Clara Baldwin Stocker Home For Women
Inspection history, citations, penalties and survey trends for this long-term care facility in West Covina, California.
- Location
- 527 S Valinda Avenue, West Covina, California 91790
- CMS Provider Number
- 555832
- Inspections on file
- 44
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Clara Baldwin Stocker Home For Women during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a documented maintenance schedule for its two AC units and relied only on undocumented daily visual checks by maintenance staff. One AC unit was not working while a belt was being changed, and another had been nonfunctional previously. An AC technician reported that the units required monthly PM, including filter changes and testing of water valves and pneumatic controls, but these tasks were not part of the facility’s PM program. Review of the facility’s maintenance policy showed that the Maintenance Director was required to develop and maintain maintenance schedules for building systems, which was not done, creating the potential for residents in general to lack a comfortable environment.
A resident with encephalopathy, COPD, and dysphagia, who was cognitively impaired and dependent on staff for ADLs, had a physician order for weekly weights for four weeks after readmission. Review of the weight records showed the resident had not been weighed since an earlier documented date, and the resident’s name was missing from the facility’s weekly weight binder used to track residents needing weekly weights. The DON confirmed that weekly weights had not been obtained as ordered, despite a facility policy requiring weekly weights for newly admitted residents.
A resident requiring moderate assistance with daily activities was discharged to an assisted living facility without being offered choices or adequate time to consider alternatives. The family was not provided with a list of options, and the only facility presented was identified shortly before discharge, contrary to facility policy and the resident's need for family support.
A resident with severe cognitive impairment and multiple health conditions was observed with new discoloration and redness on the arm after reporting that a CNA had grabbed them during a transfer, causing pain. Two LVNs noted the resident's distress and reported the incident to the DON, who recognized it as a possible abuse case. Despite facility policy requiring abuse allegations to be reported to the State Agency within two hours, the report was delayed by two days.
The facility did not follow its policy for N95 fit testing, failing to test a newly hired CNA, which is required upon hire and annually. This oversight was acknowledged by the DSD and highlighted by the IPN as crucial for preventing airborne disease transmission.
Two residents with severe cognitive impairment had their call lights out of reach, leading to delayed assistance. One resident's call light was tucked under the mattress, while another's was hooked around a dresser. A CNA and the DON confirmed the importance of accessible call lights for safety and communication, as per facility policy.
The facility failed to adhere to physician orders and document care for three residents. A resident with seizures did not have padded side rails as ordered, hospice staff did not consistently document visits for another resident, and a STAT chest x-ray was delayed for a third resident. These deficiencies highlight lapses in following care plans and ensuring timely medical interventions.
The facility failed to prevent employee beverages from being stored in a kitchen refrigerator alongside resident food items, as observed during an inspection. The Dietary Supervisor confirmed that the beverages belonged to employees and acknowledged the risk of cross contamination. This practice was against the facility's policy, which prohibits storing employee food in the kitchen refrigerator.
The facility failed to maintain its infection prevention and control program, with unlabeled urinals in shared restrooms, a lack of disinfection of a pill counting tray by an LVN, insufficient hand hygiene supplies in the laundry area, and a Housekeeping Supervisor not performing hand hygiene after touching the dumpster. These deficiencies could lead to cross-contamination and increased infection risk among residents and staff.
A facility failed to conduct a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by policy. The resident, with multiple medical conditions, needed an interpreter to communicate effectively. Staff attempted to communicate using non-verbal cues without any tools, which was inadequate. A nurse confirmed the necessity of a communication assessment to provide proper care.
A facility failed to implement a person-centered care plan for a resident who only spoke Arabic, despite the resident's need for an interpreter being documented. The resident, with conditions including hemiplegia and dysphagia, was observed attempting to communicate with staff who did not use any communication tools. The absence of a communication care plan was confirmed by a Registered Nurse, highlighting a deficiency in meeting the facility's policy for effective and person-centered care.
A resident who spoke Arabic was not provided with communication tools, hindering effective communication of care needs. Despite the facility's policies on language access, staff relied on gestures and limited English, failing to use appropriate resources to assist the resident, who had multiple medical conditions requiring clear communication.
A resident receiving hemodialysis did not have an emergency kit at their bedside, which is crucial for addressing potential bleeding emergencies. The resident, with end-stage renal disease and type 2 diabetes, required dialysis thrice weekly. An LVN could not find the kit during an inspection, and the DON confirmed the facility's policy did not explicitly require it, despite its necessity for immediate response.
A resident with an indwelling foley catheter was observed with dark amber urine containing sediments, indicating a potential infection. Despite daily catheter care, the abnormal urine appearance was not reported to the physician, contrary to the facility's policy. The resident had a history of Alzheimer's, psychosis, and hypertension, and the catheter was ordered due to uropathy.
A facility failed to provide an emergency kit at the bedside of a resident requiring hemodialysis, potentially delaying emergency treatment. The resident, with end-stage renal disease and diabetes, needed dialysis thrice weekly. An LVN could not find the kit, which is crucial for addressing bleeding from the dialysis site. The DON confirmed the policy did not specify the need for a bedside kit, leading to the deficiency.
A facility failed to justify the use of fluoxetine for a resident with dementia and mild depression, lacking documentation for a gradual dose reduction (GDR) and non-pharmacological interventions. Staff interviews indicated the resident did not show depressive symptoms, and the prescriber did not document why GDR was contraindicated, contrary to facility policy.
The facility failed to properly label and discard medications in Med Cart 2, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer, which were not marked with an opened date. Staff interviews revealed inconsistencies in following the facility's protocol, which required labeling to ensure medications were not used past the recommended due date. The facility's policy required proper labeling in accordance with guidelines, indicating a lapse in adherence.
The facility failed to secure its premises, leaving the back door unlocked after dark and allowing unauthorized access. Observations showed the staff parking area gate was open, and several LVNs were unaware of how to lock the facility doors. The DON acknowledged the broken gate chain and emphasized the importance of locking doors for safety. Despite policies on safety, staff lacked training on securing the facility, putting 37 residents at risk.
The facility failed to provide adequate isolation supplies for two residents with C. diff infection, as they did not have their own package of incontinent wipes during the night shift. Staff interviews revealed a lack of sufficient wipes and uncertainty about obtaining more supplies, contrary to the facility's policy requiring dedicated equipment for isolated residents.
A resident with severe cognitive impairment was not readmitted to the first available bed at the facility after hospitalization, violating the facility's policy. Staff interviews confirmed the refusal was against policy, and the Administrator later acknowledged the error.
Failure to Maintain AC Preventative Maintenance Schedule and Critical Component Testing
Penalty
Summary
The facility failed to maintain a documented maintenance schedule for its two air conditioning (AC) units and did not include testing of water valves and pneumatic controls in its preventative maintenance program. During interviews, the Maintenance Supervisor (MS) reported that the facility had two AC units, with the front unit currently working and the back unit not working due to a belt change. The MS stated that the front unit had not been working approximately two months earlier. The MS explained that the only preventative maintenance performed on the AC units was a daily visual inspection, and that the facility did not keep any log or documentation of these daily checks. In a telephone interview, the AC technician stated that they had been called to the facility a few weeks earlier for AC issues and indicated that the facility’s AC units required monthly preventative maintenance, including changing filters, testing water valves, and testing pneumatic controls. The MS reported that the AC technician had previously informed them that the problem with the AC unit was related to water valves on the roof that needed to be exercised (opened and closed). Review of the facility’s Maintenance Service policy, revised December 2009, showed that the Maintenance Department was responsible for maintaining buildings, grounds, and equipment in a safe and operable manner, providing routinely scheduled maintenance service, and that the Maintenance Director was responsible for developing and maintaining a schedule of maintenance service and maintaining maintenance schedules. The failure to maintain such schedules and to include testing of water valves and pneumatic controls in preventative maintenance had the potential for residents in general not to have a comfortable environment while at the facility.
Failure to Obtain Ordered Weekly Weights for Newly Admitted Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to obtain weekly weights as ordered and as required by its own policy. A resident was admitted with diagnoses including encephalopathy, COPD, and dysphagia, and was documented on the MDS as having moderately impaired cognitive skills and being dependent on staff for bathing, dressing, and toileting hygiene. The physician’s order summary dated 3/31/2026 directed that the resident be weighed weekly for four weeks following readmission. However, review of the Weights and Vitals Summary on 4/28/2026 showed that the resident had not been weighed since 4/3/2026, despite the active weekly weight order. During a concurrent interview and record review with the DON on 4/28/2026, the facility’s Weekly Weight Binder, which lists all residents requiring weekly weights, was examined. The resident’s name was not included in this binder, and the DON acknowledged that the resident should have been weighed weekly for four weeks due to the recent readmission. The DON confirmed that the resident had not been weighed weekly since readmission. The facility’s undated Weight Change Protocol policy stated that residents are to be weighed monthly and weekly for newly admitted residents, but this protocol was not followed for this resident.
Failure to Ensure Resident Discharge Location Met Needs and Preferences
Penalty
Summary
The facility failed to ensure that a resident's discharge location met the resident's needs for family support and resources. The resident, who had a history of pneumonia and falls, required partial to moderate assistance with activities of daily living and mobility, as documented in the Minimum Data Set and Physical Therapy Discharge Summary. Despite these needs, the discharge planning process did not provide the resident or their family member with choices regarding potential discharge locations. The family member reported that no options were offered and that the only assisted living facility (ALF) presented was provided on the day of discharge, leaving insufficient time to evaluate alternatives or appeal the decision due to external circumstances. Interviews with facility staff, including the case manager, social services director, and director of nursing, confirmed that the resident and family were not given a list of ALFs to consider and that there was no documentation of other options being discussed. The case manager indicated that the ALF was found within 48 hours before discharge, and the family was informed that if they did not agree to the transfer, they would need to pay for additional days until a safe placement was found. The facility's policy required assisting residents in selecting a post-acute care provider relevant to their goals and preferences, but this was not followed in this case.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its Abuse Prevention Policy by not reporting an allegation of staff-to-resident physical abuse to the State Agency within the required two-hour timeframe. A resident with severely impaired cognitive skills and multiple medical diagnoses, including hypertensive heart disease with heart failure and rheumatoid arthritis, was observed by two LVNs to have discoloration and redness on the right forearm. The resident indicated that a CNA had grabbed their arm during a transfer, causing pain and visible marks. Both LVNs noted the resident appeared upset and frustrated, and one LVN confirmed the discoloration was not present earlier that same morning. The incident was reported by the LVN to the DON on the same day it occurred, and the DON acknowledged that the situation constituted a possible case of physical abuse, which should have been reported to the State Agency within two hours according to facility policy. However, the allegation was not reported until two days later. The facility's policy, reviewed by surveyors, clearly states that all allegations of abuse must be reported within the federal requirement timeframe, which was not adhered to in this case.
Failure to Conduct N95 Fit Testing for New Staff
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding N95 fit testing, as outlined in their document titled 'N95 Fit Testing.' This policy mandates that all employees must be fit tested for an N95 respirator upon hire and annually, in accordance with OSHA's Respiratory Protection Standard. However, one of the four sampled staff members, a Certified Nurse Assistant (CNA 4), was not fit tested upon hire. CNA 4 began working at the facility on February 3, 2025, and confirmed during an interview on February 25, 2025, that they had not been fit tested for the N95 mask. The Director of Staff Development (DSD) acknowledged during a concurrent interview and record review that CNA 4 should have been fit tested before starting work, as per the facility's policy. The Director of Nursing (DON) reiterated the requirement for fit testing upon hire and annually. The Infection Prevention Nurse (IPN) emphasized the importance of fit testing to prevent the transmission of airborne diseases between employees and residents. The failure to conduct the fit testing had the potential to result in the spread of COVID-19 and other airborne diseases within the facility.
Plan Of Correction
F 880 It is the policy of the facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicated disease and infections. Corrective Action for Resident found to have been affected by this deficiency: No Resident was identified to have been affected by this deficiency. Identification of Other Residents having the potential to be affected by the same deficient practice and corrective action that will be taken: All Residents have the potential to be affected by this deficiency. On 2/25/2025, the IP Nurse designee completed N95 Fit Testing for CNA 4. What measures will be put into place to ensure that the deficient practice does not recur: On March 14, 2025, the DON inserviced the IP LVN Designee on the facility's policy and procedure on N95 Fit Testing; including that all new hire employees must have N95 Fit Testing upon hire and before being assigned to work with any Resident(s) and annually thereafter. On February 25, 26, and 27, 2025, the IP LVN Designee completed an N95 Fit Testing Audit on all current Employees. There were no additional employees identified as not having been N95 Fit Tested upon hire. There were 15 current employees identified as not being current with annual N95 Fit Testing. On February 28, 2025, the IP LVN Designee completed N95 Fit Testing on the identified 15 employees. On March 14, 2025, the DON gave a 1:1 inservice to the IP LVN Designee on the facility's policy and procedures on N95 Fit Testing; including that all new hires must have N95 Fit Testing upon hire and before being assigned to any Resident(s), and annually thereafter. Measures that will be implemented to ensure that solutions are sustained: The IP LVN Designee will conduct monthly audits X 3 months on all new hire employees and all employees due for the prior months' annual N95 Fit Testing to ensure that all current employees are compliant with the facility's policy and procedures on N95 Fit Testing. Results of the monthly audits will be documented on the Quality Improvement Audit Tool. The documented results will be forwarded to the QA & A Committee monthly X 3 months for review and action planning as indicated or until the QA & A Committee determines compliance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide reasonable accommodation to meet the needs of two residents by not ensuring that their call lights were within reach. Resident 21, who was admitted with diagnoses including anxiety disorder and failure to thrive, had severe cognitive impairment and required substantial assistance with activities of daily living. During an observation, it was noted that Resident 21's call light was tucked below the bed mattress, making it inaccessible. The resident expressed being wet and unable to call for assistance, highlighting the deficiency in care. Similarly, Resident 25, who had severe cognitive impairment and was dependent on assistance for daily activities, also had an inaccessible call light. The call light was found hooked around a small dresser drawer, out of the resident's reach. Interviews with a CNA and the DON confirmed the importance of call lights for resident safety and communication, emphasizing that they should always be within reach. The facility's policy on call lights, which mandates their accessibility, was not adhered to, resulting in delayed service provision and potential negative impacts on the residents' well-being.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and professional standards for three residents. Resident 15, who had a history of seizures, was not provided with bilateral padded side rails as ordered by the physician to prevent injury during seizure episodes. Despite the care plan and physician orders indicating the need for padded side rails, observations confirmed their absence, and staff interviews highlighted the importance of adhering to such orders for resident safety. Resident 23, who was receiving hospice care, did not have consistent documentation of hospice staff visits as required. The hospice staff were supposed to sign in during each visit, but the sign-in sheets did not reflect the frequency of visits as per the staff assignment. Interviews with facility staff emphasized the necessity of proper documentation to ensure coordinated care and communication between hospice and facility staff, which is crucial for providing end-of-life care. Resident 38, who had severe cognitive impairment and multiple health issues, did not receive a STAT chest x-ray as ordered by the physician. The x-ray was intended to address respiratory concerns, but due to delays with the diagnostic imaging company, the x-ray was not performed in a timely manner. The Director of Nursing acknowledged the issue and stressed the importance of following STAT orders promptly to allow for immediate medical interventions if necessary.
Improper Storage of Employee Beverages in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure that personal beverages for employees were not stored in one of the kitchen refrigerators, specifically Refrigerator 1. During an observation and interview with the Dietary Supervisor, two Starbucks beverages with plastic open tops were found in the refrigerator next to resident food items. The Dietary Supervisor acknowledged that the beverages belonged to employees and should not have been stored in the refrigerator due to the potential for cross contamination. A review of the facility's policy and procedure titled 'Employee Meals,' dated 2018, indicated that food brought by employees from outside the facility should not be kept in the facility's refrigerator in the kitchen.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain its infection prevention and control program, as evidenced by several deficiencies observed during the survey. In shared restrooms used by residents, urinals were found unlabeled, which could lead to cross-contamination. Certified Nurse Assistant (CNA) 3 and the Infection Preventionist Nurse (IPN) confirmed that urinals should be labeled with the resident's initials and room number to prevent the spread of infectious diseases. This oversight was noted in restrooms shared by residents with severe cognitive impairments and those requiring assistance with activities of daily living. Additionally, a Licensed Vocational Nurse (LVN) did not disinfect the pill counting tray before and after use, which is a critical step in infection control. The LVN acknowledged the failure to clean the tray, which could result in drug residue and potential cross-contamination. The Infection Preventionist Nurse emphasized the importance of disinfecting the tray to prevent drug interactions and allergies. The facility also lacked sufficient hand hygiene supplies in the laundry area, which did not have a sink, soap, paper towels, or alcohol-based hand sanitizer. The Housekeeping Supervisor (HS) failed to perform hand hygiene after touching the dumpster, acknowledging the need for at least an alcohol-based hand sanitizer in the area. The facility's policy on hand hygiene stresses the importance of readily accessible supplies to prevent the spread of infections, highlighting the deficiency in the laundry area.
Failure to Conduct Communication Assessment for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop a comprehensive communication assessment for a resident who primarily spoke Arabic, as required by the facility's policy and procedure. The resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) indicated that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the resident's preferred language. However, the resident was not assessed regarding their ability and preferred way of communication upon admission, which was a requirement according to the facility's policy. Observations and interviews revealed that staff members, including a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN), attempted to communicate with the resident without using any communication tools, despite acknowledging the resident's language barrier. The staff relied on non-verbal cues such as facial expressions and pointing, which was inadequate for understanding the resident's needs. A Registered Nurse (IPN) confirmed that a communication assessment should have been conducted to address the resident's preferred language, emphasizing the importance of such an assessment for providing proper care.
Failure to Implement Person-Centered Care Plan for Non-English Speaking Resident
Penalty
Summary
The facility failed to develop or implement an individualized person-centered care plan for a resident who only spoke and understood Arabic. This deficiency was identified during a review of the resident's admission record, which indicated the resident was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss. The Minimum Data Set (MDS) assessment noted that the resident needed or wanted an interpreter to communicate with healthcare staff due to Arabic being the preferred language. Despite this, the facility did not have a communication care plan in place for the resident, which was confirmed during an interview with the Registered Nurse (IPN) who reviewed the resident's charts and acknowledged the absence of such a plan. Observations and interviews with facility staff further highlighted the communication barriers faced by the resident. A Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN) both attempted to communicate with the resident without using any communication tools, relying instead on gestures and facial expressions. The LVN acknowledged the importance of providing a form of communication to understand the resident's needs and wants. The facility's policy on baseline care plans, which was revised in 2016, requires the inclusion of instructions needed to provide effective and person-centered care, yet this was not adhered to in the case of the resident in question.
Failure to Provide Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide a communication tool or resources for a resident who spoke Arabic, which hindered effective communication of the resident's needs. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, psychosis, and hearing loss, was noted to require an interpreter to communicate with healthcare staff. Despite this, the facility did not provide any communication aids, and staff attempted to communicate using non-verbal cues such as facial expressions and pointing, which were inadequate for the resident's needs. Observations and interviews revealed that staff, including a CNA and an LVN, did not utilize any communication tools when interacting with the resident, relying instead on gestures and limited English. The facility's policies on language access and interpreter services were not followed, as staff did not provide the necessary resources to ensure meaningful communication. This deficiency had the potential to impact the resident's ability to convey care needs effectively, as highlighted by the staff's acknowledgment of the importance of communication in determining the resident's needs.
Failure to Provide Emergency Kit for Hemodialysis Resident
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had an emergency kit available at their bedside, which is necessary for immediate response in case of bleeding from the dialysis site. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation and interview, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, acknowledging that it should have been present to quickly address any potential bleeding emergencies. The Director of Nursing (DON) confirmed that the facility's policy on Hemodialysis Access Care did not specifically mention the need for an emergency kit at the bedside, but emphasized its importance due to the resident's condition. The policy outlined the steps to take in case of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require the presence of an emergency kit. This oversight had the potential to delay critical treatment for the resident during an emergency.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling foley catheter, which was observed to have dark amber urine with sediments. This observation was made during an interview with an LVN, who acknowledged that the presence of sediments could harm the resident and indicated a potential infection. The LVN stated that the resident's physician should have been informed to determine the cause of the abnormal urine appearance. The resident, who was admitted with diagnoses including Alzheimer's Disease, psychosis, and hypertension, had a physician's order for an indwelling foley catheter due to uropathy, with instructions to change the catheter or bag as needed. Further interviews with a Registered Nurse revealed that catheter care was performed daily, and the presence of sediments was a sign of infection. The resident's care plan aimed to prevent urinary infections and included monitoring and reporting symptoms such as pain, burning, blood-tinged urine, and cloudiness to the physician. However, the facility's policy on catheter care, which was intended to prevent catheter-associated urinary tract infections, was not adequately followed, as the abnormal urine appearance was not reported to the physician or supervisor immediately.
Failure to Provide Emergency Kit for Dialysis Resident
Penalty
Summary
The facility failed to provide an emergency kit at the bedside of a resident who required hemodialysis, which could potentially delay treatment during an emergency. The resident, who was admitted with end-stage renal disease and type 2 diabetes mellitus, required hemodialysis three times a week. During an observation, a Licensed Vocational Nurse (LVN) was unable to locate the emergency kit in the resident's room, which is necessary to quickly address any bleeding from the dialysis site. The Director of Nursing (DON) confirmed that the facility's policy did not specifically mention the need for an emergency kit at the bedside, but acknowledged its importance in case of major bleeding post-dialysis. The policy outlined the steps to take in the event of major bleeding, including applying pressure to the site and contacting emergency services, but did not explicitly require an emergency kit to be readily available. This oversight in policy and practice led to the deficiency noted by the surveyors.
Lack of Clinical Justification for Fluoxetine Use in Resident
Penalty
Summary
The facility failed to ensure that a resident's use of fluoxetine, a medication for depression, was clinically justified and that a gradual dose reduction (GDR) was not contraindicated. The resident, who was diagnosed with dementia and mild, recurrent major depressive disorder, was receiving fluoxetine without clear documentation of the necessity for its continued use or evidence of non-pharmacological interventions prior to its initiation. The resident's care plan indicated interventions for resistance to care due to dementia, but there was no documentation of depressive symptoms or behaviors that would justify the use of fluoxetine. Interviews with facility staff, including a CNA, LVN, and the DON, revealed that the resident did not exhibit signs of depression, such as sadness or crying, and often complied with care after initial refusal. The consultant pharmacist recommended a GDR, but the prescriber did not provide documentation to justify why a reduction was contraindicated. The facility's policy required determining the cause of behaviors before using psychotropic medications, but this was not documented in the resident's case.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and medications used were labeled properly and discarded according to professional standards. During an observation, it was found that Med Cart 2 contained multiple opened house supply medications, including a bottle of Geri Care Stool Softener and a box of Alka-Seltzer Buffered aspirin, which were not marked with an opened date. This was contrary to the facility's protocol, which required labeling with an opened date to ensure medications were not used past the recommended due date, typically ninety days from opening. Interviews with staff revealed inconsistencies in the application of the facility's protocol. LVN 2 indicated that staff followed the manufacturer's expiration date rather than labeling with an opened date, while the Director of Nursing emphasized the importance of labeling to ensure medication effectiveness. LVN 6 acknowledged that the opened pouch of Alka-Seltzer should have been discarded for infection control. The facility's policy, revised in April 2019, required all medications to be properly labeled in accordance with state and federal guidelines, highlighting a lapse in adherence to these standards.
Facility Security Lapses Lead to Safety Risks
Penalty
Summary
The facility failed to ensure that unauthorized individuals did not enter the premises undetected, as the back door remained unlocked after dark. Observations revealed that the gate to the staff parking area was wide open, providing easy access to the facility's back door, which was also unlocked. Interviews with several Licensed Vocational Nurses (LVNs) indicated that they were unaware of how to lock the facility doors, and the back door had been left unlocked consistently during the night shifts for weeks. The Director of Nursing (DON) acknowledged that the chain to the gate of the staff parking area had broken, and the gate was supposed to be locked with a passcode. However, the DON was unaware of the exact date when the chain broke. The DON emphasized the importance of locking the facility doors for the safety of the property, residents, and employees. Despite this, the LVNs and Certified Nursing Assistants (CNAs) interviewed did not know how to lock the facility doors, and some were not shown how to do so when they started working at the facility. The facility's policy and procedure on safety and supervision of residents highlighted the importance of making the environment free from accident hazards and ensuring resident safety through employee training and monitoring. However, the lack of knowledge among staff about locking the facility doors and the broken gate chain indicated a failure to adhere to these policies. The facility's failure to secure the premises placed all 37 residents at risk for accident hazards and harm.
Failure to Provide Adequate Isolation Supplies for C. diff Patients
Penalty
Summary
The facility failed to implement its policy and procedure for isolation and transmission-based precautions, specifically for two residents diagnosed with Clostridium difficile (C. diff) infection. Both residents were placed on contact isolation, but during the night shift, they did not have their own package of incontinent wipes in their isolation rooms. This oversight was identified during interviews with staff, including CNAs and LVNs, who reported a lack of sufficient wipes for the entire shift and uncertainty about how to obtain more supplies during the night shift. The facility's policy required that non-critical resident-care equipment be dedicated to a single resident when possible, which was not adhered to in this case. Interviews revealed that the housekeeper typically provided one package of wipes per shift and placed one package in each isolation room in the morning. However, during the night shift, there was no clear process for obtaining additional wipes, leading to a potential risk of infection spread. The Director of Nursing and the Infection Prevention Nurse confirmed the necessity of having dedicated wipes in isolation rooms to prevent cross-contamination.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident to the first available bed after hospitalization, as required by their policy. The resident, who had severe cognitive impairment and was initially admitted with diagnoses including Parkinson's Disease and hyperlipidemia, was transferred to a General Acute Care Hospital (GACH) due to refusal of all oral intake. Upon being ready for discharge from the GACH, the facility's case manager refused to accept the resident back, citing the absence of a bed hold, despite the facility's policy allowing for readmission to the first available bed. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and Director of Staff Development (DSD), confirmed that the refusal to readmit the resident was against the facility's policy. The DON and DSD both stated that the facility should not refuse readmission unless the resident's condition is severe and imminently dangerous or if the resident poses a threat to themselves or others. The Administrator acknowledged the error and instructed the case manager to accept the resident back, but the initial refusal constituted a violation of the resident's rights to resume residency at the facility.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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