Delta Oaks Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 6940 Pacific Avenue, Stockton, California 95207
- CMS Provider Number
- 055735
- Inspections on file
- 90
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Delta Oaks Post Acute during CMS and state inspections, most recent first.
A resident being discharged for non-payment did not receive a complete and timely 30‑day transfer/discharge notice, and the State LTC Ombudsman was not notified as required. The initial notice listed the same day as the effective discharge date, omitted the discharge destination, and was not copied to the Ombudsman. The resident reported not receiving a copy of the 30‑day notice. Staff confirmed that the Ombudsman was not notified when the initial notice was issued and that the facility’s practice was to fax notices on the day of discharge. After a board‑and‑care destination was identified, an updated notice including the location was created but not signed by the resident until the day of discharge, and it was faxed to the Ombudsman shortly before the resident left. Facility policy requires that notices include the specific destination, be given at least 30 days in advance, be sent to the Ombudsman at the same time as to the resident, and that significant changes such as a new destination trigger a new notice and reset of the 30‑day period.
A resident with multiple sclerosis was originally care planned as a long-term placement on the skilled nursing unit, but later expressed a desire to discharge closer to a significant other and then to the community, with progress notes documenting evolving discharge plans and a completed discharge evaluation and discharge planning communication form. Despite these documented changes and initiation of a 30-day transfer/discharge notice by social services and the business office, the comprehensive care plan in the EHR was never revised to include a discharge plan and continued to list the resident as a long-term placement. The DON confirmed there was no discharge care plan, and the SSD acknowledged responsibility for discharge planning and that the care plan had not been properly updated, contrary to facility policy requiring ongoing review and revision of care plans to address discharge goals and preparation.
A dependent, cognitively impaired resident with anoxic brain damage and chronic respiratory failure, who was nonverbal and required total assistance for all ADLs and bed mobility, was being provided clothing, bedding, and hygiene care by a CNA working alone on a raised LAL mattress. Despite documented requirements and unit expectations for a two-person assist for residents on LAL mattresses and for major care, the CNA elevated the bed, stood on one side, and rolled the resident away from herself, with only small head rails up and no floor mats in place. The resident, known to wiggle unpredictably during care, began moving her legs, which slipped off the slippery LAL surface; the CNA was unable to maintain her hold, and the resident fell from the elevated bed onto the concrete floor. The resident sustained a chin laceration requiring sutures, an acute C1 fracture, and multiple bruises and skin injuries, and records and staff interviews confirmed that the fall was attributed to providing care without the required second staff member and improper positioning during the maneuver.
Multiple infection control lapses were observed, including an RN performing tracheostomy inner cannula care and suctioning for a resident without hand hygiene between glove changes, an LPN administering medications via G-tube to a resident on Enhanced Barrier Precautions while initially omitting the required gown, and CNAs moving a shower chair used for a resident on Contact Precautions into a hallway without sanitizing it, where another CNA attempted to use it assuming it was clean. The IP and DON confirmed these actions did not meet facility expectations for hand hygiene, PPE use, and cleaning of shared equipment.
A resident with multiple comorbidities, including atrial fibrillation and existing antiplatelet therapy, was mistakenly given another resident’s heparin injection and levetiracetam via G-tube when an LN used the wrong MAR and failed to follow the rights of medication administration or verify the resident’s identity per facility policy. The resident, already care planned as being at risk for bleeding due to anticoagulation/antiplatelet therapy, later experienced coffee-ground emesis and was transferred to the hospital, where records documented a diagnosis of coffee-ground emesis and low hemoglobin. The DON and MD confirmed the event was a medication error, with the MD acknowledging heparin as a high-alert medication and facility policy explicitly prohibiting administration of one resident’s medications to another.
A nurse was observed preparing about seven medications, placing them in a medication cup on top of an unlocked medication cart, and then walking away, leaving both the medications and the cart unattended. In a later interview, the nurse acknowledged that medications should have been removed from the top of the cart and the cart locked before leaving. The DON confirmed that facility policy requires medication carts to be closed and locked when out of the nurse’s sight, with no medications kept on top of the cart, and that carts must remain locked whenever they are out of the nurse’s view.
The facility failed to conduct and document required quarterly IDT care conferences for three residents with complex conditions, including SAH, CVA, hypertension, and diabetes. Policy required the IDT—comprising the attending physician, RN, dietary, social services, activities, and nursing—to develop a comprehensive care plan after the MDS and to evaluate and update it at least quarterly with resident or representative participation when practicable. Record review showed only sporadic IDT meetings tied to specific issues such as skin concerns, falls, weight, hospice, and discharge, with gaps in quarterly conferences and missing or undocumented attendance. In interviews, the DON confirmed that quarterly IDT conferences were not consistently completed, and a responsible party reported not having participated in care plan discussions for about a year, acknowledging that facility policy was not followed.
A resident with severe cognitive impairment and total dependence for care developed a left shoulder dislocation of unknown origin after an RP noticed shoulder pain and requested an x-ray. Nursing staff documented the complaint, obtained an MD order, and the x-ray later confirmed an anterior shoulder dislocation without fracture, leading to transfer to the ER. The DON acknowledged the injury met the definition of an injury of unknown origin, and the ADM reported relying on the RP’s belief that contractures caused the injury, did not document that conversation, and did not suspect abuse. The facility did not investigate or report this serious injury of unknown source to the Department as required by its abuse P&P and federal and state reporting regulations.
A resident with a history of neurological and medical conditions developed left shoulder pain and discomfort noted by the responsible party, who requested an x‑ray after observing grimacing when the shoulder was touched. Nursing staff documented recent incontinent care and repositioning, notified the MD, obtained an order for a left shoulder x‑ray, and administered PRN pain medication. The x‑ray later showed a left anterior shoulder dislocation without acute fracture, and the resident was sent to the ER for treatment. During subsequent interviews, the DON, SSD, ADON, and Administrator acknowledged that no investigation was initiated to determine the cause of this injury of unknown origin or to rule out abuse or neglect, despite facility policy requiring investigation and reporting of injuries of unknown source.
A resident with a history of SAH, TBI, and HTN sustained a left shoulder dislocation, after which the care plan and MD orders were updated to include ER transfer, pain management, immobilization of the left upper extremity, and a restriction on RNA services to the affected shoulder. The PT and RNAs adjusted PROM to exclude the injured shoulder, continued PROM to the right upper extremity, and used two-person assistance with a sling and pillows for repositioning, while noting that the responsible party opposed upper arm PROM and showers. Despite these changes and the facility’s policy and RAI criteria requiring a Significant Change in Status Assessment (SCSA) when there is a major change affecting multiple health areas and necessitating IDT review and care plan revision, the MDS-C confirmed that no SCSA was completed for this resident.
A resident with osteomyelitis, a PICC line for IV Ertapenem, insulin‑dependent type 2 DM, and on Heparin for DVT prophylaxis signed out for a self‑scheduled medical appointment and did not return at the time staff expected. Nursing notes and interviews show that although staff recognized the resident was overdue and unsuccessfully attempted phone contact with the resident and his family, they delayed notifying the MD and did not contact law enforcement until the following morning, contrary to facility elopement and out‑on‑pass policies. During the approximately 29‑hour absence, the resident missed scheduled IV antibiotic, insulin, and Heparin doses, and later hospital testing showed positive methamphetamine and opiate screens. The facility’s own policies required timely verification of authorized leave, immediate activation of missing resident procedures, and prompt notification of administration, the MD, and police, which were not followed in this case.
A resident with ESRD on dialysis and sequelae of cerebral infarction was identified through an Elopement Evaluation as being at risk for elopement, but no corresponding elopement care plan was developed. During interview and record review, the DON confirmed the absence of an elopement care plan, acknowledged that one should have been in place, and stated that comprehensive care plans guide staff interventions and vigilance when a resident may try to leave. Review of the facility’s wandering and elopement P&P showed it requires residents identified as at risk for wandering or elopement to have care plan strategies and interventions for safety, which were not implemented for this resident.
A resident with polyneuropathy, gout, and a stage 4 sacral pressure injury had physician orders for PRN acetaminophen for mild pain and hydrocodone/acetaminophen via G-tube for pain levels 5–10, assessed using the PAINAD scale. Nursing staff, including an LN who was reluctant to use hydrocodone/acetaminophen, used their own judgment rather than the ordered pain scale parameters, administering acetaminophen when documented pain scores were high and hydrocodone/acetaminophen when pain scores were low or zero. Review of the MAR and confirmation by the DON showed that pain medications were not given according to the physician’s orders or the care plan, resulting in the resident’s pain not being effectively managed.
A resident with a history of agitation was involved in a verbal altercation with another resident and attempted to hit them, prompting an IDT care conference that recommended a psychiatric evaluation and treatment for agitation. The physician entered an order for a psych evaluation, but the ADON and social services staff were unsure whether the referral was completed, and the SSA, who was responsible for sending referrals, had no access to the psychiatrist’s portal and found no psych notes in the EHR. The DON confirmed the order for psychiatric services, the absence of psychiatric documentation in the chart, and acknowledged that without the psychiatrist’s recommendations the facility would not be compliant with psychiatric services and the resident’s psychosocial health would be affected.
A deficiency was found when a garbage dumpster lid was observed left open, as confirmed by multiple staff including the DSD, IP, and DON. Facility policy requires dumpster lids to be closed when not in use to prevent pests and infection, but this was not followed, resulting in non-compliance with established procedures.
Staff failed to maintain resident dignity by standing over two residents while assisting with meals instead of sitting at eye level, as required by policy. Additionally, multiple residents who required incontinence care were left without necessary briefs due to a supply shortage, leading staff to instruct them to urinate or defecate in their beds or use makeshift alternatives. Residents reported feelings of embarrassment and loss of dignity, and staff confirmed the lack of supplies and the actions taken during the shortage.
The facility did not ensure safe water temperatures in resident bathrooms, with some areas exceeding 120°F, and failed to complete a required post-fall mobility assessment for a resident with dementia and diabetes after a bathroom fall. Staff acknowledged the risks of high water temperatures and the importance of post-fall assessments, but facility policies were not followed in these instances.
A nurse left oral medications at a resident's bedside for self-administration, despite facility policy requiring staff to remain with the resident until all medications are taken and to observe ingestion. The resident, who had advanced CKD and was on dialysis, had not been evaluated for self-administration, and the DON confirmed this practice was not permitted.
Surveyors found that drugs and biologicals were not properly stored or labeled, with dirty air-conditioning filters placed on medication refrigerators, soiled Drug Buster bottles in medication carts, and pill cutters with residue. Several medications and sterile supplies were opened without being labeled with the date opened, and opened single-use wound care supplies were available for use, contrary to policy and manufacturer instructions. Staff confirmed these practices did not meet facility standards for cleanliness and safe medication handling.
Surveyors identified several food safety and sanitation deficiencies, including the presence of moldy produce in the refrigerator, uncovered frozen foods in the freezer, worn and unsanitary kitchen equipment, incomplete food cool down logs, and a two-compartment sink lacking an air gap. These issues were confirmed by dietary staff and had the potential to cause cross-contamination and foodborne illness for residents receiving facility-prepared meals.
Staff failed to follow infection control protocols, including improper storage and replacement of urinals for a resident with multiple health conditions, leaving food and drink in another resident's room which attracted pests, and not disinfecting a glucometer according to manufacturer guidelines. These actions did not comply with facility policies and increased the risk of infection.
A resident with multiple chronic conditions was readmitted, but staff did not develop a baseline care plan within 48 hours as required. Both a nurse and the MDS coordinator confirmed the omission, which was not in line with facility policy and left staff without documented instructions for immediate care.
Two residents prescribed blood thinners did not have individualized care plans developed to monitor for side effects or risks associated with their medications. Nursing staff and the DON confirmed that no care plans or monitoring orders were in place, despite facility policy requiring comprehensive, resident-centered care plans for all medical needs.
A resident with hemiplegia, hemiparesis, and functional quadriplegia, who was dependent on staff for ADLs and had documented severe ROM impairments in multiple joints, was not provided with restorative nursing therapy or passive ROM exercises despite facility policy and staff acknowledgment that such services were needed.
A resident with chronic congestive heart failure and on diuretic medication did not have water within reach on multiple occasions, as staff moved the bedside table and failed to return it. Staff interviews confirmed the importance of water access for this resident, and facility policy required regular provision and encouragement of fluids.
A resident with cerebral palsy repeatedly requested transfer to a facility closer to home, but staff failed to proactively pursue alternate placement or document referral efforts as required. The lack of action and documentation led to the resident's emotional distress, including a reported episode of self-harm, and staff confirmed that facility policy was not followed.
Two residents received Midodrine outside of physician-ordered hold parameters, with the medication administered 13 times for each resident when their systolic blood pressure was above the specified threshold. Nursing staff and the DON confirmed that the medication was given in error, despite facility policy and staff awareness of the required parameters.
The facility was found to have a medication error rate of 6.25% after two residents received medications incorrectly: one received insulin after a meal instead of before as ordered, and another received only one drop of prescribed eye medication per eye instead of two. Nursing staff acknowledged the errors, and the DON confirmed expectations for adherence to medication administration protocols.
Two residents were not properly offered or educated about flu and pneumococcal vaccines, and there was no documentation of consent or refusal in their medical records. One resident did not receive the flu vaccine for two years, and another was not offered the pneumococcal vaccine within the required timeframe after admission, despite both being eligible. Facility staff confirmed that the required processes and documentation were not completed.
A resident was not provided the COVID-19 vaccine within 30 days of admission, and there was no documentation of vaccine administration or history in the medical record. Despite a signed consent form, the vaccine was not given, and the immunization record was left blank. Interviews with the IP, SAD, and DON confirmed the lack of documentation and follow-through on facility policy.
Two residents with G-tubes had care plans requiring dressing changes and skin care at the G-tube site, but there were no physician orders specifying the care or frequency. Staff confirmed the absence of these orders, despite facility policy and care plan requirements for such interventions.
A resident with contracture deformity and total dependence on staff did not receive ordered passive range of motion (PROM) therapy to both lower extremities after the service was discontinued without a new therapy referral. Staff confirmed that only upper extremity PROM was provided, and documentation showed the lower extremity PROM had not been given since the discontinuation, despite facility policy and care plan requirements.
Two residents with gastrostomy tubes did not have physician orders in place to direct the care of their G-tube sites. Licensed nursing staff and the Director of Sub-Acute Services confirmed that required treatment orders were missing, and treatment administration records showed a lack of documented care. This was not in accordance with facility policy, which requires daily G-tube site care and clear physician instructions.
A CNA entered the room of two COVID-19 positive residents without wearing the required PPE, including a gown, N-95 respirator, face shield, and gloves, despite clear signage and available supplies. The CNA was aware of the residents' COVID-19 status and the facility's PPE policy but only wore a surgical mask while providing care.
A resident with a history of stroke and diabetes was able to leave the facility undetected after staff failed to verify and document the placement and functioning of a Wanderguard device each shift, as required by physician order and facility policy. The lapse was confirmed by multiple staff and through medical record review, resulting in the resident's unsupervised exit and subsequent return by a family member.
The facility did not submit a required abuse investigation report to the Department within five days after an allegation of abuse involving two residents with dementia. Although the incident was investigated and a summary was prepared, the Administrator confirmed the report was not sent as required by facility policy.
Nursing staff, including CNAs, an LPN, and a restorative nursing assistant, were observed using personal cellphones during work hours in resident care areas, contrary to facility policy. Multiple staff admitted that cellphone use could distract them and delay response to residents' needs. Two residents reported seeing staff on their phones and expressed concern about staff attention and professionalism. Facility leadership confirmed that these actions violated established policies and could result in delayed care.
A resident who was dependent on staff for ADLs, including bathing, did not receive scheduled showers over several weeks, with documentation showing only occasional bed baths and no evidence that showers were offered or refused. Staff interviews and record reviews confirmed that showers were not provided as required, and facility policy for maintaining hygiene and documenting refusals was not followed.
A resident with severe cognitive impairment and a history of domestic abuse was subjected to repeated physical abuse by another resident, including being struck on multiple occasions. Despite facility policies requiring identification and supervision to prevent abuse, staff failed to update care plans with appropriate interventions, did not adequately monitor the residents involved, and did not document necessary actions, resulting in emotional distress and visible injury to the affected resident.
The facility did not provide required written discharge notices to the State LTC Ombudsman for two residents, both of whom had significant medical conditions and received discharge notices. Staff interviews and record reviews confirmed that the Ombudsman was not notified as required by facility policy, removing the opportunity for resident advocacy.
A resident with a history of depression and suicidal ideation was not monitored every 15 minutes as ordered by a physician, despite recent self-harm threats. Staff failed to document required checks, and the resident was able to obtain a razor blade and inflict multiple deep cuts, resulting in hospitalization. Facility policy and care plans requiring close supervision and documentation were not followed, leading to harm.
A resident's prescribed insulin lispro was not continued upon admission to a skilled nursing facility, despite hospital discharge orders. The omission was confirmed by a Licensed Nurse and the Director of Nursing, who acknowledged the failure to transcribe the orders into the Medication Administration Record. The resident's medical doctor confirmed the insulin was to be continued as ordered.
A resident with encephalopathy and hemiplegia was found without access to their call light on two occasions, leading to them screaming for help. The call light was either on the floor or hanging on a pole, out of reach. Licensed nurses and the assistant administrator confirmed the inaccessibility, acknowledging the resident's inability to call for assistance. The resident's care plan noted a history of falls, and the facility's policy required call lights to be accessible.
A resident with encephalopathy and hemiplegia did not receive scheduled twice-weekly showers, leading to discomfort and skin issues. Despite being dependent on staff for personal hygiene, the resident received inconsistent care due to staffing issues and documentation errors. Facility policies required regular bathing, but this standard was not met.
A CNA applied a discontinued prescription cream on a resident with encephalopathy and hemiplegia, following instructions from an LN. The cream, Clotrimazole and Betamethasone, had no active order and was discontinued months earlier. The facility's policy requires only licensed personnel to administer medications, which was not followed in this case.
A resident's shared bathroom contained three soiled and unlabeled bedpans, which were not cleaned or labeled as required by the facility's policy. A CNA confirmed the oversight, acknowledging the risk of infection spread. The resident had purchased the bedpans due to size issues with the facility's bedpans, and staff placed them in the bathroom after use. Both the Assistant Administrator and Infection Preventionist stated that the bedpans should have been cleaned and labeled to prevent infection.
The facility failed to administer medications and monitor blood sugars in a timely manner for three residents, leading to potential negative effects on their health. A resident with diabetes and other conditions experienced late medication and insulin administration, while another resident with hypertension and lupus had medications given hours late. A third resident with diabetes had delayed blood sugar checks and insulin due to staff being unable to locate him. Interviews with staff highlighted the importance of timely administration and the lack of documentation for delays.
A facility failed to follow infection control protocols when a nurse did not wear the required PPE while suctioning a subacute resident with MDROs. The resident, with a history of sepsis, respiratory failure, and ventilator dependence, was on Enhanced Standard Precautions. Despite clear policies and signage, the nurse did not wear a gown, increasing the risk of infection spread. The Infection Preventionist and DON confirmed the expectation for PPE use during such procedures.
The facility was cited for multiple food safety and storage deficiencies, including expired and mislabeled food items, unclean kitchen equipment, and improper food handling by staff. These issues could lead to foodborne illnesses among residents. Additionally, the facility lacked adequate utensils during meal service, and residents reported difficulty chewing improperly cooked vegetables.
The facility failed to accommodate the needs of four residents, resulting in deficiencies in care. A resident with limited arm mobility could not reach her call light, while another with a history of stroke had inaccessible side rails, contrary to physician orders. Two other residents were found without reachable call lights, increasing their risk of unmet needs and falls. These issues were confirmed by staff and highlighted a failure to adhere to care plans and facility policies.
Failure to Provide Complete and Timely Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to follow required transfer/discharge notice procedures for one resident who was being discharged for non-payment of share of cost. On 4/9/26, the facility issued a NOTICE OF TRANSFER / DISCHARGE to the resident, listing non-payment as the reason and using the same date, 4/9/26, as the effective date of discharge. The notice was signed by a facility representative, but the "Transfer/Discharge to" field was left blank because no destination had yet been identified, and the "Copy to: State LTC Ombudsman Office" line was also left blank. The resident later reported that she received what she understood to be a 30-day eviction notice around 4/10/26, signed it with her initials due to shaky hands, and was not given a copy of the 30-day notice. Interviews with staff confirmed that the Social Services Director and Business Office Manager initiated the 30-day notice on 4/9/26 due to non-payment and that a copy of the notice was not provided to the resident because she did not specifically request one. The Social Services Director and DON both stated that the notice had not been submitted to the Ombudsman at the time of the initial issuance, and the facility’s practice was to fax the notice to the Ombudsman on the day of discharge. The Administrator acknowledged that regulations require a copy of the notice to be given to the resident and that all discharge and transfer notices should be sent to the Ombudsman within 24 hours. The Ombudsman confirmed that their office should receive a copy of the 30-day notice at the same time it is given to the resident and reported that, as of 4/22/26, their office had not received the notice for this resident. A board-and-care placement was identified as the discharge destination on 4/20/26, and the Social Services Director created an updated notice including the discharge location on that date. However, the resident was not asked to sign this updated notice until the actual day of discharge, 4/23/26, as the facility was still waiting for DME. The Medical Records Director stated that the updated notice, dated 4/23/26, was faxed to the Ombudsman on 4/23/26 at 2:58 PM, and the resident was discharged at approximately 3:55 PM that day. The resident reported that the facility had her sign another paper as she was leaving on 4/23/26. The Administrator later stated that the original notice with the blank discharge destination did not meet facility requirements, but that the updated notice signed on the day of discharge was not considered a new notice that reset the 30-day period, and also stated that the facility’s process when a discharge destination is unknown is to inform residents they will be discharged within 30 days to a safe location and update them later. The facility’s written policy requires that notices include the specific transfer/discharge location, be provided to the resident and representative at least 30 days in advance, be sent to the State LTC Ombudsman at the same time, and that significant changes such as a change in destination require a new notice that resets the 30-day advance notification period.
Failure to Update Care Plan for Resident Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive person-centered care plan to reflect changes in discharge planning. The resident, admitted with multiple sclerosis, had a long-term care plan dated 12/4/25 that identified them as a long-term placement on the skilled nursing unit. Subsequent progress notes documented that, as of 1/16/26, the resident was requesting discharge to the Oakland Bay area to be closer to a significant other, with social services to assist with placement. Additional progress notes on 4/17/26 indicated the resident planned to discharge to the community and was pending placement to a named care home, and on 4/20/26 a discharge evaluation was completed. A discharge planning communication form completed on 4/20/26 documented a planned discharge to a room and board home for long-term care with a specified anticipated discharge date and time. Despite these documented changes and plans, the resident’s care plan in the electronic health record was not updated to include a discharge plan. During interviews, the Social Services Director stated that she and the Business Office Manager initiated a 30-day notice of transfer/discharge on 4/9/26 and acknowledged that the care plan still classified the resident as a long-term placement and did not include a discharge plan. The DON confirmed there was no discharge care plan documented and indicated that discharge planning was managed by social services. The Social Services Director further stated she was primarily responsible for developing and summarizing discharge plans, acknowledged that the care plan had not been updated, and confirmed that the resident’s care plan was not properly updated, despite facility policy requiring ongoing assessment and revision of care plans to include resident preferences, potential for future discharge, and a discharge plan as applicable.
Failure to Use Required Two-Person Assist and Bed Safety Measures During Care on LAL Mattress
Penalty
Summary
The deficiency involves the facility’s failure to implement required safety measures and adequate supervision during bed-level care for a dependent resident, resulting in a fall from an elevated bed onto a concrete floor. The resident had chronic respiratory failure and anoxic brain damage, with MDS assessments showing severely impaired cognitive skills for daily decision-making, inability to speak or be understood, and significant bilateral upper and lower extremity ROM impairments. The resident was coded as totally dependent for all ADLs, including bed mobility, hygiene, bathing, dressing, and transfers, requiring the assistance of two or more helpers for these activities. The resident’s care plans documented total dependence for ADLs and bed mobility, and the resident was on a LAL mattress for pressure redistribution, which staff and the DON acknowledged as a fall risk surface. On the day of the incident, CNA 1 provided clothing, bedding, and personal hygiene care to the resident alone, despite facility expectations and documented requirements that at least two staff assist with major care and repositioning for residents on LAL mattresses. CNA 1 raised the bed approximately three or more feet to a working height and proceeded to roll the resident from her right side to her back while standing on the opposite side of the bed, with the resident facing away from her. CNA 1 reported that the resident, known to sometimes move or wiggle during care, began wiggling her legs, which then slipped off the LAL mattress. CNA 1 attempted to hold the resident’s upper body but was unable to maintain her grip, and the resident slipped out of her hands and fell from the elevated bed onto the concrete floor between the bed and the window. CNA 1 confirmed that only the small side rails near the resident’s head were up, there were no floor mats in place, and the bed was not in the low position. Nursing staff and the DON confirmed that the resident was total care, not alert or aware, unable to control body movement, known to wiggle hands and feet unpredictably, and considered a fall risk, particularly in the context of being on a LAL mattress. LN 1 and LN 2 both stated that the sub-acute unit staff were supposed to work in pairs for clothing changes, hygiene care, and bedding changes due to residents’ multiple tubes and high dependency, and LN 2 specifically noted that LAL mattresses can be slippery and residents can slide off easily, which is why the facility always required at least two staff for care. The DON’s review of the EHR and the Lift Transfer Reposition document confirmed that the resident required two staff for repositioning in bed, and CNA 1’s skills evaluation showed she had been checked off on the protocol requiring a two-person assist for residents using a LAL mattress. The DON determined that the cause of the fall was CNA 1 providing care alone, not using the required two staff, raising the bed, and rolling the resident away from herself onto the unprotected side of the bed, which left no barrier to prevent the resident from falling. As a result of this fall from the elevated bed onto the concrete floor, the resident sustained a chin laceration requiring nine sutures, an acute C1 cervical spine fracture, and multiple bruises and skin injuries, including periorbital bruising and denuded skin over the right clavicle, as documented in the hospital emergency department notes and the facility’s post-hospital skin assessments. The emergency department record described the event as an accident following a fall at the facility, with MRI confirming the acute C1 fracture and neurosurgery recommending an Aspen cervical collar for several months. The facility’s Fall Management policy stated that those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury, but the documented practices during this incident did not align with the resident’s identified need for two-person assistance and the known risks associated with a LAL mattress and the resident’s condition.
Infection Control Failures in Hand Hygiene, PPE Use, and Equipment Sanitization
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices observed during care of several residents. In one instance, a licensed nurse provided tracheostomy inner cannula care and suctioning for a resident without performing hand hygiene between glove changes. The nurse initially donned sterile gloves to change the resident’s disposable inner cannula, then removed the sterile gloves and put on non-sterile gloves from a box in the resident’s room, continuing care without cleansing her hands. She later removed those gloves and donned another pair, again without performing any form of hand hygiene. During interview, the nurse confirmed she did not perform hand hygiene after either glove removal and stated that facility policy required hand hygiene before putting on gloves and after removing them, acknowledging the risk of infection to the resident. A second deficiency was observed when another licensed nurse administered medications via a gastrostomy tube to a resident who was on Enhanced Barrier Precautions. The nurse prepared the medications, performed hand hygiene, and put on gloves, then accessed the resident’s G-tube, checked placement by pushing air into the tube and auscultating the stomach, flushed the tube with water, and administered multiple crushed medications mixed with water through the G-tube. Only after these steps did the nurse realize she had forgotten to don the required protective gown for Enhanced Barrier Precautions. She then retrieved and put on a gown. In interview, the nurse confirmed she had accessed and used the G-tube without the required gown and stated that staff were required to wear a gown and gloves when caring for residents with indwelling lines such as a G-tube to prevent the spread of germs. A third deficiency involved improper handling and sanitizing of shared equipment used for a resident on Contact Precautions. Two CNAs transferred a resident on Contact Precautions from a shower chair to bed using a mechanical lift, then removed the shower chair from the resident’s room and placed it in the hallway in front of the nurses’ station without sanitizing it. Both CNAs confirmed the resident was on Contact Precautions and that a Contact Precautions sign was posted on the door. Later, another CNA attempted to take the same shower chair from the hallway, assuming it was clean because it was stored along the wall and available for use. One of the original CNAs stopped her and stated the chair had not been sanitized. The CNAs acknowledged they were supposed to sanitize the shower chair before removing it from the room, especially for a resident on Contact Precautions, and stated that failing to sanitize equipment after use, particularly in such rooms, could spread infection and make residents sick. Interviews with the Infection Preventionist and the Director of Nursing confirmed that these observed practices did not meet facility expectations or policy. The Infection Preventionist stated that staff were expected to perform hand hygiene before donning clean gloves and after removing dirty gloves, to wear appropriate PPE including gown and gloves when performing care involving bodily fluids such as accessing a G-tube, and to sanitize equipment like shower chairs before and after use, regardless of whether the resident was on Contact Precautions. The Director of Nursing similarly stated she expected hand hygiene before and after glove use during any resident care, proper PPE including gown and gloves when administering medications via G-tube, and cleaning and disinfecting equipment such as shower chairs before and after each use. Both the Infection Preventionist and the Director of Nursing stated that improper infection control practices and failure to clean shared equipment could lead to the spread of infection among residents.
Significant Medication Error When Resident Receives Another Resident’s Heparin and Keppra
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident received another resident’s medications. Resident 2 had multiple serious diagnoses, including acute respiratory failure, tracheostomy with ventilator dependence, posthemorrhagic anemia, thrombocytopenia, chronic kidney disease stage 3B, and atrial fibrillation. Resident 2’s MAR for April 2026 showed daily antiplatelet therapy with aspirin 81 mg and clopidogrel 75 mg to prevent blood clots. Resident 2’s care plan documented that he was at risk for injury or complications related to anticoagulation/antiplatelet therapy, with a goal that he would not exhibit signs or symptoms of bleeding. On 4/1/26, Licensed Nurse 3 documented a change in condition note stating that Resident 2 was noted to have received medications intended for another resident, Resident 4, specifically heparin and levetiracetam (Keppra). LN 3 confirmed he administered a 5000-unit heparin injection subcutaneously into Resident 2’s abdomen and 750 mg of levetiracetam via G-tube. After leaving the room and checking the MAR, LN 3 realized he had been looking at Resident 4’s MAR and had given Resident 4’s medications to Resident 2. LN 3 stated he made the error because he did not follow the rights of medication administration, including right resident, right medication, right dose, right time, and right documentation. He further stated that Resident 4 did not have a photograph in the MAR and that he did not verify Resident 2’s identity by confirming his name or checking a wristband before administering the medications. Resident 4’s MAR showed orders for heparin 5000 units subcutaneously every 12 hours and levetiracetam oral solution 500 mg/mL, 7.5 mL via G-tube every 12 hours for encephalopathy and epilepsy. Facility policy titled “Administering Medications” required that medications be administered as prescribed, that the individual administering medications verify the resident’s identity by checking an identification band, checking a photograph attached to the medical record, or verifying with other personnel, and that the nurse check the label three times to ensure the right resident, medication, dosage, time, and route. The policy also stated that medications ordered for a particular resident may not be administered to another resident. The Director of Nursing confirmed that the medication error involving Resident 2 was reviewed and that it was determined the error could have been prevented if LN 3 had used safe medication administration practices and followed facility policy and procedures. Subsequently, Resident 2 reported being sent to the hospital about a week later for vomiting blood and indicated this had not happened to him before. On 4/6/26, LN 2 stated he was caring for Resident 2 when informed that Resident 2 was vomiting blood; he observed coffee-ground emesis, which he recognized as likely due to a GI bleed, and notified the nurse practitioner present in the facility. The NP confirmed he observed bloody vomit and blood on the floor next to the bed and ordered Resident 2 sent to the hospital for further evaluation, noting he was aware of the prior heparin medication error but was unsure if the vomiting blood was related. Hospital records documented a discharge diagnosis of coffee-ground emesis and noted hemoglobin around 8 g/dL with monitoring of hemoglobin and hematocrit. The Medical Director stated he was not aware that Resident 2 had received heparin and levetiracetam in error, confirmed the error should not have happened, and acknowledged that heparin is a high-alert medication, while indicating he did not believe the accidental heparin was the cause of the vomiting blood but could not be sure due to Resident 2’s other blood-thinning medications.
Unsecured Medication Cart and Unattended Medications During Medication Pass
Penalty
Summary
A deficiency occurred when a licensed nurse failed to securely store medications during a medication pass. On 4/14/26 at 9:23 AM, the nurse was observed preparing medications by removing them from the medication cart, placing approximately seven medications into a medication cup, and leaving them on top of the medication cart. The nurse then walked away from the cart to retrieve something from another cart down the hall, leaving both the medications on top of the cart and the medication cart itself unlocked and unattended. During a subsequent interview, the nurse confirmed that she had left the medications unattended on top of the cart and had left the cart unlocked when she walked away, acknowledging she was supposed to remove the medications from the top of the cart and lock the cart prior to leaving it. The DON stated it was her expectation that medications were never to be left unattended on top of a medication cart and that the cart should never be left unlocked when unattended, noting that some residents were confused and could possibly take medications from the cart, which could be harmful. Review of facility policies titled "Administering Medications" and "Security of Medication Cart" showed that the medication cart must be kept closed and locked when out of the nurse’s sight, no medications are to be kept on top of the cart, and medication carts must be securely locked at all times when out of the nurse’s view.
Failure to Conduct and Document Quarterly IDT Care Conferences
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that Interdisciplinary Team (IDT) care conferences were conducted and documented at least quarterly, as required by facility policy and federal care planning requirements. The facility’s policy stated that a comprehensive care plan must be developed within seven days of completion of the comprehensive MDS assessment and that the IDT is responsible for evaluating and updating care plans at least quarterly. The policy also specified that the IDT should include the attending physician, an RN responsible for the resident, the dietary manager/dietitian, social services, activities, the charge nurse, and others as appropriate, with participation of the resident and/or representative encouraged and meetings scheduled at times convenient for them. For one resident admitted in 2023 with diagnoses including subarachnoid hemorrhage and hypertension, record review of 2025 IDT care conference notes showed only sporadic meetings related to specific issues such as skin assessment findings, possible discharge, needed supplies, and possible hospice, as well as discharge planning. During interview, this resident’s responsible party reported that the primary physician had not discussed the plan of care with her and that she had not attended IDT care conferences to discuss the resident’s care for about a year. In a concurrent record review, the DON, SSD, and Subacute ADON confirmed that IDT care conferences for this resident were not completed on a quarterly basis in 2025, contrary to facility policy. For a second resident admitted in 2025 with diabetes mellitus and cerebral infarction, IDT notes for 2025 showed an IDT meeting for a fall incident, an IDT meeting for weight, and one quarterly IDT care conference, with no evidence of quarterly conferences throughout the year. For a third resident admitted in 2024 with cerebral infarction and hypertension, 2025 IDT quarterly care conference notes showed multiple conferences where the resident and/or responsible party did not attend, and one conference with no documented attendees. During interview and record review, the DON confirmed that quarterly IDT care conferences were not completed for both of these residents in 2025 and stated that, when conferences are not completed quarterly, care concerns may not be addressed and the resident’s care plan may not be updated, acknowledging that facility policy was not followed.
Failure to Report and Investigate Injury of Unknown Origin Involving Shoulder Dislocation
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown source to the Department in accordance with its abuse prohibition policy and state and federal reporting requirements. A resident with significant medical conditions, including subarachnoid hemorrhage, traumatic brain injury, and hypertension, had a Minimum Data Set (MDS) indicating a Brief Interview for Mental Status (BIMS) score of 00, reflecting severe cognitive impairment, and was totally dependent on others for all care needs. On one afternoon, the resident’s responsible party (RP) informed nursing staff that the resident appeared unwell, pointed to the resident’s left shoulder, and stated that something was wrong and that the resident had a bad shoulder. The nurse documented that the resident appeared to be in some discomfort, administered PRN pain medication, notified the MD, and arranged for a left shoulder x-ray. Later that evening, the x-ray was performed and showed a left anterior shoulder dislocation with no acute fractures. In the early morning hours following the x-ray, nursing notes documented that the x-ray results revealed a significant finding of a left anterior shoulder dislocation, that the MD was called, and that the resident was sent to the emergency department for treatment, with the RP notified. During an interview, the RP stated that she had requested the x-ray after noticing the resident grimace when she touched his shoulder and that staff had told her the resident had recently been cleaned and repositioned after incontinent care. The RP confirmed that the x-ray showed the resident’s left shoulder was dislocated. In subsequent interviews, the DON confirmed that the resident’s left shoulder injury met the definition of an injury of unknown origin and acknowledged that it was not reported to the Department as required. The Administrator stated that he spoke with the RP a day or so after the injury was discovered; the RP denied any fall or observed trauma and suggested the injury was due to contractures, and the Administrator did not document this conversation. The Administrator stated he followed the RP’s lead and did not suspect abuse, despite acknowledging that the resident was under the facility’s care and that the cause of the shoulder dislocation was unknown. Both the Administrator and the DON acknowledged that the injury of unknown origin should have been investigated to rule out abuse and reported in accordance with the facility’s Abuse Prohibition Policy and Procedure, which requires prompt investigation and reporting of injuries of unknown source, especially those involving serious bodily injury.
Failure to Investigate Shoulder Dislocation as Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate an injury of unknown origin for potential abuse after a resident was found to have a left anterior shoulder dislocation. The resident had been admitted with significant neurological and medical diagnoses, including subarachnoid hemorrhage, traumatic brain injury, and hypertension. On the afternoon of 2/1/26, nursing progress notes documented that the resident’s responsible party (RP) reported the resident did not look well, pointed to the resident’s left shoulder, and stated something was wrong and that the resident had a bad shoulder. The nurse noted the resident appeared to be in some discomfort, informed the RP that the resident had been changed and received wound treatment about 30 minutes earlier, and attributed the discomfort to recovery from that care. At the RP’s request, the nurse contacted the MD, obtained an order for a left shoulder x‑ray, administered PRN pain medication, and arranged for the x‑ray. Later that evening, an x‑ray of the left shoulder was performed, and the radiology report showed a left anterior shoulder dislocation with no acute fractures. In the early morning hours of 2/2/26, nursing notes documented that the x‑ray results showed a significant finding of left anterior shoulder dislocation, that the MD was called, and that the resident was sent to the ER for reduction of the shoulder. During an interview, the RP stated she had requested the x‑ray after noticing the resident grimaced when she touched his shoulder and that staff had told her the resident had recently been cleaned and repositioned after incontinent care. The RP confirmed that the x‑ray showed the resident’s left shoulder was dislocated. Subsequent interviews and record reviews with the DON, Social Services Director, Subacute ADON, and Administrator revealed that no investigation was conducted to determine the cause of the shoulder dislocation as a potential injury of unknown origin. The DON stated there was no investigation into the cause of the dislocation, and the SSD stated the facility should have investigated to see if a cause could be found. The Administrator reported he was aware the resident had a chronic shoulder issue documented in the EMR and that the RP had told him the resident had shoulder problems for years and was concerned about arm extension during repositioning; he also stated he asked the RP if the resident had fallen and she said no and reported no observed trauma. The Administrator acknowledged he did not document this conversation, was unsure if an investigation was done, and ultimately acknowledged, along with the DON, that an investigation into the injury of unknown origin was not conducted to rule out abuse, despite facility policy requiring that injuries of unknown source be investigated and reported as potential abuse or neglect.
Failure to Complete SCSA After Resident Shoulder Dislocation
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a Significant Change in Status Assessment (SCSA) for a resident who experienced a left shoulder dislocation. The resident had been admitted with diagnoses including subarachnoid hemorrhage, traumatic brain injury, and hypertension. On the date of the shoulder dislocation, the care plan was updated with a new focus that the resident had a dislocated left shoulder, with goals and interventions such as sending the resident to the ER, administering pain medication, immobilizing the left upper extremity, and monitoring for pain and swelling. A physician order was entered indicating no Restorative Nursing Aide (RNA) services to the left shoulder until further notice. During interviews and record reviews, the PT and RNAs reported that the resident previously had upper and lower extremity PROM ordered, which was later changed to lower extremity PROM only due to the left shoulder dislocation. They also stated that PROM was still provided to the right upper extremity, that the resident’s responsible party did not want upper arm PROM or showers because of the shoulder dislocation, and that the resident required two-person assistance for repositioning using a sling and pillows or rolled towels to support the left arm. The PT and RNAs indicated they did not participate in the resident’s IDT meetings but held separate therapy plan of care meetings, with the MDS Coordinator setting up those meetings and documenting notes in the EMR. When the DON, SSD, and Subacute ADON reviewed the EMR, the DON indicated she needed to verify whether an SCSA had been completed. In a subsequent review with the MDS Coordinator, it was confirmed that no SCSA had been completed for the shoulder dislocation. The MDS Coordinator described the RAI definition and criteria for an SCSA, acknowledged that the resident’s condition met the significant change criteria, and stated that the facility policy, which requires an SCSA when there is a major decline or improvement affecting more than one area of health status and requiring IDT review and care plan revision, had not been followed. Facility policies on RAI assessments and baseline care plans specified that assessments are ongoing, care plans must be reviewed and revised with changes in condition, and the IDT is responsible for evaluating and updating care plans when there has been a significant change, but this process was not carried out for the resident’s left shoulder dislocation.
Failure to Timely Respond to Resident’s Non-Return From Appointment Resulting in Elopement and Missed Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and timely intervention when a resident did not return from an outing as expected, resulting in an elopement. The resident had been admitted in 2025 with diagnoses including acute osteomyelitis of the right ankle and foot, cellulitis of the right lower limb, a non‑pressure chronic ulcer of the right heel and foot, type 2 diabetes with long‑term insulin use, asthma, difficulty walking, and generalized muscle weakness. The resident also had a right upper arm PICC line for IV Ertapenem to treat osteomyelitis and was receiving Heparin for DVT prevention and insulin for diabetes management. On the day of the incident, the resident left the facility around 12:30 p.m. for a medical appointment that he reported he had independently scheduled, including arranging his own transportation, and he signed out at the nursing station stating he was going out for this appointment. Progress notes and interviews show that the resident did not return at his expected time, which staff understood to be between 6 p.m. and 7 p.m., and he remained out of the facility for approximately 29 hours. A late entry nurse progress note timed at 6 p.m. on the day of departure documented that the charge nurse reported the resident had signed out for his appointment and had not yet returned, and that the resident had also left the previous day with a friend but returned around 6:30 p.m. The note indicated the writer instructed the charge nurse to call the resident’s cell phone and listed contacts, and that the MD and administration were notified. Another progress note the following morning documented that the resident had not returned since leaving for the appointment, that attempts to reach him and his emergency contacts by phone were unsuccessful, and that the DON, Administrator, and MD were notified. The DON later confirmed that the physician was not called until 10 p.m. on the day the resident left and that law enforcement was not contacted until around 7 a.m. the next day, despite the facility’s policy that staff should immediately notify administration, the physician, and then law enforcement when a resident on pass or at an appointment does not return within four hours or by the expected time. Interviews with nursing leadership and staff further described inaction and delays in following the facility’s elopement and out‑on‑pass procedures. The DON stated that based on the facility’s definition, the resident’s absence from the time he failed to return as expected until his arrival the next day constituted an elopement. The DON and ADON both confirmed that the facility did not promptly contact the police the night the resident failed to return, and the ADON stated she was the one who called law enforcement when she came on duty at 7 a.m. the following morning. LN 1 acknowledged that she did not call the police when the resident did not return at his expected time and recognized that not calling could affect the resident’s safety and left staff unaware of his whereabouts or condition. The DON also acknowledged that staff did not follow up with the community medical center to determine whether the resident was there. During the resident’s absence, medication records show missed doses of IV Ertapenem, insulin glargine, and Heparin, with the MAR marked as "AW" (away from center) or "X" (not given) on relevant dates. When the resident eventually returned, he was sent to the hospital, where toxicology screening was positive for methamphetamine and opiates, and social services documented that the resident described his experience outside the facility as frightening. The facility’s written policies outlined specific steps that were not followed in this situation. The "Wandering and Elopements" policy required that if a resident is missing and not on an authorized leave, staff must initiate a search and, if the resident is not located, notify the Administrator, DON, legal representative, attending physician, and law enforcement. The "Out On Pass" policy required that residents have a physician’s order for an out‑on‑pass and that licensed nurses assess the resident’s status and ensure instructions for special needs and medication orders while on pass. Interdisciplinary team notes later clarified that the resident had an MD‑approved one‑day out‑on‑pass order for the previous day only and that he left on the day of the incident believing he did not need a new order. At the time he left, the facility did not have a current out‑on‑pass order for that day, and staff did not promptly implement the missing resident/emergency procedures when he failed to return within the expected timeframe, leading to the identified deficiency in supervision and accident prevention.
Failure to Develop Elopement Care Plan for At-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop a comprehensive, person-centered care plan addressing elopement risk for one resident. The resident’s admission record showed multiple diagnoses, including End Stage Renal Disease, dependence on renal dialysis, and sequelae of cerebral infarction. An Elopement Evaluation dated 12/24/25 documented that the resident was at risk for elopement. Despite this documented risk, review of the resident’s care plans revealed that no elopement care plan had been created. During a concurrent interview and record review on 2/12/26 at 3:20 PM, the DON confirmed that the resident did not have an elopement care plan and stated there should have been one. The DON acknowledged that not having such a care plan put the resident at risk of elopement and emphasized that a comprehensive care plan is important to guide staff with interventions and to help them be more vigilant if a resident attempts to leave the facility. Review of the facility’s “Wandering and Elopements” policy, revised 3/19, showed that when a resident is identified as at risk for wandering or elopement, the resident’s care plan is required to include strategies and interventions to maintain safety, which was not done in this case.
Failure to Follow Physician-Ordered Pain Management Regimen
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive pain management and to administer pain medication according to physician orders for one resident with significant pain-related conditions. The resident was admitted with diagnoses including polyneuropathy and gout and had a care plan noting acute/chronic pain related to chronic physical disability and a stage 4 pressure wound to the sacrum. Physician orders included acetaminophen 325 mg, two tablets by mouth every four hours as needed for mild pain, and hydrocodone/acetaminophen 5-325 mg, one tablet via G-tube every six hours as needed for pain levels 5–10. Staff used the PAINAD scale to assess this non-verbal resident’s pain, observing increased respirations and heart rate, open eyes and mouth, and facial grimacing when the resident was in pain. However, the nurse reported using nursing judgment to decide which pain medication to give and expressed reluctance to administer hydrocodone/acetaminophen due to concern that the resident’s body would get used to it. Record review of the Medication Administration Record for the month showed that when the resident had documented pain levels of 8, 5, 6, and 7, staff administered only acetaminophen, despite the physician’s order specifying hydrocodone/acetaminophen for pain levels 5–10. Conversely, hydrocodone/acetaminophen was given when the resident’s documented pain levels were 4 and 0, when acetaminophen should have been used according to the orders. The DON confirmed that the resident sometimes received acetaminophen when pain was above 5 and hydrocodone/acetaminophen when pain was lower, contrary to the physician’s orders and the care plan intervention to administer hydrocodone/acetaminophen as ordered. This failure to follow the prescribed pain management regimen and the facility’s medication administration policy resulted in the resident’s pain not being effectively managed and not being treated per physician orders.
Failure to Complete and Document Psychiatric Evaluation After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received necessary behavioral health services following an altercation. The resident was admitted with diagnoses including muscle weakness and difficulty walking. After a verbal altercation with another resident in which the resident attempted to hit the other party, an IDT care conference was held and documented on 10/27/25. The IDT recommended a psychiatric evaluation and treatment for episodes of agitation. The physician subsequently entered an order on 10/29/25 for a psychiatric evaluation and treatment related to agitation. Despite this, there was no documentation in the resident’s medical record that a psychiatric evaluation occurred or that psychiatric treatment was provided. During interviews and concurrent record reviews, the ADON, SSA, and DON each confirmed key gaps in the referral and documentation process. The ADON acknowledged the IDT recommendation for a psychiatric evaluation and stated she was not sure if the referral had been completed, noting that social services needed to be informed when such referrals were required. The SSA confirmed that social services were responsible for sending psychiatric referrals and that a psychiatrist contracted with the facility typically visited and documented in an external portal, but she did not have access to that portal and was unsure if the resident had been seen; she also confirmed there were no psychiatric notes in the EHR. The DON confirmed the resident’s history of agitation, the altercation details, and the existence of the physician’s psychiatric evaluation order, but stated she did not know if the resident had been seen and also lacked access to the psychiatrist’s portal. The DON verified that no psychiatric notes were present in the resident’s chart and stated it was important for the facility to know the psychiatrist’s recommendations and that without this information the facility would not be compliant with psychiatric services, affecting the resident’s psychosocial health.
Improper Disposal of Garbage Due to Open Dumpster Lid
Penalty
Summary
A deficiency was identified when one of two outside garbage dumpster lids was observed to be left open at the facility, which had a census of 112. During multiple observations and interviews with the Central Supply, Director of Staff Development (DSD), and Infection Preventionist (IP), it was confirmed that the dumpster lid was not adequately closed. The staff members interviewed, including the DSD, IP, and Director of Nursing (DON), all acknowledged that the dumpster lids should have been closed when not in use. The facility's policies and procedures, including those for food-related garbage and refuse disposal and infection prevention and control, require that all garbage containers have tight-fitting lids and remain covered when not in continuous use. The staff confirmed that leaving the dumpster lids open could allow pests and insects to gather and potentially enter the facility, increasing the risk of infection and cross-contamination. The observations and staff statements directly indicated non-compliance with the facility's established procedures for proper garbage disposal.
Failure to Maintain Resident Dignity During Meal Assistance and Incontinence Care
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect in two main areas: meal assistance and incontinence care. Staff were observed standing over two residents while assisting them with their lunch, rather than sitting at eye level as required by facility policy. Both CNAs involved acknowledged that they did not follow the expected procedure due to time constraints and the need to assist other residents. The Director of Nursing and a Licensed Nurse confirmed that staff should be seated next to residents during meal assistance to maintain dignity and ensure safety, as outlined in the facility's policy on dignity and dining experience. A more significant deficiency occurred when the facility ran out of incontinent briefs over a weekend, affecting multiple residents who required these supplies for bladder and bowel incontinence. Several residents reported that staff instructed them to urinate or defecate in their beds due to the lack of available briefs. Some residents described staff taking briefs from their rooms to give to others, and in one case, a resident was told to use a towel. Residents expressed feelings of embarrassment, degradation, and a loss of dignity as a result of these actions. Staff interviews confirmed the shortage, with CNAs and nurses stating that they searched the facility for briefs, asked residents to share, and instructed residents to use their beds when supplies were unavailable. The supply shortage was attributed to the absence of the central supply staff member responsible for ordering and stocking supplies, leading to disorganization and delayed deliveries. Management and nursing staff confirmed awareness of the shortage and described efforts to locate or borrow supplies, but these were insufficient to meet residents' needs. Facility policies reviewed in the report emphasized the importance of treating residents with dignity, respecting their property, and providing necessary care and supplies to avoid neglect and maintain well-being. The events described resulted in residents being left without essential incontinence products, compromising their dignity and comfort.
Failure to Maintain Safe Water Temperatures and Complete Post-Fall Assessment
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment in two key areas: water temperature control in resident-accessible areas and post-fall assessment for a resident. During observations and interviews, it was found that water temperatures in several resident bathrooms exceeded the facility's policy limit of 120°F, with some readings as high as 130°F and 135°F. Staff, including the Maintenance Director, Director of Staff Development, Infection Preventionist, and DON, all acknowledged that water temperatures above 120°F could cause burns or skin damage to residents. A resident also reported that the water would get too hot in the bathroom, but did not report it to staff and simply stopped using it. The facility's policy required water heaters servicing resident areas to be set no higher than 120°F, but this was not consistently followed. In addition, the facility failed to complete a post-fall mobility assessment for a resident who had a fall in the bathroom. The resident, who had dementia and diabetes, was found on the bathroom floor in pain and was subsequently sent to the emergency room. Although the facility's policy required a joint mobility screen after a fall, the DON confirmed that this assessment was not completed after the incident. The last mobility screen for the resident had been done prior to the fall. The DON acknowledged that not completing the assessment meant staff would not have updated information on the resident's mobility status. Facility policies reviewed indicated that water temperatures and fall risk assessments were to be closely monitored and managed to prevent harm. However, the observed failures in both maintaining safe water temperatures and completing required post-fall assessments demonstrated lapses in following these policies, potentially exposing residents to physical harm.
Medications Left Unattended at Bedside Without Supervision
Penalty
Summary
A licensed nurse left a medication cup containing four pills on a resident's bedside table, rather than directly administering the medications and observing ingestion as required by facility policy. The resident, who had chronic kidney disease stage 4 and was dependent on renal dialysis, stated that it was common for the nurse to leave medications at the bedside so she could take them with coffee when delivered by her CNA. The nurse confirmed this practice, acknowledged it was against facility policy, and admitted that the resident had not been evaluated or care planned for self-administration of medications. Facility policies reviewed indicated that medications are to be administered in a safe and timely manner, with staff remaining with the resident until all medications are taken and observing the resident after administration to ensure the dose is ingested. The DON confirmed that medications should not be left unattended at the bedside and that the nurse should be present during administration. The failure to follow these procedures was observed and confirmed through interviews and record review.
Deficient Medication Storage, Labeling, and Cleanliness Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to medication storage and labeling practices in the facility. In two out of three medication rooms and four out of five medication carts, drugs and biologicals were not stored or labeled according to accepted professional standards. Specifically, an external air-conditioning unit with a dirty filter containing grayish dust and debris was placed on top of a medication refrigerator, raising concerns from the Infection Preventionist, Director of Staff Development, and Director of Nursing about potential contamination of medications stored inside the refrigerator. Facility policy required medication storage areas to be kept clean, which was not followed in this instance. Additionally, two bottles of Drug Buster solution, used for medication disposal, were found soiled and in active use in two different medication carts. Licensed nurses confirmed the bottles were dirty and posed a risk of cross-contamination within the carts. The Director of Staff Development and Director of Nursing both acknowledged that the presence of dirty Drug Buster could lead to unwanted drug-to-drug interactions and make the carts difficult to clean. Furthermore, pill cutters in three different medication carts were observed with white and grayish residue, and staff confirmed these devices should have been cleaned to prevent cross-contamination between medications. The survey also found that several medications and sterile supplies were opened but not labeled with the date opened, including a bottle of Miralax, a box of Bisacodyl suppositories, and a bottle of Clobetasol Propionate Topical Solution. Single-use sterile wound care supplies were also found opened and available for use in a treatment cart, contrary to manufacturer instructions and facility policy. Staff interviews confirmed the importance of labeling opened medications and discarding opened sterile supplies, as failure to do so could result in the use of expired or non-sterile products.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with safety standards, as evidenced by multiple observations during a kitchen tour and staff interviews. Surveyors found three moldy tomatoes and a discolored, flattened, and mushy apple in the walk-in refrigerator, which were verified by the Certified Dietary Manager (CDM) and Registered Dietitian (RD) as being unfit for consumption and posing a risk for foodborne illness. Additionally, frozen fish fillets, beef patties, meatballs, and veggie patties were left uncovered in the reach-in meat freezer, exposing them to the environment and potentially affecting their quality and safety, as confirmed by the District Dietary Manager (DDM) and RD. Further deficiencies were observed in the condition of kitchen equipment and adherence to food safety protocols. Three bowls were found to be worn, chipped, and without glaze, and a green cutting board was visibly worn with deep gouges, making them difficult to clean and sanitize. Both CDM and DDM acknowledged that such equipment should have been discarded due to the risk of bacterial growth. Review of facility policy and the FDA Food Code supported the need for clean, sanitary, and properly maintained food service equipment to prevent contamination. The facility also failed to properly document food cooling processes and maintain plumbing standards. The cool down log for egg salad did not indicate when the food reached the required safe temperature, which staff recognized as necessary to ensure food safety and prevent bacterial growth. Additionally, the two-compartment sink used for rinsing and manual dishwashing did not have an air gap, a required feature to prevent backflow of contaminated water, as verified by the DDM and CDM. These combined failures had the potential to lead to cross-contamination and foodborne illness for the 85 residents receiving facility-prepared meals.
Infection Control Failures in Urinal Handling, Room Cleanliness, and Glucometer Disinfection
Penalty
Summary
Staff failed to follow appropriate infection prevention and control measures in several instances. In one case, a resident with multiple diagnoses, including cerebral infarction, heart failure, and chronic kidney disease, had three labeled urinals containing urine placed inside a trash can in their room. The urinals were not replaced with clean ones, and the designated urinal holder at the bedside was left empty. The resident reported that staff were inconsistent in replacing the urinal and that it was not their preference to store it in the trash can. Staff interviews confirmed that this practice did not follow standard procedures and posed an infection control risk. Facility policy required urinals to be cleaned, labeled, and stored in the designated holder, but this was not followed. Another deficiency was observed in a resident's room where multiple flying pests were present. The room contained an uncollected empty fruit cup with used tissue paper and a spoon, a mug with coffee, an empty glass, and another cup with water, all of which had attracted insects. The resident stated that staff were not cleaning the room regularly and that meal trays were not being picked up after meals. Staff confirmed that leaving food and drink at the bedside could attract insects and increase infection risk. There was no care plan documenting any refusal by the resident to have the room cleaned or trays removed, and facility policy required prompt removal of meal trays and maintenance of a pest-free environment. A further issue involved improper cleaning and disinfection of a glucometer by a licensed nurse. The nurse cleaned the device for only 10 seconds with a disinfectant towelette, not following the manufacturer's instructions, which required a two-minute wet contact time using two wipes. Both the infection preventionist and the DON confirmed that the correct procedure was not followed, increasing the risk of cross-contamination. Facility guidelines specified the need for proper cleaning and disinfection of the glucometer after each use, but this protocol was not adhered to.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission or readmission for one resident, as required by both regulation and the facility's own policy. Specifically, a review of the resident's medical record showed that no baseline care plan was created following the resident's readmission in March 2021. This was confirmed during interviews with both a licensed nurse and the MDS coordinator, who acknowledged that the baseline care plan was not completed as required. The facility's policy states that a baseline care plan must be developed within 48 hours of admission to provide effective, person-centered care and to guide staff in meeting the resident's needs. The resident involved had a complex medical history, including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, hypertensive heart disease with heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease. The absence of a baseline care plan meant that there were no documented instructions for staff to follow to address the resident's specific care needs immediately after admission. Both the licensed nurse and the MDS coordinator confirmed that this omission was contrary to facility policy and could negatively affect the resident's health and well-being.
Failure to Develop and Implement Care Plans for Residents on Blood Thinners
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for two residents who were prescribed blood thinner medications. For one resident with diagnoses including deep vein thrombosis (DVT), hypertension, and mobility issues, there was no care plan in place to monitor for potential side effects or risks associated with apixaban, a blood thinner prescribed upon admission. Licensed nursing staff confirmed that there were no orders or documentation for monitoring side effects such as bleeding, and that this monitoring was essential due to the serious complications that could arise from the medication. A review of the facility's policy and procedure for comprehensive care planning indicated that care plans should incorporate identified problem areas, risk factors, and targeted interventions. However, interviews with both nursing staff and the Director of Nursing (DON) confirmed that these procedures were not followed for the resident on apixaban, as no care plan or monitoring orders were present in the medical record. The DON acknowledged that staff were expected to monitor for bleeding each shift and check for signs in the mouth, urine, and stool, but this was not documented or implemented. Similarly, another resident with multiple chronic conditions, including COPD, heart failure, and diabetes with chronic kidney disease, was prescribed both aspirin and Eliquis for DVT prophylaxis. Despite active orders for these blood thinners, there was no corresponding care plan developed. Nursing staff and the DON confirmed the absence of a care plan and recognized the importance of care planning as a guiding tool for providing person-centered care and coordinating services. The facility's policy required comprehensive care plans to address all medical, physical, and psychosocial needs, but this was not done for the residents in question.
Failure to Provide Restorative Nursing Therapy for Resident with Severe ROM Impairment
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, and functional quadriplegia was admitted to the facility and was dependent on nursing staff for activities of daily living. Clinical records, including a comprehensive assessment, indicated the resident had impairments in range of motion (ROM) in both upper and lower extremities. A joint mobility screen documented severe impairment in the resident's right wrist, left hand, and right hand, with approximately 25% or less of full ROM. Despite these findings, the resident was not placed on a restorative nursing therapy program, which would have included passive range of motion (PROM) exercises. Both the Director of Rehab and the Assistant Director of Nursing confirmed that the resident should have been offered restorative nursing therapy services following the decline in ROM. The facility's policy stated that restorative nursing care should be provided as needed to promote optimal safety and independence, but this was not implemented for the resident in question.
Failure to Ensure Water Access for Resident at Risk of Dehydration
Penalty
Summary
A resident with chronic congestive heart failure, who was at risk for dehydration due to the use of diuretic medication, did not have proper access to fluids as required. The resident's care plan identified the risk for dehydration, and the facility's policy stated that adequate hydration should be provided. During multiple observations, the resident's water pitcher was found out of reach, once on a nightstand and another time on a bedside table that had been moved against the wall by staff and not returned to its original position. The resident was unable to reach the water pitcher on both occasions. Staff interviews confirmed that the water pitcher should have been within the resident's reach at all times, especially given the resident's increased risk for dehydration. The certified nursing assistant acknowledged moving the bedside table and forgetting to return it, while both the licensed nurse and the director of nursing confirmed the importance of water access for this resident. The facility's policy also required nursing aides to provide and encourage fluid intake as part of daily routines.
Failure to Provide Medically-Related Social Services for Resident Transfer Requests
Penalty
Summary
The facility failed to provide medically-related social services to a resident with cerebral palsy and paresthesia of the skin by not honoring repeated requests to be transferred to a facility closer to his home. The resident, who had been admitted in 2019, consistently expressed his desire to move closer to his hometown, as documented in care plans, social service assessments, and progress notes. Despite these documented requests, the facility did not proactively pursue alternate placement or maintain documentation of referral efforts as required by facility policy. Interviews with the Social Service Director (SSD), nursing staff, and the Health Information Manager (HIM) confirmed that the resident's requests for transfer were known to staff over several years. The SSD acknowledged that although referrals were reportedly sent to other facilities, there was no documentation to support this, and the HIM confirmed that no such records were received or uploaded into the resident's medical file. The facility's policy required social services to document all referrals in the resident's medical record, which was not followed in this case. The resident's ongoing requests and the lack of action led to emotional distress, as evidenced by multiple progress notes and interviews indicating the resident's frustration and a reported episode of self-harm. Nursing staff and the Director of Nursing (DON) confirmed that the resident's psychosocial well-being was negatively affected by the facility's failure to act on his transfer requests. The DON also confirmed that the facility's policy and expectations regarding documentation and proactive placement efforts were not met.
Failure to Follow Physician-Ordered Hold Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that physician-ordered parameters for the administration of Midodrine, a medication used to treat hypotension, were followed for two residents. For both residents, the physician's order specified that Midodrine should be held if the systolic blood pressure (SBP) was greater than 100. Despite these clear instructions, the medication was administered outside of these parameters on 13 separate occasions for each resident, as confirmed by a review of the Medication Administration Records (MAR) and interviews with the Director of Nursing (DON). The DON acknowledged that the medication was given in error and outside of the prescribed parameters on the specified dates. Interviews with nursing staff confirmed their awareness of the hold parameters and the importance of not administering Midodrine when the SBP exceeded 100, as per the physician's orders. The facility's policy on medication administration required that medications be given as prescribed and that vital signs, including blood pressure, be checked and verified prior to administration. Despite these policies and staff knowledge, the medication was repeatedly administered inappropriately, as documented in the MAR and confirmed by the DON.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.25%, which exceeds the acceptable threshold of 5%. During medication administration observations, two errors were identified out of 32 opportunities involving two residents. In one instance, a licensed nurse administered 4 units of Insulin Lispro subcutaneously to a resident after the resident had already eaten breakfast, despite the order specifying that the insulin should be given before meals. The nurse confirmed the insulin was given late and acknowledged that the medication should have been administered prior to the meal as ordered. In another case, a licensed nurse administered only one drop of Visine Dry Eye Relief in each eye to a resident, contrary to the physician's order for two drops in each eye twice daily. The nurse admitted to the error, stating unfamiliarity with such an order. The Director of Nursing confirmed that her expectation was for staff to follow the rights of medication administration and to give medications as prescribed, including correct timing and dosage. Facility policy also requires medications to be administered in accordance with prescriber orders and within specified time frames.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer, obtain informed consent, and provide education regarding influenza and pneumococcal vaccinations to two out of five sampled residents. One resident was not offered the flu vaccine for two consecutive years, and there was no documentation of a refusal or education provided to the resident or their responsible party. The resident's medical record did not contain a signed consent or refusal form for the flu vaccine during the relevant flu seasons, despite the facility's policy requiring annual offering and documentation. Another resident was not offered the pneumococcal vaccine within 30 days of admission, as required by facility policy. The resident, who was eligible for the vaccine and had a history of pneumonia requiring antibiotic treatment, had no record of being offered the vaccine, no consent form, and no documentation of education or refusal in the medical record. Interviews with facility staff confirmed that the vaccine should have been offered and documented, but there was no evidence this occurred. Facility policies for both influenza and pneumococcal vaccines require that residents be assessed for eligibility, offered the vaccines, and that informed consent or refusal be documented, along with education about the risks and benefits. In both cases, the required processes were not followed, and the necessary documentation was missing from the residents' medical records.
Failure to Administer and Document COVID-19 Vaccine for a Resident
Penalty
Summary
The facility failed to provide and document the administration of the COVID-19 vaccine for one resident within 30 days of admission, as required. The resident's clinical record did not contain evidence that the COVID-19 vaccine was administered, nor was there documentation of the resident's COVID-19 vaccine history. Interviews with the Infection Preventionist (IP), Sub-acute Director (SAD), and Director of Nursing (DON) confirmed that although the resident signed a consent form for the COVID-19 vaccine on the day of admission, the vaccine had not been given, and there was no documentation of prior vaccination or a valid reason for not administering the vaccine. The medical record also lacked any completed, active, or discontinued orders for the COVID-19 vaccine, and the immunization record was left blank regarding the resident's COVID-19 vaccine status. Facility policy requires that if a resident requests vaccination or missed earlier opportunities, the vaccine should be offered as soon as possible and all efforts, including each dose administered, should be documented in the medical record. In this case, the facility did not follow its own policy, as there was no documentation of the resident's COVID-19 vaccine administration, history, or refusal. The DON acknowledged that the absence of this documentation made it unclear whether the resident had received the vaccine, and the process for obtaining and recording prior vaccination information was not completed.
Failure to Implement Physician-Ordered G-Tube Site Care
Penalty
Summary
The facility failed to ensure that interventions listed on the resident-centered comprehensive care plans were specific to the care and services implemented for two residents with gastrostomy tubes (G-tubes). For both residents, the care plans indicated that dressing changes and skin care at the G-tube site should be provided as ordered, but there were no corresponding physician orders detailing the required care, frequency, or instructions for these interventions. Licensed nurses and the Director of Sub-Acute Services confirmed during interviews and record reviews that the necessary treatment orders were missing from the residents' records, despite facility policy requiring daily treatment to the G-tube site. Both residents were admitted with diagnoses requiring attention to their G-tubes, and their care plans included interventions to monitor and care for the G-tube site. However, the lack of specific physician orders meant that the care plans could not be properly implemented. Staff acknowledged that this omission was inconsistent with facility policy and recognized the importance of having clear, physician-directed instructions for G-tube site care. The facility's policy and procedure for comprehensive care plans also required that interventions reflect professional standards of practice and be tailored to identified problem areas.
Failure to Provide Ordered PROM Therapy to Lower Extremities
Penalty
Summary
A deficiency occurred when a resident with a history of contracture deformity and complete dependence on staff for all activities of daily living did not receive the ordered passive range of motion (PROM) therapy to both lower extremities. The resident's care plan included goals to prevent a decrease in range of motion and worsening of contractures, and physician orders were in place for PROM to both upper and lower extremities. However, the PROM therapy for the resident's lower extremities was discontinued on 2/5/25 without an updated referral from the therapy department, and the resident subsequently only received PROM to the upper extremities. Interviews with facility staff, including the Restorative Nurse Assistant, Director of Nursing, and Physical Therapy Assistant, confirmed that the lower extremity PROM was stopped without proper authorization or a new therapy referral, despite the resident's ongoing risk for contractures due to immobility. Documentation review showed that the last lower extremity PROM was provided on 2/13/25, and facility policy required restorative nursing care as needed to promote optimal safety and independence. This lapse in care resulted in the resident not receiving the necessary services to maintain or improve range of motion as outlined in their care plan and physician orders.
Failure to Obtain Physician Orders for G-Tube Site Care
Penalty
Summary
The facility failed to ensure that physician orders were in place to direct the care of gastrostomy tube (G-tube) sites for two residents who required such care. For both residents, clinical record reviews and interviews with licensed nursing staff confirmed that there were no active physician treatment orders specifying the necessary care for the G-tube sites. Staff acknowledged that facility policy required daily treatment of G-tube sites, and the absence of these orders meant that the prescribed care was not documented or provided as required. Further review of treatment administration records showed no evidence that one resident received any G-tube site care upon readmission, and the other resident lacked orders for dressing changes or site cleaning over a specified period. The Director of Sub-Acute Services confirmed that it was expected for residents with G-tubes to have physician orders detailing treatment instructions. The facility's own policy emphasized the importance of keeping the skin around the G-tube exit site clean, dry, and lubricated, but this standard was not met due to the missing orders.
Failure to Use Required PPE When Entering COVID-19 Isolation Room
Penalty
Summary
A Certified Nursing Assistant (CNA) entered the room of two residents who had tested positive for COVID-19 without wearing the required personal protective equipment (PPE), which included a gown, N-95 respirator, face shield, and gloves. The CNA was observed wearing only a surgical mask despite clear signage posted at the room entrance specifying the necessary PPE for entry. The CNA acknowledged awareness of both the residents' COVID-19 status and the PPE requirements, and confirmed that appropriate PPE was available near the room door. The CNA stated uncertainty as to why the proper PPE was not worn and admitted understanding the risk associated with this action. The two residents involved had significant medical histories, including cerebral infarction, kidney cancer, anxiety disorder, osteoarthritis, and anemia. Both had recently tested positive for COVID-19, as documented in their medical records. The facility's Infection Preventionist confirmed that the expectation was for staff to perform hand hygiene and wear the required PPE when entering isolation rooms for COVID-19 positive residents, in accordance with facility policy. The Infection Preventionist acknowledged that the facility's policy was not followed in this instance.
Failure to Verify Wanderguard Placement Led to Resident Elopement
Penalty
Summary
Staff failed to ensure adequate supervision and monitoring for a resident with a history of cerebral infarction and type 2 diabetes mellitus by not verifying the placement and functioning of the resident's Wanderguard device every shift, as required by physician order and facility policy. The Wanderguard is a monitoring device intended to alert staff if a resident at risk for elopement attempts to leave a designated area. Medical record reviews and staff interviews confirmed that there was no documentation of the required checks, and staff did not follow the established procedures for the Wanderguard system. As a result of this failure, the resident was able to leave the facility without staff knowledge. The incident was discovered only after the resident contacted his mother from outside the facility, prompting the facility to initiate an elopement code and search for the resident. The resident was eventually returned to the facility by his mother. Multiple staff, including the Sub-acute Director, a licensed nurse, the Administrator, and the Director of Nursing, confirmed that the required checks were not performed or documented, placing the resident at risk for elopement.
Failure to Submit Abuse Investigation Report Within Required Timeframe
Penalty
Summary
The facility failed to submit the required investigation report to the Department within five days following an allegation of abuse involving two residents, both of whom had diagnoses including dementia. Record review showed that an incident of alleged abuse between these two residents was investigated, and a '5 Day Summary' was prepared, but the report was never sent to the Department as required by facility policy. During an interview, the Administrator confirmed that the report should have been submitted but was not. The facility's policy states that a written report of the findings must be provided to the appropriate agencies within five working days of the incident, which was not followed in this case.
Staff Use of Personal Cellphones During Work Hours
Penalty
Summary
Several nursing staff, including CNAs, a licensed nurse, and a restorative nursing assistant, were observed using their personal cellphones during work hours while on the floor, in the dining room, and at the nurses' station. Staff members acknowledged during interviews that cellphone use while working could lead to distractions, delayed response times, and failure to meet residents' needs. Facility policy, as outlined in the employee handbook and a specific policy on telephone use, prohibits the use of personal electronic devices during work hours except during meal and break periods. Despite this, staff admitted to using their phones in violation of these policies. Residents reported witnessing nursing staff using cellphones in hallways and expressed concerns about staff not paying full attention to residents who might need help. The Director of Staff Development and the Director of Nursing both confirmed that staff use of personal cellphones during work hours was against facility policy and not in line with professional expectations. The Director of Nursing further confirmed that this behavior could result in delays in care and place residents' health at risk. The deficiency was identified through direct observation, staff and resident interviews, and review of facility policies.
Failure to Provide Scheduled Showers and Document Refusals for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for activities of daily living (ADLs), including bathing, was not provided showers as scheduled over a period of several weeks. The resident's care plan indicated a need for extensive to total assistance with ADLs, and the facility's shower schedule specified that the resident should receive showers twice weekly. However, documentation revealed that during the months of January, February, and March, the resident did not receive scheduled showers and, in some weeks, received only one bed bath. There was no documented evidence that showers were offered or refused by the resident during this time. Interviews with staff confirmed that the resident was supposed to be offered showers at least twice a week, and if refused, additional attempts should have been made and refusals reported to the charge nurse. The Director of Nursing verified that showers were not provided on the scheduled dates and that documentation did not reflect whether showers were offered or refused. The documentation codes used did not indicate if the resident had refused showers, and there was no evidence that a shower was offered before a bed bath was given. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene, including bathing, and that refusals be documented with attempts to address the underlying cause. The lack of documentation and failure to provide scheduled showers or record refusals constituted a failure to follow the care plan and facility policy for supporting ADLs and maintaining hygiene for a dependent resident.
Failure to Protect Resident from Repeated Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of domestic abuse from physical abuse by another resident. The resident, who had a BIMS score of 1 indicating severe cognitive impairment and a care plan noting a history of an abusive spousal relationship, was involved in two separate incidents where another resident allegedly hit her. The first incident was reported by a roommate who overheard the altercation and by the resident herself, who stated she was hit on the chin and stomach. The second incident was witnessed by another resident and resulted in visible injury, with the resident crying and calling the police after being struck on the face. Following the first incident, the interdisciplinary team met to discuss the situation, but the care plan created for the victimized resident was incomplete, lacking specific goals and interventions to prevent further abuse. Additionally, the staff member responsible for social services was unaware of the resident's history of abuse until after the first altercation, and the care plan had not been updated to reflect this risk. Documentation and monitoring of the alleged perpetrator were also lacking, as confirmed by the ADON, who noted that there was no evidence of increased supervision or monitoring after the initial incident. Facility policies required staff to identify and respond to potential abuse, including providing adequate supervision when resident-to-resident altercations are suspected and updating care plans accordingly. However, these procedures were not followed, as evidenced by the lack of documented interventions, incomplete care planning, and insufficient monitoring of both the victim and the alleged perpetrator. This failure resulted in repeated abuse and emotional distress for the resident involved.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide the required written notice of discharge to the State Long-Term Care Ombudsman's office for two residents who were being discharged. Both residents received a Notice of Discharge with an effective discharge date, but there was no documentation that a copy of this notice was sent to the Ombudsman as required. Interviews with the Business Office Manager, Director of Nursing, and Administrator confirmed that the Ombudsman was not notified, and the Ombudsman’s office also confirmed they did not receive the required notifications. The facility’s own policy and procedure stated that a copy of the discharge notice must be sent to the Ombudsman at the same time it is provided to the resident and their representative, but this was not followed. Resident 1 had a history of necrotizing fasciitis and a below-knee amputation, while Resident 2 had type 2 diabetes with diabetic neuropathy and cellulitis of the left lower limb. Both residents confirmed receipt of their discharge notices. The failure to notify the Ombudsman removed the opportunity for advocacy on behalf of the residents regarding their discharge decisions.
Failure to Supervise and Monitor Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate supervision and follow physician orders for a resident with a history of suicidal ideation, depression, and psychoactive substance abuse. The resident had recently exhibited self-harm behavior by holding scissors to his neck and expressing suicidal thoughts, which led to a physician order for every 15-minute monitoring and the use of plastic utensils. The care plan and facility policy required close monitoring and documentation of the resident's status to prevent self-harm. Despite these orders and interventions, there was no documentation to show that the required 15-minute checks were performed on the day of the incident. Staff interviews confirmed that the monitoring form for the relevant time period was left blank, and the administrator could not provide evidence that the checks were completed or properly discontinued. Staff members, including CNAs and LNs, were either unaware of the resident's risk or could not confirm how the resident obtained a razor blade, which was used in the self-harm incident. As a result of the lack of supervision and failure to follow the monitoring protocol, the resident was able to obtain a razor blade, inflict multiple deep lacerations on his arms and legs, and required emergency medical intervention and hospitalization. The facility's own policy and job descriptions emphasized the importance of monitoring and documentation for residents at risk of self-harm, but these procedures were not followed, directly leading to the resident's injury.
Failure to Continue Prescribed Insulin for Resident
Penalty
Summary
The facility failed to ensure that care provided to a resident met professional standards when the resident's prescribed medication, insulin lispro, was not continued upon admission to the skilled nursing facility. The resident was admitted with a diagnosis of dementia and had been discharged from the hospital with specific orders to continue insulin lispro in two different mixes. However, upon review, it was found that these orders were not transcribed into the Medication Administration Record (MAR) at the facility, and there was no documentation to support the administration of the insulin. Licensed Nurse 1 confirmed that the insulin orders were missing from the MAR and stated that the admitting nurse should have verified all orders with the medical doctor to ensure they were correctly inputted into the system. The Director of Nursing also confirmed the oversight and acknowledged that the facility did not meet its practice standards by failing to carry over the hospital's orders. The resident's medical doctor stated that the insulin was supposed to be continued as ordered upon discharge from the hospital.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not ensuring the call light was within reach. The resident, who was admitted with diagnoses including encephalopathy and hemiplegia, was observed on two separate occasions without access to the call light. On the first occasion, the call light was found on the floor, and on the second occasion, it was hanging on a tube feeding pump pole, both times out of the resident's reach. The resident was observed screaming for help during these instances. Licensed nurses confirmed that the call light was not accessible, acknowledging that the resident would be unable to call for assistance, which could lead to potential falls. The assistant administrator also confirmed that residents should have access to their call lights. The resident's care plan indicated a history of an unwitnessed fall, with interventions to remind the resident to use the call light for assistance. The facility's policy on answering call lights emphasized ensuring the call light is accessible to residents when in bed.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to provide a resident with the scheduled twice-weekly bathing, which was necessary for maintaining personal hygiene and preventing infection. The resident, who was admitted with diagnoses including encephalopathy and hemiplegia, was dependent on facility staff for personal hygiene and bathing. Despite being scheduled for showers on Tuesdays and Fridays, the resident reported not receiving these showers consistently for over two months. Instead, the resident received bed baths only three times out of eight scheduled shower days over a four-week period, leading to discomfort, itching, and rashes. Interviews with multiple CNAs revealed that the resident did not refuse personal care and preferred showers over bed baths. However, due to staffing issues, such as the need for multiple CNAs to assist the resident, showers were not consistently provided. Documentation inconsistencies were also noted, with some CNAs mistakenly recording showers when only bed baths were given. The facility's policies required residents to receive showers or bed baths at least twice a week, but the documentation and interviews confirmed that this standard was not met for the resident in question.
Discontinued Medication Applied by CNA
Penalty
Summary
The facility failed to provide services that meet professional standards of quality when a Certified Nursing Assistant (CNA) applied a discontinued prescription cream on a resident. The incident involved a resident with multiple diagnoses, including encephalopathy and hemiplegia. During an observation and interview, the CNA was seen holding a medication cup with white cream, which he stated was given to him by a Licensed Nurse (LN) to apply on the resident's back, arms, and legs. The LN confirmed she provided the cream, identified as Clotrimazole and Betamethasone, to the CNA. However, a review of the resident's Treatment Administration Record (TAR) and Order Summary Report indicated there was no active order for this cream, as it had been discontinued months earlier. Further investigation revealed that the Treatment Nurse confirmed there was no active order for the cream and stated that licensed nurses, not CNAs, should apply prescription ointments. The Assistant Administrator acknowledged that nurses should verify orders before administering medications and that discontinued medications should be removed from the treatment cart. The facility's policy on administering medications specifies that only licensed personnel should administer medications, and they must verify the right resident, medication, dosage, time, and method before administration. The CNA's job description did not include applying prescription creams, highlighting a deviation from established protocols.
Inadequate Infection Control Practices with Bedpans
Penalty
Summary
The facility failed to implement safe infection prevention and control practices for a resident when three soiled and unlabeled bedpans were found in a shared bathroom. During an observation, two grey and one pink used bedpans were seen in a black storage basket on the floor of the bathroom shared by two residents. A Certified Nursing Assistant (CNA) confirmed that the bedpans were used, soiled, and lacked any resident identifiers. The CNA acknowledged that all soiled bedpans should have been cleaned after use and labeled with a resident identifier, and that staff were responsible for cleaning them. The CNA also recognized the risk of infection spread due to the improper handling of the bedpans. Interviews with the resident and facility staff revealed that the resident had purchased the bedpans because the facility's bedpans were too small, and the CNAs placed them in the bathroom after use. The Assistant Administrator and the Infection Preventionist both stated that the bedpans should have been cleaned and labeled to prevent infection. The facility's policy, revised in February 2018, indicated that bedpans should be cleaned, dried, and not left in the bathroom or on the floor, which was not followed in this instance.
Delayed Medication Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to meet professional standards of quality care for three residents by not monitoring blood sugars before meals and not administering scheduled medications in a timely manner. Resident 1, who has a history of Type 2 diabetes, atrial fibrillation, hypertension, and heart failure, reported that his medications were administered late, and he had to request his insulin. His Medication Administration Record (MAR) showed that medications scheduled for 9 AM were given almost two hours late, and his insulin was administered over two hours after the scheduled time. This delay in insulin administration could potentially lead to unnecessary insulin doses due to inaccurate blood sugar readings. Resident 2, diagnosed with hypertension, systemic lupus erythematosus, and arthritis, also experienced delays in medication administration. Her MAR indicated that medications scheduled for 9 AM were administered several hours late on two consecutive days. An interview with a Licensed Nurse (LN) revealed that she was unaware of her responsibility to pass medications and was delayed by other duties, resulting in the late administration of medications. Resident 3, who has Type 2 diabetes, had his blood sugar checks and insulin administration delayed due to the nurse's inability to locate him in a timely manner. His MAR showed that blood sugar checks and insulin administration scheduled for 11 AM were performed hours later on multiple occasions. Interviews with the nursing staff and the Medical Director confirmed the importance of timely insulin administration and the expectation that medications be given as ordered. The Director of Nurses acknowledged the lack of documentation explaining the delays and emphasized the potential for unnecessary insulin doses if blood sugar readings were taken after meals.
Failure to Follow Infection Control Protocols for Subacute Resident
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures for a subacute resident who required special medical equipment and treatments. The deficiency was observed when a licensed nurse (LN) was seen suctioning the resident without wearing the required personal protective equipment (PPE), specifically a gown, despite the resident being on Enhanced Standard Precautions (EBP) due to multidrug-resistant organisms (MDROs). The nurse acknowledged the requirement for a gown, mask, and gloves during such procedures but did not comply, increasing the risk of infection transmission. The resident involved had a complex medical history, including sepsis, respiratory failure, ventilator dependence, a tracheostomy, and pneumonia. Laboratory results indicated the presence of MDROs, including carbapenem-resistant Klebsiella pneumoniae and Enterococcus faecalis, which were resistant to multiple antibiotics. The resident's room was marked for isolation under EBP, which mandates the use of specific PPE to prevent the spread of these resistant organisms. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed the expectation for staff to wear appropriate PPE during resident care, especially in the subacute unit where residents are considered vulnerable. The facility's policies on infection prevention and control, as well as enhanced barrier precautions, clearly outline the need for gowns and gloves during high-contact activities, such as tracheostomy care, to prevent MDRO transmission. The failure to comply with these protocols was acknowledged by both the IP and the DON, highlighting a lapse in adherence to established infection control measures.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility was found to have multiple deficiencies in food storage, preparation, and service, which could potentially lead to foodborne illnesses among the 94 residents. Observations revealed a dented can of red sweet bell peppers in the dry storage area, which the Registered Dietician (RD) acknowledged could lead to botulism. Expired food items, including graham cracker crumbs, cheese sandwiches, broth concentrates, and frozen bread rolls, were found in various storage areas. The Certified Dietary Manager (CDM) confirmed these items were expired and attributed the errors to new trainees. Additionally, cereal was left uncovered in dry storage, posing a risk of contamination by critters. The kitchen was noted to have several cleanliness issues, including a can opener with metal wearing off, a meat slicer with food residue, and a dirty floor sink. Nonstick pans were found with flaking coating, and the grill was covered in black grease. The CDM acknowledged the need for replacement of the pans and the potential fire hazard posed by unclean equipment. Furthermore, food items were mislabeled or lacked proper labeling, which could lead to confusion and potential allergic reactions among residents. The CDM and RD both emphasized the importance of proper labeling to prevent foodborne illnesses. Additional deficiencies included a coffee machine with an outdated filter, improper handling of food and beverages by nursing staff, and a lack of adequate utensils during meal service. The CDM was unaware of the utensil shortage, which residents confirmed during a council meeting. The facility also failed to properly cool down custard, and staff were unable to articulate the manual dishwashing process. Hot food was not maintained at safe temperatures during meal preparation, as the facility lacked a functioning steamer. Residents reported difficulty chewing vegetables due to improper cooking methods, further highlighting the facility's failure to adhere to food safety standards.
Deficiencies in Resident Care Due to Inaccessible Call Lights and Side Rails
Penalty
Summary
The facility failed to ensure that the needs and preferences of four residents were reasonably accommodated, leading to deficiencies in care. Resident 11, who had diagnoses including respiratory failure, heart failure, and muscle weakness, was unable to reach her call light due to limited range of motion in her right arm. Despite her care plan indicating that the call light should be within reach, it was placed above her head, making it inaccessible. This oversight was confirmed by both a CNA and a licensed nurse, who acknowledged the risk of unmet needs and safety concerns. Resident 37, with a history of muscle weakness and a stroke, required 1/4 upper side rails to assist with repositioning in bed. However, the side rails were incorrectly positioned, making them inaccessible. This was contrary to the physician's order and the resident's care plan, which emphasized the importance of the side rails for maintaining mobility and independence. The Director of Nursing and other staff confirmed the incorrect positioning and acknowledged the potential impact on the resident's ability to participate in his care. Residents 62 and 16 also experienced issues with call light accessibility. Resident 62, who had metabolic encephalopathy and dementia, was found without a call light within reach, as it was on the floor. This was confirmed by a treatment nurse, who noted the risk of falls and unmet needs. Similarly, Resident 16, with diagnoses including dementia and respiratory failure, was observed calling for help because her call light was tied to the back of her siderail, out of reach. A licensed nurse confirmed the inaccessibility and adjusted the bed to provide access. The facility's policy required call lights to be accessible, but this was not adhered to, leading to potential risks for the residents involved.
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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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