Fresno Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 1233 A Street, Fresno, California 93706
- CMS Provider Number
- 555426
- Inspections on file
- 29
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Fresno Postacute Care during CMS and state inspections, most recent first.
A resident received oxygen at 5 LPM by nasal cannula without a physician order, an LPN gave metoprolol without checking the resident’s pulse first, and another LPN administered aspirin enteric coated instead of the ordered chewable formulation. In addition, an LPN left the EMAR screen visible in a hallway, exposing resident information, and licensed nurses did not complete a change-of-condition SBAR for a resident with significant weight gain, dialysis, fluid restriction, and bilateral lower-extremity edema.
A resident kept expired vapor rub and calcium carbonate tablets at the bedside without a physician order for self-administration, despite being assessed as not self-administering medications. The resident was alert and oriented, and staff observed the OTC products in her room while an LVN stated the antacid had been stored there for two days. In a separate event, an LPN left a medication cart unlocked and unattended in the hallway, and another LPN confirmed the cart was not locked even though it contained medications.
Ice machine had visible pale pink residue on the ice grate and was returned to service after being out of use without documentation that the internal components were cleaned first. The KS, RD, MND, and IDON stated the machine was expected to be clean, sanitized, and free of discoloration or debris, and the facility’s logs did not show an internal cleaning before it was placed back into use.
Care Plan Not Timely Reviewed for Bilateral Leg Edema: A resident with cerebral infarction, HTN, dysphagia, localized edema, and kidney disease had persistent bilateral lower extremity swelling noted on observation, but the CP for edema was not reviewed or revised for months. Staff reported the resident was monitored, but there was no medication or treatment for the edema, and the physician was not notified of the continued swelling. The CP still listed edema goals and interventions, including elevation and furosemide, without a documented timely reassessment or update.
Failure to provide basic grooming and nail care for two residents was observed. One resident had long, jagged, dirty fingernails and thick, long toenails, and stated no one had cleaned or trimmed them; staff confirmed the nails were not maintained and that podiatry had not yet seen the resident. Another resident had a thick, long beard and stated he had been waiting two weeks to be shaved; staff acknowledged the shave was not completed because they were busy with other residents.
A resident with autistic disorder and contractures had thick yellow plaque buildup on the forehead and flaky scalp skin while receiving ketoconazole shampoo for seborrheic dermatitis. CNAs applied the medicated shampoo like a regular shampoo even though they were not authorized to administer medications, and an RN signed the EMAR without actually applying it. Licensed nurses did not document the resident's scalp condition or monitor the treatment's effectiveness, despite facility policy stating that nurses must apply medicated shampoos and assess the skin.
A resident continued receiving scheduled Hydrocodone-Acetaminophen for epigastric pain even though EMARs documented pain scores of 0 for months, and staff also gave the opioid for headache and generalized pain. The resident’s record did not show epigastric pain as an admitting diagnosis, and interviews confirmed nurses were expected to follow the ordered indication, assess pain location, and seek MD re-evaluation when pain remained absent. The pharmacy consultant stated the prolonged opioid use should have triggered review for possible tapering or discontinuation.
Failure to use EBP for a resident with MRSA and another resident with a tracheostomy stoma dressing. A CNA was observed providing care to the MRSA-positive resident without gown or gloves, and no EBP signage was posted. The second resident had ordered trach stoma dressing care, but no EBP signage or PPE cart was outside the room. Staff interviews and record review showed both residents met criteria for EBP under the facility policy.
The facility failed to maintain a full-time RN DON or appoint an acting DON after the previous DON resigned, despite having a census of 71 residents. The administrator and multiple staff members, including RNs, LVNs, and the MDS coordinator, confirmed that there was no DON or interim DON in place and that staff instead relied on shift RNs, an LVN DSD, and a corporate RN available by phone and occasional visits for clinical and staffing issues. Facility policy and professional references reviewed by surveyors required that nursing services be under the direct supervision of a full-time RN DON responsible for managing nursing services, overseeing licensed nurse schedules, and ensuring care and documentation follow resident assessments and care plans, and staff acknowledged that the absence of a DON could lead to potential medication errors, improper assessments, and non-compliance with policies and procedures.
A nurse completed an admission assessment for a resident with hypertension and Parkinson’s disease that contained multiple errors, including contradictory fall risk information and incorrect documentation that the resident did not have hypertension, did not take antihypertensive medication, and did not have Parkinson’s disease, despite active physician orders for metoprolol and ropinirole. These inaccuracies affected the data used to develop the resident’s fall risk care plan. In a separate incident, an LVN applied medicated cream to another resident’s peri-area for MASD without wearing gloves, as confirmed by the LVN, a CNA witness, and a police officer’s interview. The DON stated that gloves are required for any contact with the vagina and cited facility policy requiring appropriate PPE and protection of resident privacy, dignity, health, and safety during clinical procedures.
A CNA failed to provide adequate incontinent care for three residents during a night shift, resulting in neglect. Two residents received only one brief change, while a third resident was not changed at all, leading to feelings of anger, frustration, and loss of dignity. The facility's investigation confirmed the neglect, and the Director of Nursing acknowledged the findings.
A LTC facility failed to meet professional standards in medication administration and bed rail use. A resident received Metformin without food, risking stomach upset. Another resident's medication was left unattended, accessible to others. Two residents had incorrect bed rail setups, contrary to physician orders, posing safety risks.
The facility failed to follow prescribed menus and portion sizes for residents on various therapeutic diets, leading to incorrect servings during a lunch meal. Residents on Consistent Carbohydrate, mechanical soft, puree, large portion, and renal diets received inappropriate portions, and pureed coleslaw was not measured. Additionally, cappuccino mousse was not served, and chocolate pudding was inconsistently portioned. Corn was missing from the corn coleslaw, and the facility's Resident Council Minutes indicated ongoing issues with portion sizes and food preferences.
A CNA failed to perform hand hygiene after handling soiled linen, potentially contaminating a linen cart and causing cross-contamination. Interviews with staff confirmed the importance of hand hygiene in preventing infection spread, as outlined in the facility's policy.
Three residents were not provided privacy during medication administration in a LTC facility. An RN administered medication to a resident in the hallway, while another RN gave an injection without closing the privacy curtain. An LVN also failed to close the privacy curtain or door during medication administration. All residents involved had no cognitive deficits, and staff acknowledged the importance of providing privacy.
The facility failed to uphold resident dignity and privacy for four residents. A resident was transported with their back exposed post-shower, another was spoon-fed while lying in bed, a third ate while lying flat, risking aspiration, and a fourth had an uncovered urinary catheter bag. Staff interviews confirmed these actions violated facility policies on dignity and resident rights.
The facility failed to accurately code the smoking habits of four residents in their MDS assessments, despite evidence from Smoking-Safety Screens and staff interviews confirming their tobacco use. This oversight involved residents with various medical conditions, including diabetes, hyperlipidemia, asthma, and hemiplegia, who smoked under supervision. The MDS Nurse acknowledged the errors, and the facility's policy required accurate certification of MDS assessments, which was not adhered to in these cases.
A resident's preference for female caregivers was not documented in her care plan, despite verbal communication among staff. This oversight could lead to male staff unknowingly providing care, potentially upsetting the resident. The facility's policies emphasize the importance of documenting personal preferences, but this was not reflected in the resident's care plan.
The facility failed to store medications securely and in accordance with professional standards. Medication carts were left unlocked and unattended, and some medications lacked visible expiration dates. Additionally, medications for multiple residents were not stored separately, increasing the risk of errors. Expired glucometer control solution was also found in a medication cart.
The facility failed to ensure food service staff were competent, resulting in incorrect portion sizes being served during meal service. Dietary aides used incorrect scoops and did not follow specific diet orders from meal tickets. Competency checks were not completed for the staff, and the Certified Dietary Manager could not provide documentation of necessary in-services. This oversight risked non-compliance with residents' diet orders and facility menus.
The facility failed to provide palatable and flavorful meals, as evidenced by resident complaints and observations of undercooked peas, dry chicken, and bland rice. The Certified Dietary Manager confirmed these issues, and previous Resident Council concerns about food quality were not adequately addressed.
The facility failed to accommodate food preferences for several residents, leading to dissatisfaction and potential nutritional issues. Some residents received meals with items they disliked, such as chocolate pudding, without alternatives. Additionally, residents who disliked certain vegetables were not offered substitutes. One resident's specific preferences were not documented or honored, resulting in skipped meals. The facility's policy on food preferences was not followed, as confirmed by staff.
A facility failed to maintain accurate and complete POLST forms for three residents, leading to potential confusion and risk regarding their healthcare decisions. One resident's POLST form had a misspelled last name, another's was missing a necessary signature, and a third's had an inaccurate date. Staff interviews confirmed the importance of accurate documentation for these critical medical records.
The facility failed to maintain an effective pest control program, resulting in cockroach sightings in the kitchen and hallway. A Dietary Aide and a resident confirmed frequent cockroach issues, and the Pest Control Technician noted unaddressed recommendations to seal cracks. The facility's pest control policy was not effectively implemented.
A resident with Vitamin D deficiency did not receive their prescribed Ergocalciferol medication because the RN did not verify a discrepancy between the medication bubble pack and the eMAR with the pharmacy. The DON stated that licensed nurses are responsible for ensuring timely medication administration, which was not adhered to in this instance.
A LTC facility reported a medication error rate of 10.34%, exceeding the acceptable limit. An RN administered metformin without food to a resident, contrary to instructions, and failed to fully dilute a therapeutic powder for another resident, leaving residue. Additionally, the RN did not administer a vitamin D supplement due to confusion over packaging, resulting in a missed dose. The DON confirmed these errors, emphasizing adherence to medication guidelines.
The facility did not ensure pureed meat maintained its shape for several residents on pureed diets. During an observation, the Certified Dietary Manager confirmed that the pureed curry chicken was spread across the plate and did not hold its form. The facility's diet manual requires pureed food to be smooth, moist, and able to hold its shape, which was not followed.
A resident was not provided with a sippy cup, as required for safe drinking, due to a shortage in the kitchen. Despite the resident's meal ticket and order summary indicating the need for a sippy cup, regular cups were used instead. Staff interviews revealed a lack of awareness and communication about the resident's needs, and the facility's policy on self-feeding devices was not followed.
The facility did not provide the required minimum square footage per resident in 17 rooms, each housing two residents. Although the Maintenance Supervisor noted adequate privacy and space for care, the rooms did not meet the regulatory requirement of at least 80 square feet per resident, potentially affecting residents' comfort and privacy.
A persistent strong odor of urine was noted in a resident room and hallway, affecting four residents. Despite cleaning efforts, the smell remained, causing discomfort. The residents had various medical conditions, including muscle weakness and cognitive impairments. Staff confirmed the odor, which violated the facility's policy on maintaining a homelike environment.
Medication Administration, Oxygen Order, Privacy, and Weight Change Assessment Failures
Penalty
Summary
Resident 32 was observed with a nasal cannula connected to an oxygen concentrator that was turned on at 5 LPM on multiple observations. RN 4 confirmed the cannula was delivering 5 LPM of oxygen therapy, and record review showed there was no active physician order for nasal cannula oxygen therapy. RN 4 stated oxygen required a physician order and that Resident 32 did not have any documented history of administering or titrating oxygen on his own. The resident’s care plan listed acute respiratory failure with hypoxia, COPD, and CHF, and the facility’s oxygen administration policy required verification of a physician’s order before oxygen was given. Resident 64 received Metoprolol Tartrate without the nurse following the physician’s order to check pulse rate before administration. LVN 2 obtained a blood pressure reading, prepared Metoprolol Tartrate and Vitamin D, and administered both medications before checking the resident’s pulse. The EMAR indicated the medication was to be held if systolic blood pressure was below 100 and heart rate was below 60. During interview, LVN 2 stated she did not check the pulse before giving the medication and acknowledged she should have verified the pulse rate first. Resident 64’s record showed a diagnosis of essential hypertension and a BIMS score of 6, indicating severe cognitive impairment. Resident 59 was ordered Aspirin 81 mg chewable, but LVN 1 administered Aspirin 81 mg enteric coated instead. During observation, LVN 1 prepared and gave the enteric coated aspirin and then signed the EMAR for the chewable aspirin order. LVN 1 later stated she had administered the enteric coated formulation and believed it was not a medication error because the name and dose were the same. The pharmacy consultant and the IDON both stated the chewable and enteric coated formulations were not the same medication and that giving enteric coated aspirin instead of chewable aspirin was a medication error. LVN 2 also left the medication cart computer screen open while moving through a hallway, and the EMAR with resident names and photos remained visible to staff, families, and residents passing by. LVN 2 acknowledged the screen should be hidden when not in use and that resident health information should be protected. In addition, Resident 1 had significant weight gain documented in the record, including a 10% gain over six months and a 7.5% gain over three months, but licensed nurses did not complete a change-of-condition SBAR for March and April 2026. Resident 1 was receiving dialysis, was on a fluid restriction, and had chronic bilateral lower extremity edema. The record and interviews showed the significant weight gain was recognized, but no SBAR was completed for the change in condition during the months reviewed.
Improper Medication Storage and Unlocked Medication Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional standards when Resident 21 kept over-the-counter medications at the bedside without a physician’s order for self-administration. During observation, Resident 21 had two jars of expired medicated vapor rub in her room, including one in a blue basket with personal belongings and another in a basket on top of her cabinet. Resident 21 stated she had been applying the vapor rub into her nose when needed and had used it the prior week for flu symptoms. She was alert and oriented x4, and her MDS showed a BIMS score of 15. The resident also had four colored calcium carbonate tablets in a medication cup on her bedside table and stated she was taking them for stomach pain. The LVN stated the antacid medication had been stored at the resident’s bedside for two days and that he had administered an antacid to the resident that morning. The LVN stated he was not aware the resident was keeping antacid medication at her bedside and taking it when needed. The resident’s EMR showed an order for calcium carbonate chewable tablets, 2 tablets by mouth three times a day for epigastric pain, but there was no physician’s order for vapor rub or for self-administration of medications. The nursing admission assessment indicated self-administration was not permitted, and the care plan contained no self-administration plan. The medication storage deficiency also involved an unlocked medication cart at station 1 hallway. LVN 1 opened the cart, removed disinfectant wipes, and left the cart unlocked and unattended. LVN 2 later observed that the cart was not locked and stated it should be locked when unattended because it contained medications. Both LVNs stated the cart should be locked at all times when not in use. The Interim DON stated it was her expectation that licensed nurses follow the facility’s medication storage policy, which required drugs and biologicals to be stored in locked compartments and medication carts to be locked when unattended.
Ice Machine Had Visible Residue and Was Returned to Service Without Documented Internal Cleaning
Penalty
Summary
The facility failed to ensure food was stored, distributed, and served safely when the ice machine was observed with pale pink colored residue on the ice grate. During a concurrent observation and interview, the Maintenance Director removed the ice grate cover and a pale pink residue was seen at the top of the ice grate, which was removed with a white napkin. The Kitchen Supervisor stated the ice machine was expected to always be free from discoloration and residue. Record review and interviews showed the ice machine had been removed from service on 1/7/26 for a new filter and was not placed back into service until approximately the first week of 3/2026. The Kitchen Supervisor stated the kitchen maintained an external cleaning log and maintenance maintained an internal sanitation log posted on the ice machine, but the internal log did not indicate the ice machine was cleaned before it was returned to service. The Kitchen Supervisor stated the ice machine was expected to be internally cleaned before being placed back into service and inspected between cleanings to ensure there was no discoloration or residue. The Registered Dietician, Maintenance Director, and Interim Director of Nursing all stated the ice machine was expected to be cleaned after periods of inactivity and to remain free from discoloration and debris. The facility’s diet report showed 69 residents had diets and one resident was NPO. The facility policy stated the ice machine needed to be cleaned and sanitized monthly, with internal components cleaned monthly or per manufacturer recommendation and the date recorded when cleaned. The manufacturer’s guidance stated special precautions were needed if the ice machine was removed from service for an extended period of time.
Care Plan Not Timely Reviewed for Bilateral Leg Edema
Penalty
Summary
The facility failed to review and revise the care plan in a timely manner for a resident with bilateral lower extremity edema. The deficiency involved Resident 6, who was admitted with diagnoses including cerebral infarction, hypertension, dysphagia, localized edema, tubule-interstitial nephritis, and leg pain. On observation, the resident was in bed with both lower legs uncovered and swelling noted in both lower limbs. Record review showed an order dated 10/27/2025 to monitor +2 edema to the bilateral lower extremities for signs and symptoms of worsening and to notify the physician if any worsening was noted. RN 3 stated the resident had bilateral leg swelling, was being monitored, and was not receiving medication or treatment for the swelling except elevation of the right foot while in bed for foot pain. RN 1 stated the resident was not receiving medication for edema, was being monitored for right foot pain but not for bilateral leg swelling, and the physician should have been notified of the continued swelling. RN 1 also stated the resident should have had a new assessment, new orders, and a revised care plan. The care plan for bilateral lower extremity edema remained in place without review or revision since October 2025. It included goals to maintain optimal fluid balance, assess and document the extent of edema, avoid prolonged standing or sitting, and elevate affected extremities above heart level several times daily, with furosemide listed for localized edema for 2 weeks. The MDS Coordinator stated the care plan should have had a time frame to determine whether the intervention was working, and if not, the nurse should have reassessed the resident and notified the physician. The IDON stated the resident’s care plan should have been revised with a time frame for the condition and intervention, and that monitoring the resident for bilateral edema with no change or other intervention since October 2025 was not acceptable.
Failure to Provide Basic Grooming and Nail Care
Penalty
Summary
The facility failed to provide adequate ADL assistance for two residents who were unable to maintain grooming needs independently. One resident, admitted with a diagnosis of cerebral infarction and assessed as cognitively intact with a BIMS score of 14, was observed in bed with long, jagged fingernails and toenails that were long, thick, and dirty with brownish to blackish buildup under the nails. The resident stated that no one had cut or cleaned the fingernails and that he had been biting them because they were long. The resident also stated he wanted his fingernails to be clean and trimmed. During the observation, an LVN confirmed that the resident’s fingernails were long, uneven, sharp, and dirty, and that the toenails were long and thick. The LVN stated the resident required assistance with ADLs and that nail care should be provided by nursing staff and podiatrists to prevent infection and skin scratches. The SSD stated the resident had not been seen or evaluated by a podiatrist since admission and was not on the podiatry list because no communication form had been received from licensed nurses. Facility staff also stated that CNAs were expected to provide nail care during showers and as needed, and that residents’ fingernails and toenails should be checked during shower days. A second resident, who was cognitively intact with a BIMS score of 15, was observed self-propelling in a wheelchair with a thick, silvery, long beard. The resident stated he had been waiting to be shaved and that the last shave had been two weeks earlier. Later observations showed the beard remained thick and long, and the resident again stated no one had shaved him yet. A CNA stated shaving was part of good hygiene and should be done during showers and as needed, but the CNA did not complete the shave that day because he became busy with other residents. The IP stated the resident should have been shaved as requested and that it was not acceptable for him to have waited two weeks. The IDON stated it was her expectation that residents be shaved within the shift when requested and that shaving should occur during shower days.
Unauthorized Administration of Medicated Shampoo and Lack of Nursing Assessment
Penalty
Summary
Resident 54, who was admitted with autistic disorder and bilateral lower leg contractures and was nonverbal or rarely understood, had thick yellowish plaque buildup on the forehead and yellow flakes in the hair during observation. CNA staff noted the buildup was difficult to remove and stated the resident was totally dependent on staff for ADLs. A licensed nurse later observed the forehead to be red with thick yellowish plaques and skin flakes in the hair and stated the resident was at risk for skin breakdown, while also noting the condition had not been documented in the weekly skin summary as described. The resident had an order for Ketoconazole 2% shampoo to be applied to the scalp on Wednesdays and Saturdays, left on for 5 minutes, and rinsed. During the shower process, a CNA stated she gave the shampoo bottle to another CNA, and the shampoo was applied to the resident's hair like a regular shampoo. The CNA stated CNAs were not authorized to apply medicated shampoo and that only licensed nurses could do so. A registered nurse later signed the EMAR indicating the medicated shampoo had been administered, but stated she did not actually apply it and did not provide instructions to the CNAs on how to apply it correctly. Record review and staff interviews showed the medicated shampoo had been used since December 2025, but licensed nurses were not monitoring and assessing the resident's scalp condition during treatment. Staff stated licensed nurses were responsible for applying medicated shampoo, assessing the skin and scalp for effectiveness, and notifying the physician if treatment was not effective. The resident's shower sheet did not document the skin findings, and the weekly nursing summary stated the skin was clean and intact despite the observed buildup. Facility policy and staff statements confirmed that CNAs were not authorized to administer medicated shampoos and that nurses were expected to assess the resident's skin condition and treatment response.
Unnecessary Scheduled Opioid Use Without Ongoing Indication
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when the resident continued to receive Hydrocodone-Acetaminophen 5-325 mg every 8 hours for an extended period despite documentation showing a pain level of 0. The medication order listed epigastric pain as the indication, but staff also administered the opioid for headache and generalized body pain. The resident was observed with four tablets in a medication cup at the bedside and stated she was taking the medication for stomach pain. Record review showed the resident was admitted with acute upper respiratory infection, migraine, and leg pain, and the admission record did not include epigastric pain or other chronic pain. The resident’s MDS showed a BIMS score of 15, indicating she was cognitively intact. The EMAR documented Hydrocodone-Acetaminophen scheduled every 8 hours from 12/2025 through 4/2026 with pain level documented as 0. Staff interviews confirmed that the medication was being given routinely even when the pain level was 0, and one nurse stated he administered it for headache and generalized body pain rather than the ordered indication. The resident’s care plan identified Hydrocodone-Acetaminophen as related to epigastric pain and directed staff to evaluate pain interventions, monitor for opioid adverse effects, and document pain characteristics and probable cause. Interviews with nursing staff, the pharmacy consultant, and the interim DON confirmed that licensed nurses were expected to follow the physician’s order, assess pain location, and notify the physician when pain scores remained 0 for an extended period. The pharmacy consultant stated she missed the need to recommend reassessment despite months of pain scores of 0, and the interim DON stated pain assessment should include location and that prolonged pain scores of 0 should prompt physician re-evaluation.
Failure to Use EBP for MRSA and Tracheostomy Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program when a resident with documented MRSA was not placed on Enhanced Barrier Precautions (EBP). During observation, no EBP signage was seen on the resident’s door, and a CNA attempted to wake and assist the resident to activities without wearing a gown or gloves. The resident was observed in bed, asleep, and covered with a blanket. The resident’s record showed severe cognitive impairment, a diagnosis history including dementia, and an order for doxycycline hyclate 100 mg twice daily for one year for MRSA to the right hip. Record review and staff interviews showed the resident had been admitted from an acute care hospital and was still receiving doxycycline for MRSA related to the right hip. An RN stated the resident was not on isolation precautions, while the Infection Preventionist stated residents were placed on EBP for indwelling medical devices and open wounds and that appropriate PPE should be used during patient care. The Interim DON stated residents were placed on EBP if they had implanted devices, open wounds with dressings, or MDROs such as MRSA, and that staff should have recognized the need for EBP based on the physician orders and notified the IP. The facility also failed to place another resident with a tracheostomy stoma dressing on EBP. The resident was observed in bed with a dressing over the tracheostomy stoma site, and no EBP signage or PPE cart was observed outside the room. The resident’s record showed tracheostomy care was ordered, including cleansing the stoma site and applying a dry dressing daily and as needed. An RN stated the resident should have been on EBP because she had an opening in her skin to prevent infection, and the facility’s policy stated EBP may be indicated for residents with wounds or indwelling medical devices, including tracheostomy/ventilator care and any skin opening requiring a dressing.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The deficiency involves the facility’s failure to have a full-time Registered Nurse (RN) designated as the Director of Nursing (DON), as required by federal and state regulations and the facility’s own policy. Interviews with the administrator and multiple nursing staff confirmed that the previous DON, an RN, resigned and her last day was 3/6/26, and no interim or acting DON had been appointed since that time. The administrator, who had been in the role for eight days, acknowledged that the facility did not have a DON or interim DON, that the DON position was only posted and they were actively recruiting, and that it is a regulatory requirement to have a full-time DON onsite. The facility census at the time was 71 residents. Multiple staff members, including RNs, LVNs, and the MDS Coordinator, consistently reported that there was no DON or acting DON in place. Staff described relying on RNs on their shifts, a corporate RN available by phone and visiting intermittently, and an LVN Director of Staff Development for staffing and clinical questions, but none of these individuals were designated as DON. One LVN reported that there were RNs on the day and evening shifts but no RN on the night shift. Review of the facility’s policy on Director of Nursing Services stated that nursing services are under the direct supervision of an RN DON employed full-time (40 hours per week) and responsible for managing nursing services, overseeing licensed nurse schedules, and ensuring care and documentation are in accordance with assessments and care plans. Professional references reviewed by surveyors confirmed the regulatory requirement for a full-time RN DON. The MDS Coordinator stated that without a DON or acting DON, there could be a potential risk of medication errors, improper resident assessment, and non-compliance with facility policies and procedures.
Inaccurate Admission Assessment and Failure to Use Gloves During Peri-Care
Penalty
Summary
The facility failed to ensure professional standards were met when a nurse inaccurately completed admission assessment data for a newly admitted female resident with diagnoses including muscle weakness, musculoskeletal problems, hypertension, and Parkinson’s disease. Review of the resident’s Nursing Admission Assessment dated 1/9/26 showed contradictory fall risk information, documenting that the resident ambulated without problems while also having balance and gait problems when standing or walking. The assessment also incorrectly indicated that the resident did not take an antihypertensive medication, despite a physician’s order for metoprolol tartrate for hypertension, and incorrectly documented that the resident did not have Parkinson’s disease, despite a diagnosis of Parkinson’s and an order for ropinirole. The RN interviewed confirmed these entries were errors and stated they contributed to inaccurate assessment data used to develop the resident’s fall risk care plan. The resident’s Medication Review Report dated 2/17/26 confirmed active physician’s orders for ropinirole for Parkinsonism and metoprolol tartrate for primary hypertension, both ordered on 1/9/26. These orders conflicted with the admission assessment entries that denied the presence of hypertension and Parkinson’s disease and the use of antihypertensive medication. The facility’s Falls and Fall Risk Managing policy, dated 11/17, stated that staff, with input from the attending physician, would identify appropriate interventions related to specific risks and causes to try to prevent residents from falling, indicating that accurate assessment data were required to identify appropriate fall risk interventions. The facility also failed to ensure professional standards were met when a nurse did not use appropriate personal protective equipment while performing peri-care on another female resident. The resident had an order for medicated cream to be applied to the peri-area for MASD, and a progress note documented treatment to the peri-area on 1/19/26 by an LVN. In interviews, a local police officer reported that the LVN admitted he was not using gloves while applying the cream, and the LVN himself stated that after applying the cream to the resident’s vaginal area and between her thighs and vagina, he noticed cream on his bare fingers and acknowledged his finger was exposed. A CNA who was present stated she stood shoulder to shoulder with the LVN and observed him apply the cream over the vaginal area and upper thighs without gloves. The DON stated that nurses should wear gloves for any contact with the vagina and that if a glove breaks, the procedure should be stopped and new gloves applied, and referenced the facility’s Standards for Clinical Practice policy, which requires appropriate PPE (gloves) and protection of privacy, dignity, health, and safety during clinical procedures.
Neglect of Incontinent Care by CNA
Penalty
Summary
The facility failed to ensure residents were free from neglect when a Certified Nursing Assistant (CNA) did not provide adequate incontinent care for three residents during a night shift. The CNA, identified as CNA 9, limited incontinent care to one change for two residents and did not provide any care for the third resident throughout the entire shift. This neglect resulted in the residents experiencing feelings of anger, frustration, loss of dignity, and disrespect. Resident 1 and Resident 2, both cognitively intact and requiring substantial assistance with toileting hygiene, expressed their dissatisfaction with the care they received. They reported that CNA 9 informed them of being short-staffed and only able to provide one brief change during the shift. Despite their requests for additional changes, they were left in soiled briefs for extended periods, leading to emotional distress. Resident 3, who was dependent on staff for toileting hygiene, was not changed at all during the shift, contrary to his preference to be changed before breakfast. The facility's investigation confirmed the neglect, and the Director of Nursing acknowledged the accuracy of the findings. The facility's policy on abuse prevention and neglect defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The report highlights the failure of the facility to meet the residents' needs, resulting in substantiated claims of neglect.
Medication and Bed Rail Deficiencies in LTC Facility
Penalty
Summary
The facility failed to meet professional standards of practice in the administration of medication for several residents. A registered nurse administered Metformin to a resident without food, contrary to the medication's instructions, which could lead to stomach upset. The resident had a history of diabetes and quadriplegia, and the nurse acknowledged the potential for stomach irritation if the medication was not given with food. In another instance, a medication cup containing a tablet was left unattended on a resident's bedside table, accessible to other residents. The resident had dysphagia and muscle weakness, and the medication was a multivitamin. The licensed vocational nurse responsible admitted that it was against nursing practice to leave medications unattended, as it posed a risk of other residents ingesting the medication, potentially causing allergic reactions. Additionally, the facility did not adhere to physician orders regarding bed rails for two residents. One resident, with a history of convulsions and falls, had bed rails without the required padding, increasing the risk of injury during seizures. Another resident, under hospice care, had full bed rails instead of the ordered half rails, which was not in compliance with the physician's instructions. The facility's policy on the proper use of side rails was not followed, compromising resident safety.
Failure to Adhere to Prescribed Menus and Portion Sizes
Penalty
Summary
The facility failed to adhere to the planned menus for the lunch meal on August 12, 2024, resulting in incorrect portion sizes being served to residents on various therapeutic diets. Specifically, 20 residents on a Consistent Carbohydrate (CCHO) diet received 1/2 cup of sweet potato fries instead of the prescribed 1/4 cup. Additionally, eight residents on a mechanical soft diet were served 2 ounces of roast beef instead of the required 3.2 ounces, and seven residents on a puree diet received 2.67 ounces of pureed roast beef instead of 4 ounces. Furthermore, three residents on a large portion diet were given double portions of all food items, and two residents on a renal diet received sweet potato fries, which were not included in their prescribed menu. The facility also failed to measure pureed coleslaw when serving it to residents on a puree diet. During the meal preparation, the dietary aide poured the pureed coleslaw into bowls without measuring, contrary to the facility's Summer Menu, which specified a #12 scoop for portioning. Additionally, the facility did not serve cappuccino mousse as planned, and the chocolate pudding served as a substitute was inconsistently portioned, with some bowls not filled to the required amount. The facility's registered dietitian confirmed that the kitchen staff did not follow the portion sizes on the menu spreadsheet. Moreover, the facility did not include corn in the corn coleslaw served during the lunch meal, as specified in the Summer Menu. The dietary aide admitted that some ingredients were not available for the recipes. The facility's Resident Council Minutes from previous months indicated ongoing issues with portion sizes and food preferences, highlighting a pattern of non-compliance with menu planning and execution. These deficiencies had the potential to result in residents not meeting their physician-prescribed diet orders and nutritional needs.
Failure to Perform Hand Hygiene After Handling Soiled Linen
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the spread of communicable diseases and infections, as observed in the actions of a Certified Nursing Assistant (CNA) who did not perform hand hygiene after handling soiled linen. Specifically, CNA 1 exited the shared room of two residents, carrying a bag of soiled linen, and disposed of it without washing or disinfecting his hands. Subsequently, CNA 1 moved the linen cart without performing hand hygiene, which had the potential to contaminate the cart and cause cross-contamination of other surfaces. Interviews with various staff members, including CNA 1, CNA 5, the infection preventionist, the director of staff development, and the director of nursing, confirmed that the facility's policy required staff to perform hand hygiene after contact with potentially contaminated substances. The staff acknowledged the importance of hand hygiene in preventing the spread of infections and maintaining a clean environment. The facility's policy on handwashing emphasized the necessity of washing hands before and after direct resident care and after contact with potentially contaminated substances to prevent nosocomial infections.
Failure to Provide Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during medication administration for three of the nine sampled residents. Registered Nurse (RN) 2 administered medication to Resident 20 in the hallway, where other residents, staff, and visitors were present, without providing privacy. Resident 20, who had no cognitive deficit, was exposed to a lack of privacy during this process. RN 2 acknowledged the mistake and stated that privacy should have been provided. Similarly, RN 1 administered an aspart injection to Resident 24 without closing the door or privacy curtain, exposing the resident's abdominal area. Resident 24, who also had no cognitive deficit, was not afforded the privacy they were entitled to during the medication administration. RN 1 admitted to not providing the necessary privacy and recognized the importance of respecting residents' rights to privacy. Licensed Vocational Nurse (LVN) 1 administered medication to Resident 40 in their room but failed to close the privacy curtain or door, leaving the resident exposed to others passing by. Resident 40, with no cognitive deficit, was not given the privacy required during medication administration. The Director of Nursing (DON) confirmed that the expectation was to provide privacy by closing curtains or doors and acknowledged that residents' rights to privacy were not upheld in these instances.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that four residents were treated with respect and dignity, as required by federal and state laws. Resident 30 was transported from the shower room with his back exposed, which violated his right to privacy. Interviews with staff, including CNAs and the Director of Nursing, confirmed that residents should be fully covered after showers to maintain their dignity. The facility's policy on dignity and resident rights emphasized the importance of treating residents with respect and ensuring their privacy. Resident 8 experienced a lack of dignity during meal assistance. A CNA stood over him while spoon-feeding him breakfast, rather than sitting at eye level, which would have provided a more respectful dining experience. The CNA acknowledged the mistake, and other staff members confirmed that the proper practice is to lower the bed and sit next to the resident during meals. The facility's policy on dignity supports the need for residents to be treated with respect and to have their self-esteem and self-worth maintained. Resident 57 was observed lying flat in bed while eating, unable to see her food, which posed a risk for aspiration and choking. Despite her refusal of assistance, staff should have ensured she was positioned correctly to prevent health risks and maintain her dignity. Additionally, Resident 65's urinary catheter bag was left uncovered, visible to others, which violated her privacy. Staff interviews confirmed that catheter bags should be covered to protect residents' dignity, as outlined in the facility's policies on resident rights and quality of life.
Inaccurate MDS Assessments for Resident Smoking Habits
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the smoking habits of four residents, leading to potential unmet care needs. Resident 14, who was admitted with diagnoses including pain, diabetes, and mobility issues, was identified as a smoker through a Smoking-Safety Screen, yet this was not coded in the MDS assessment. Similarly, Resident 29, with diagnoses of hyperlipidemia and diabetes, was also a smoker according to the Smoking-Safety Screen, but this information was omitted from the MDS assessment. Resident 34, who had muscle weakness and asthma, reported smoking and following a smoking schedule supervised by staff, yet her tobacco use was not recorded in the MDS assessment. Resident 38, with hyperlipidemia and hemiplegia, also smoked under supervision, but his smoking habit was not documented in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged the oversight in each case, stating that the residents should have been coded as smokers. Interviews with the Activity Assistant and the Director of Nursing highlighted the facility's expectation for accurate assessments, with the Director noting that inaccuracies could be considered falsification of records. The facility's policy required staff to certify the accuracy of MDS assessments, and the Resident Assessment Instrument manual specified that tobacco use should be recorded if used during the look-back period. Despite these guidelines, the smoking habits of the residents were not accurately captured in the MDS assessments.
Failure to Document Resident's Care Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident 66, who had specific preferences regarding the gender of the staff providing her care. Despite verbal communication among staff members about Resident 66's preference for female caregivers, this preference was not documented in her care plan. Interviews with multiple certified nursing assistants (CNAs) and a registered nurse (RN) revealed that the lack of documentation could lead to male staff members unknowingly entering Resident 66's room, which would upset her. The absence of a written care plan meant that new or temporary staff might not be informed of her preferences, potentially compromising her comfort and sense of safety. Resident 66 was admitted with diagnoses including heart failure, atrial fibrillation, and major depressive disorder. The facility's policy and job descriptions for licensed vocational nurses (LVNs) and registered nurses (RNs) emphasize the importance of incorporating residents' personal and cultural preferences into care plans. However, the review of Resident 66's care plan showed no mention of her preference for female staff, and interviews with the minimum data set coordinator (MDSC) and the director of nursing (DON) confirmed that this preference should have been documented to ensure all staff were aware of the necessary interventions to respect her wishes.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with accepted professional standards of practice. On multiple occasions, medication carts were left unlocked and unattended, making medications accessible to unauthorized individuals. Specifically, a medication cart in Station 1 was left unlocked by an RN while she washed her hands and used the restroom, and again when she entered a resident's room to administer medication. Similarly, another medication cart was found unlocked and unattended in a hallway outside a resident's room. These actions were acknowledged by the staff involved, who admitted that such lapses could lead to unauthorized access to medications by residents, staff, or visitors. Additionally, the facility did not ensure that all medications had visible expiration dates. Two bottles of Perampanel, a medication used to prevent seizures, were found without expiration dates on the labels. The LVN responsible for these medications admitted that the expiration dates should have been checked and clarified before administering the medication to residents. The absence of expiration dates could result in the administration of expired medications, which may have lost efficacy or could cause unwanted side effects. Furthermore, the facility failed to store medications in an orderly manner. Medication bubble packs for 12 of 19 sampled residents were not separated in the medication cart, increasing the risk of administering the wrong medication to residents. This lack of organization was noted by the LVN, who stated that medications should be stored separately as a safety measure. The facility's policies and procedures were not followed, as evidenced by the presence of expired glucometer control solution in a medication cart, which could lead to incorrect glucose readings and improper medication dosing.
Incompetence in Food Service Staff Leads to Incorrect Meal Portions
Penalty
Summary
The facility failed to ensure that three food service staff members were competent in carrying out the functions of food and nutrition services safely and effectively. During the lunch meal service and preparation, it was observed that incorrect portion sizes of food items were served. Specifically, the dietary aides used incorrect scoops for various food items, such as roast beef and sweet potato fries, which did not align with the facility's menu requirements. Additionally, one dietary aide did not call out specific diet orders, such as Consistent Carbohydrate (CCHO) and renal diets, from the meal tickets when instructing the cook. The facility's records revealed that the dietary aides did not have competency or skills checks completed, despite being employed for varying lengths of time. The Certified Dietary Manager confirmed the lack of competency checks and was unable to provide documentation of in-services regarding portion sizes, menu adherence, and therapeutic diets. The facility's policy required annual competency testing for food and nutrition services employees, which was not adhered to in this case. This oversight had the potential to result in residents' diet orders and facility menus not being followed.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that the food served to residents was palatable and flavorful, as evidenced by multiple resident complaints and direct observations. Residents reported that the food was either overcooked or undercooked, with specific complaints about firm and undercooked peas, dry and bland chicken, and bland rice. Several residents expressed dissatisfaction with the taste and quality of the meals, describing them as dreadful, bland, and not appetizing. The facility's Summer Menus indicated a meal of curry lemon chicken, garlic rice, and peas with onions, but the actual food served did not meet these expectations. During a concurrent observation and interview, the Certified Dietary Manager confirmed that the peas were firm and undercooked, and the curry flavor was more pronounced in the pureed chicken than in the regular chicken. The facility's Resident Council had previously identified concerns about food quality, and responses from the Department Head indicated issues with staff not properly reading meal tickets. Despite these concerns being raised, the facility did not adequately address the issues, leading to continued dissatisfaction among residents regarding the quality and palatability of their meals.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate food preferences for several residents, leading to dissatisfaction and potential nutritional issues. Three residents, identified as Resident 12, Resident 23, and Resident 18, received meals that included items they had explicitly stated they disliked, such as chocolate pudding and pudding in general. Despite the dietary aides' acknowledgment of these preferences, the meals were not adjusted accordingly. The Certified Dietary Manager and Registered Dietitian both confirmed that residents with dislikes should have received alternatives, but this was not implemented. Additionally, the facility did not provide alternative options of similar nutritive value for residents who chose not to eat certain menu items. Three residents, identified as Resident 31, Resident 51, and Resident 34, were served meals containing vegetables they disliked, such as peas, without being offered alternative vegetables. The facility's policy stated that substitutes should be provided for disliked foods, but this was not adhered to, as confirmed by the Certified Dietary Manager and Registered Dietitian. Furthermore, the facility failed to document and provide for a resident's specific food preferences. Resident 29, who had no cognitive impairment, expressed a dislike for ham and a preference for potatoes, which was not documented or honored by the kitchen staff. Despite communicating these preferences, the resident's meal ticket was not updated, leading to dissatisfaction and the resident skipping meals. The Certified Dietary Manager admitted the oversight and acknowledged the importance of documenting meal preferences to ensure residents receive their desired food.
Inaccurate and Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to potential confusion and risk regarding their healthcare decisions. For Resident 51, the Physician Order for Life Sustaining Treatment (POLST) form contained a misspelled last name, which was identified during a review of the resident's admission record. Interviews with staff, including a certified nursing assistant, registered nurse, medical records coordinator, and the director of nursing, confirmed the importance of accurate documentation, as the POLST is a critical medical record that guides end-of-life care decisions. Resident 2's POLST form was found to be incomplete, lacking a necessary signature from either the resident or a legally recognized decision-maker. This omission was discovered during a review of the resident's admission record, which noted diagnoses of convulsions and hyperlipidemia. The medical records person acknowledged the incomplete status of the POLST and indicated that the responsibility for ensuring completeness lay with the admission nurse and licensed nurses. For Resident 22, the POLST form was inaccurately dated, with a discrepancy between the completion date and the physician's signature date. This error was noted during a review of the resident's admission record, which included diagnoses of COPD, anemia, and chronic pain. The medical records person admitted to not checking the documents closely before scanning them into the computer system. The director of nursing and the administrator both emphasized the necessity of accurate and complete POLST forms before they are entered into the system.
Pest Control Deficiency: Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of cockroaches in the kitchen and hallway areas. During an observation and interview with a Dietary Aide, a cockroach was seen crawling on the wall in the dish machine area, and the aide confirmed previous issues with cockroaches in the kitchen. Further observations revealed cockroaches on the floor by the handwashing station and under the food preparation table near the three-compartment sink. The Certified Dietary Manager acknowledged being informed by the kitchen staff about the cockroach problem. Additionally, a resident in Station 2 hallway reported frequently seeing cockroaches in the facility, and a cockroach was observed crawling into a crack on the shower room floor. The Maintenance Supervisor noted the need to seal the crack. The Pest Control Technician, who services the facility, mentioned visiting twice in the past months and had recommended sealing cracks in the kitchen, but was unsure if the recommendations were implemented. The facility's pest control policy, dated January 2018, indicated an ongoing program to keep the building free of insects and rodents, which was not effectively maintained.
Failure to Administer Prescribed Medication Due to Verification Error
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident diagnosed with Vitamin D deficiency and muscle wasting and atrophy. On a specific day, the resident did not receive their prescribed Ergocalciferol medication because the medication bubble pack had a different name than the order on the electronic Medication Administration Record (eMAR). The Registered Nurse (RN) responsible for administering the medication did not verify the discrepancy with the pharmacy but instead contacted the physician, resulting in the medication not being administered. The Director of Nursing (DON) acknowledged that licensed nurses are responsible for ordering medications and ensuring their timely administration. The facility's policy and procedure for medication administration require medications to be administered according to the physician's written orders and within a specified time frame. The failure to administer the medication as prescribed was not in accordance with the facility's policy, which emphasizes the importance of checking medications delivered from the pharmacy to ensure they are correct.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 10.34 percent. One incident involved a registered nurse (RN) administering metformin to a resident without food, contrary to the medication's instructions. The resident, who had been readmitted with diagnoses including diabetes and muscle spasms, was given the medication while lying in bed with a food tray nearby. The RN acknowledged the error, noting that the medication should have been given with food to prevent gastrointestinal upset. Another incident involved the same RN not fully diluting a therapeutic powder for a resident, leaving residue in the cup. This resident, admitted with conditions such as vitamin D deficiency and muscle wasting, did not receive the full dose of the therapeutic powder intended for wound healing. The RN admitted to not mixing the powder thoroughly, which was confirmed by the Director of Nursing (DON), who stated that the full dose was not administered due to the residue left in the cup. Additionally, the RN failed to administer a vitamin D supplement to the same resident because of confusion over the medication's packaging and order. The RN did not verify the medication with the pharmacy, resulting in the resident missing a dose. The DON emphasized the importance of ensuring routine medications are available and administered as prescribed. The facility's policy on medication errors highlights the need to follow clinical guidelines and physician orders to minimize adverse consequences.
Failure to Maintain Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that pureed meat was prepared in a form that could hold its shape or form for seven residents who were on a pureed diet. During an observation and interview with the Certified Dietary Manager, it was noted that the pureed curry chicken was spread all over the plate and did not maintain its shape. The Certified Dietary Manager acknowledged this issue. A review of the facility's Diet Type Report indicated that the affected residents were on various types of pureed diets, including regular puree, fortified puree, and puree with specific liquid consistencies such as nectar thick and honey thick liquids. The facility's diet manual specified that the pureed diet should be smooth, moist, and able to hold its shape, which was not adhered to in this instance.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment, specifically a sippy cup, for a resident who required it for safe and independent drinking. During an observation, it was noted that the resident's meal tray contained two regular cups without handles, despite the meal ticket indicating the need for a sippy cup. Interviews with dietary aides revealed that the kitchen lacked sufficient sippy cups, leading to the use of regular or disposable cups instead. The resident's order summary also specified the need for light-up utensils and a sippy cup to minimize spillage during meals. Further observations and interviews highlighted a lack of awareness and communication among staff regarding the resident's need for a sippy cup. A registered nurse confirmed the resident's requirement for a sippy cup or a cup with a handle due to seizure precautions, while a certified nursing assistant was unaware of any such order. The facility's policy stated that self-feeding devices should be kept in stock and provided with each meal, yet this was not adhered to, resulting in the deficiency.
Failure to Meet Square Footage Requirements in Resident Rooms
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in 17 resident bedrooms, specifically Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21. Each of these rooms housed two residents but did not meet the regulatory requirement of at least 80 square feet per resident. During an observation and interview with the Maintenance Supervisor, it was confirmed that the rooms did not meet the square footage requirement. However, the Maintenance Supervisor noted that the room variations were in accordance with the particular needs of the residents, and that the residents had a reasonable amount of privacy, with adequate closets, storage space, and bedside stands. There was also sufficient room for nursing care and for residents to ambulate, with accessible wheelchairs and toilet facilities. Despite these accommodations, the failure to meet the square footage requirement had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort.
Persistent Urine Odor in Resident Room and Hallway
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment for four residents, as evidenced by a persistent strong odor of urine in a specific room and the surrounding hallway. Observations made over several days noted the presence of the odor, which was confirmed by multiple staff members, including the Infection Preventionist, Activities Coordinator, and Maintenance Supervisor. Despite efforts to clean the room, the odor remained, leading to discomfort for the residents, one of whom reported experiencing a headache due to the smell. The residents affected by this deficiency included individuals with various medical conditions such as muscle weakness, chronic pain, heart failure, and cognitive impairments. The Minimum Data Set assessments indicated that two of the residents had no cognitive impairment, while the other two had moderate cognitive impairments. The facility's policy on maintaining a homelike environment, which includes ensuring pleasant and neutral scents, was not adhered to, contributing to the deficiency.
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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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