an observation, a six inch by 12 inch hole in the drywall with exposed plumbing was noted approximately two feet above the floor below the television in the resident's room. The resident indicated that the hole in the wall was bothersome. The facility's administrator confirmed the presence of the hole and acknowledged that it should have been repaired. The facility's policy on providing a safe and homelike environment, dated June 1, 2023, emphasizes the importance of maintaining a physical layout that does not pose a safety risk and allows residents to receive care and services safely.
Inaccurate Resident Assessment Leads to Deficiency
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, leading to a deficiency in care. Resident 112, who was admitted with diagnoses including surgical aftercare and chronic obstructive pulmonary disease, was inaccurately documented in the Minimum Data Set (MDS) as having an unplanned discharge to a short-term general hospital. However, the resident had actually decided to go home against medical advice (AMA) on the same date. This discrepancy was confirmed during an interview with the MDS Coordinator Assistant, who acknowledged that the MDS should have been coded to reflect a discharge to home/community. The facility's policy on conducting accurate resident assessments emphasizes the importance of documenting the resident's status accurately at the time of assessment. Despite this policy, the MDS for Resident 112 was not updated to reflect the correct discharge status, which was confirmed by a review of the resident's progress notes and the AMA release form. This oversight had the potential to lead to inaccurate care for the resident, as the assessment did not accurately reflect the resident's decision to leave the facility against medical advice.
Failure to Develop Respiratory Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 105, specifically regarding their respiratory care and nebulizer treatment. Resident 105 was admitted in October 2024 with multiple diagnoses, including parkinsonism, asthma, dementia, and schizophrenia. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and issues with breathing when lying flat. Despite a physician's order for Ipratropium-Albuterol Solution via nebulizer four times a day for asthma, there was no corresponding care plan developed for this treatment. During an interview and record review, a Licensed Nurse confirmed the absence of a respiratory care and nebulizer treatment care plan for Resident 105, acknowledging that it should have been included in the care plan. The Director of Nursing also stated that such a care plan was expected to guide nurses in providing appropriate care. The facility's policy on care plan revisions emphasized the need for comprehensive care plans that include resident-specific interventions to maintain the resident's highest practicable well-being, which was not adhered to in this case.
Inconsistent Glucometer QC and Improper Feeding Tube Care
Penalty
Summary
The facility failed to ensure consistent quality control for glucometer devices and proper nursing care practices for a resident with a feeding tube. The glucometer quality control records were incomplete and inconsistent, with missing documentation for several months. The Director of Nursing (DON) acknowledged that the night shift staff were responsible for performing quality control checks, and the Director of Staff Development and DON were responsible for verifying documentation. The facility's policy required calibration checks to be performed according to the manufacturer's instructions, which were not consistently followed. Additionally, during a medication administration observation, a nurse did not follow orders for checking feeding tube residuals and did not elevate the resident's head during medication administration. The resident's medical record indicated that residuals should be checked before feeding and medication administration, and the head of the bed should be elevated during these times. The nurse admitted to not following these orders, which could contribute to unsafe care. The DON confirmed that staff should adhere to the facility's policy and physician's orders.
Failure to Follow G-Tube Care Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and its own policy and procedure for one resident, identified as Resident 29. Resident 29 was admitted with a diagnosis of dysphagia and had a G-Tube for nutrition and medication administration. A physician's order dated 5/10/24 required the G-Tube insertion site to be cleansed daily with normal sterile saline, patted dry, covered with gauze or an abdominal pad, and monitored for signs and symptoms of worsening. However, during an observation and interview on 11/6/24, it was noted that the G-Tube insertion site lacked the required gauze or abdominal pad, which was confirmed by Licensed Nurse 1 as a deviation from the physician's order. The facility's policy titled 'Provision of Physician Ordered Services' emphasized the importance of providing services according to professional standards of quality, which was not adhered to in this instance. Additionally, the facility's 'Care and Treatment of Feeding Tube Policy' outlined the necessity of using feeding tubes in line with current clinical standards to prevent complications. The failure to follow these policies and the physician's order had the potential to lead to an infection at the G-Tube insertion site and hinder Resident 29 from achieving their highest practicable well-being.
Failure to Label Pressure Ulcer Dressing
Penalty
Summary
The facility failed to provide pressure ulcer care and treatment consistent with professional standards and its own policies for a resident with a stage 4 pressure ulcer. The resident, who was admitted in March 2023, had a diagnosis of a stage 4 pressure ulcer in the sacral region, along with severe malnutrition and muscle weakness. The resident's cognitive assessment indicated intact cognition, and the resident was at risk of developing further pressure ulcers. The resident's treatment plan included cleansing the ulcer with normal saline and Vashe, applying collagen and Opticell AG, and covering it with a foam dressing. During an observation, a treatment nurse applied the ordered treatment but failed to label the dressing with her initials and the date, which was confirmed by the nurse. Interviews with another treatment nurse, the infection preventionist, and the director of nursing revealed that labeling wound dressings with initials and dates is expected to ensure the treatment was completed and to prevent infection. The facility's policy on clean dressing changes also required securing the dressing with initials and the date, which was not followed in this instance.
Failure to Follow Physician's Order for Feeding Tube Care
Penalty
Summary
The facility failed to adhere to a physician's order regarding the care of a feeding tube for a resident, identified as Resident 107. The resident, who was admitted in October 2024, had medical conditions including Type 2 Diabetes and Dysphagia, and required assistance with personal care. The physician's order specified that the resident should receive a water flush of 200ml every 4 hours. However, during an observation, it was noted that the kangaroo epump was programmed to deliver 150ml every 6 hours, which did not match the physician's order. This discrepancy was confirmed by a licensed nurse during an interview, who acknowledged that the resident was receiving less fluid than prescribed. The Director of Nursing stated that the expectation was for nurses to follow the physician's orders, which should be reflected in the pump settings and water flush bag. A review of the facility's policy on feeding tube care indicated that feeding tubes should be used according to physician orders, including the volume and frequency of flushes. The failure to follow the physician's order placed Resident 107 at risk of receiving incorrect amounts of water flushes, potentially affecting their hydration and nutrition.
Failure to Follow Up on Resident's Surgery Date
Penalty
Summary
The facility failed to meet the medically related social services needs of a resident, identified as Resident 94, by not clarifying the date of her cranioplasty surgery with her primary physician. Resident 94, who was admitted to the facility with diagnoses including cerebral infarction, dysphagia, and depression, had a moderately impaired cognitive function as indicated by a BIMS score of 12 out of 15. After an appointment with her physician, Resident 94 and her husband returned to the facility with paperwork and a surgical kit prep, which was given to the nurse and kept in the medication room. Despite reminders from Resident 94 and her husband to the nursing and social services staff to follow up with the clinic regarding the surgery date, no action was taken. Interviews with the nursing and social services staff confirmed that they were aware of the need to follow up on the surgery date but failed to do so. The Director of Nursing expressed that the expectation was for the social services staff to clarify the surgery date and the reason for the surgical kit prep. The progress notes from August 2024 indicated that Resident 94 had a neurosurgery appointment and returned in stable condition, but no new orders were given, and the surgery was not scheduled at that time. The facility's job description for social services emphasized the responsibility to meet the medically related emotional and social needs of residents, which was not fulfilled in this case.
Medication Administration Errors Exceeding 5% Threshold
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 8.11%, which is above the acceptable threshold of 5%. This was observed during medication administration to two residents, where three errors occurred out of 37 opportunities. One error involved a Licensed Nurse (LN 3) administering a liquid inhalation medication, DuoNeb, to a resident after it had been removed from its foil pouch for more than two weeks, contrary to the product's labeling instructions. LN 3 admitted to not realizing the labeling requirement for the medication. Another error involved LN 3 crushing medications for a different resident without using gloves and without adhering to guidelines for medications that should not be crushed. Specifically, LN 3 crushed enteric-coated aspirin and finasteride, a hazardous drug, without realizing the risks involved. The Director of Nursing (DON) stated that staff were trained to follow computer prompts and could use online resources or drug books if unfamiliar with a medication. However, the Medication Administration Record did not provide warnings about non-crushable or hazardous drugs, contributing to the errors.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe medication storage practices in both the medication room and medication carts. In the Back Station medication room, expired, unlabeled, and undated medications were found, including an Osmolite bottle past its expiration date, an Omeprazole liquid bottle that was not discarded after 30 days as required, and an undated Aplisol Tuberculin Purified Protein vial. Additionally, an outdated influenza vaccine was found, and a staff drink bottle was improperly stored in the medication refrigerator. Two IV bags of Lactated Ringer's solution were also found without resident-specific labels. On Medication Cart #2, a pill cutter contained a pill and white powder, indicating improper cleaning and storage. A Pro-Stat AWC bottle had visible yellow/orange streaks, suggesting it was not properly wiped down after use. Hazardous medications were stored without proper labeling or instructions for safe handling on Medication Carts #1 and #4, including a bottle of Depakene and a bubble pack of Arimidex. Inhalation products like Ipratropium Bromide and Albuterol Sulfate were not dated or used within the recommended timeframe after being removed from their packaging. The Director of Nursing acknowledged these issues, stating that outdated medications should be removed from active storage and that products should be dated when opened. The facility's policy indicated that medications should be stored according to manufacturer recommendations and regularly inspected for expiration or deterioration. However, these practices were not consistently followed, leading to the deficiencies observed during the survey.
Inaccurate Documentation of Resident Diagnosis
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's diagnosis in the medical records, which may contribute to unsafe care and treatment. The deficiency was identified during interviews and record reviews involving the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The medical records of a resident, referred to as Resident 100, contained inconsistent and inaccurate documentation regarding the diagnosis for the use of the psychotropic medication olanzapine. The Discharge Summary indicated a history of dementia, heart disease, and bedsore infection, with olanzapine prescribed for dementia-related behavior. However, the Nursing Weekly Summary Review inaccurately included bipolar disorder as a diagnosis, which the ADON could not verify. Further discrepancies were noted in the Psychotropic Medication Consent document, which listed anxiety and bipolar disorder as indications for olanzapine, despite the ADON acknowledging these were incorrect. The Medical Doctor (MD 2) interviewed stated that the nursing staff should follow the documented diagnosis written by the medical provider, and the DON confirmed the use of bipolar indications was an error. The facility's policy on psychotropic medication use requires a comprehensive assessment and accurate documentation by the physician, which was not adhered to in this case.
Failure to Prevent Resident Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse. Resident 1, who has schizophrenia and major depressive disorder, was known for shouting racial slurs, including the N-word, in the hallway. Despite having a care plan in place to manage his verbally aggressive behavior, the facility did not effectively intervene to prevent these outbursts. Resident 2, who also has major depressive disorder and a history of poor impulse control, became frustrated with Resident 1's repeated use of racial slurs. This frustration culminated in an incident where Resident 2 slapped Resident 1 in the face after being provoked by the racial slurs. The incident was witnessed by staff members, including a CNA who observed Resident 2 tapping Resident 1's cheek after being provoked. Interviews with other residents and staff confirmed that Resident 1's behavior was a regular occurrence and that the facility staff had not taken adequate steps to address it. The facility's policy on reporting allegations of abuse and neglect was not effectively implemented, as evidenced by the lack of intervention to prevent the verbal and physical altercation between the residents.
Medications Found Unsecured in DON's Office
Penalty
Summary
The facility failed to ensure that medications were stored securely, as required by their policy and professional standards. During an observation, two bags containing approximately 30-40 bottles and boxes of medications were found on top of an unlocked cabinet in the Director of Nursing's (DON) office. The office door was open and unlocked, and the DON was not present. A female staff member was seen entering the office, and other staff members were walking in the hallway nearby. Additionally, a resident's room with three residents was located in front of the DON's office. The DON confirmed that the medications should have been stored in a locked compartment or room to prevent access by residents or staff, acknowledging the risk of medication misuse or drug diversion.
Failure to Adhere to Oxygen Tubing Replacement Policy
Penalty
Summary
The facility failed to meet professional standards of practice for a resident when the nasal cannula used for oxygen delivery was not labeled with an open date and the replacement schedule was longer than the facility's policy indicated. The resident, who had diagnoses including cirrhosis of the liver, diabetes, and chronic respiratory failure, was observed with a nasal cannula that lacked a label indicating when it was last changed. The resident mentioned that the nasal cannula was changed once every one or two months, which is inconsistent with the facility's policy of changing it every seven days. During an observation and interview, the Infection Preventionist confirmed that the nasal cannula did not have a label and that the tubing should not touch the floor. The Infection Preventionist also confirmed that the facility's policy required oxygen tubing to be changed every seven days, while the resident's order called for changes every 28 days. This discrepancy between the facility's policy and the resident's order increased the risk of bacteria buildup and infections, as timely changes were not being made.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an incident of alleged abuse involving a resident who had severe cognitive impairment and was non-English speaking. The resident reported to a Restorative Nursing Assistant (RNA) that he was hit twice on the chest by a Certified Nursing Assistant (CNA) the previous day. This incident was reported to the Director of Nursing (DON) and the Administrator, but the initial report was not sent to the appropriate authorities as required by the facility's policy and procedure. The facility's internal investigation initially deemed the incident as non-reportable, leading to a delay in notifying the necessary agencies. The resident reiterated the allegation two weeks later, prompting the facility to reconsider and report the incident to the Ombudsman, the California Department of Public Health (CDPH), and local law enforcement. The delay in reporting was attributed to the Administrator's decision to hold off on reporting due to inconsistencies in the resident's account of the incident. The facility's policy mandates that all allegations of abuse be reported to the state agency and other relevant authorities within two hours of obtaining knowledge of the incident, which was not adhered to in this case. Interviews with the DON and the Administrator revealed that the decision to delay reporting was based on the perceived inconsistencies in the resident's story and the belief that the incident was isolated. However, the facility's policy clearly states that all suspected abuse must be reported immediately. The failure to report the incident in a timely manner resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from harm.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a resident who was at risk for elopement. The resident, who had a history of cerebral infarction, mild cognitive impairment, and other medical conditions, was documented as having moderate cognitive impairment and was identified as at risk for elopement. Despite this, the resident managed to leave the facility multiple times on the same day. The resident was found outside the facility on several occasions, including once in the back parking lot and another time near a church. On the final occasion, the resident left the facility and did not return, prompting the staff to file a police report. Interviews and record reviews revealed that the facility did not notify the resident's responsible party, physician, or the Department of the elopement incidents. The Director of Nursing confirmed that there was no documentation of any scheduled appointments or leave of absence for the resident on the day of the incidents. The facility's policy on elopement and missing residents, which requires monitoring and evaluation of residents at risk for wandering and elopement, was not followed. The policy also mandates notifying the responsible party and primary care physician, which was not done in this case.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
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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