Greenfield Care Center Of Fairfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, California.
- Location
- 1260 Travis Blvd, Fairfield, California 94533
- CMS Provider Number
- 055189
- Inspections on file
- 41
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Greenfield Care Center Of Fairfield during CMS and state inspections, most recent first.
A resident with pneumonia and acute/chronic respiratory failure, normally cognitively intact and full code, developed hypoxia, shortness of breath, and altered level of consciousness. An LN found the resident repeatedly saying the same sentence, with O2 sat in the low 80s on supplemental O2, increased the O2 flow, and called the on-call physician, who ordered an ER transfer via non-emergency transport. The resident was transferred without documented escalation to a non-rebreather mask and without calling 911, despite facility policy and the DON’s and NP’s statements that O2 sat below 88% with decreased consciousness requires activation of emergency response/911. ER records later showed a GCS of 7 and intubation for acute respiratory failure, and the facility’s policies and the state Nursing Practice Act require initiation of emergency procedures based on such observed abnormalities.
A resident with multiple medical and cognitive issues was not permitted to return to the facility after a hospital transfer, despite not exhibiting behaviors that endangered herself or others. Facility staff cited safety concerns due to the resident's confusion and attempts to leave, but there was no physician documentation or evidence that the facility could not meet her needs. The refusal to readmit led to the resident remaining in the hospital unnecessarily.
A resident with confusion, impaired mobility, and a history of wandering was inaccurately assessed as low risk for elopement, resulting in the absence of a wander guard and insufficient supervision. The resident left the facility unnoticed, crossed a busy street, and was found wandering at another location, exposing her to significant health hazards.
Surveyors found that the facility did not have a required remote manual stop station for its propane emergency power supply system and could not provide documentation of a four-hour load test, as confirmed by observation, record review, and staff interview. These deficiencies affected all residents and smoke compartments.
Surveyors observed that a relocatable power tap was connected to another relocatable power tap at the nursing station, in violation of electrical safety codes. Maintenance staff were unaware of this connection, and the deficiency affected multiple residents and a smoke compartment.
A long-term care facility failed to administer medications timely for several residents, leading to severe pain and potential health risks. Delays were due to late orders, missing prescriptions, and administrative issues, affecting residents' comfort and well-being.
Four residents did not receive prescribed pain medications as ordered due to delays in order transcription, lack of valid prescriptions, and medication unavailability, leading to unnecessary pain, emotional distress, and impaired comfort, activity, and sleep.
The facility failed to properly dispose of garbage, as the dumpster was observed overflowing and unable to close, which could attract pests. This was confirmed by a kitchen staff member and the facility's RD, who emphasized the importance of keeping dumpster lids closed. The facility's policy requires garbage to be stored in a manner inaccessible to vermin, with dumpsters kept closed.
The facility failed to protect resident privacy by improperly disposing of meal tray tickets containing personal and medical information. Staff routinely discarded these tickets into regular trash, which was then taken to unsecured dumpsters, risking unauthorized access to sensitive information. The facility's policy required shredding of these tickets, but this was not followed, affecting 54 residents.
Two residents in an LTC facility did not receive appropriate pain management as per physician orders and facility policy. One resident with multiple diagnoses, including osteoarthritis and chronic pain syndrome, received inconsistent pain medication, leading to severe pain and distress. Another resident with a fracture and neuralgia received medication for moderate pain instead of severe pain, contrary to orders. The facility's policies emphasize adherence to prescriber orders, which was not followed, resulting in unnecessary pain and emotional distress.
The facility failed to provide timely pharmaceutical services, resulting in residents not receiving prescribed medications on time. Delays were due to late receipt of orders by the pharmacy and subsequent delivery issues. Residents with chronic conditions experienced adverse effects, and the facility did not follow procedures for medication delivery and accountability, increasing risks of drug diversion.
The facility had a medication error rate of 10% due to improper administration practices. Two residents received Polyethylene Glycol powder with insufficient water, contrary to manufacturer instructions. Additionally, a resident's G tube was not flushed between medications, violating protocol. These errors contributed to the facility's high error rate.
A facility failed to safely store medications in Medication Cart C, where unused medications from a discharged resident and an expired narcotic were found. A nurse acknowledged the error and removed the medications. The DON stated that nurses are expected to check expiration dates and remove expired or unused medications. The facility's policy requires disposal of such medications according to laws.
The facility failed to fill a full-time Dietary Manager/Supervisor position with a qualified individual after the current manager went on medical leave. A kitchen staff member without the necessary training and qualifications was placed in the role, potentially risking the nutritional status of 60 residents. The part-time RD confirmed the lack of proper credentials for the acting manager, and the facility Administrator acknowledged the issue.
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 residents. The sanitizing solution was below effective concentration, and a dietary aide worked without a beard cover. Food items were improperly stored and labeled, with some lacking use-by dates. Dishware was stored wet, and some cookware was unsanitary. These practices could lead to foodborne illness, as confirmed by the Registered Dietician.
The facility failed to maintain effective infection control, with staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene. A resident on EBP received wound care without required PPE, and another resident's family member provided care without PPE. Additionally, staff failed to perform hand hygiene during medication administration, and glucometers were not properly disinfected. The Infection Preventionist and Director of Nursing confirmed these lapses, highlighting the need for adherence to infection control protocols.
The facility failed to conduct mandatory Effective Communications in-services for direct care staff, affecting 60 residents. The Director of Staff Development confirmed that no communication training was included in the 2024/2025 In-Service Calendar, and none had been conducted in 2024 or 2025. This failure contradicts the facility's policy to develop and improve staff skills through ongoing in-service training.
The facility did not provide training on resident rights and facility responsibilities to indirect staff members, as confirmed by the Director of Staff Development. The in-service training calendar for 2024/2025 lacked this essential training, despite the facility's policy requiring ongoing development for all personnel. This oversight affected a census of 60 residents.
The facility failed to conduct mandatory training on its QAPI program for all staff, as confirmed by the DSD during a review of the 2024/2025 in-service calendar. The absence of QAPI training sessions was contrary to the facility's policy on ongoing staff development, potentially leading to poor communication and compromised resident care.
The facility did not conduct required behavioral health training for staff, as confirmed by the Director of Staff Development (DSD) during a review of the 2024/2025 In-Service Calendar. An in-service on the needs of aged and ill patients was scheduled but not conducted, violating the facility's policy for ongoing staff development.
Two residents with significant physical and cognitive impairments were left without appropriate or functional call light systems. One was unable to use the standard call light due to limited hand mobility, and the other was given a nonfunctional alternative after being moved to a room with a broken call light. Staff and maintenance confirmed the deficiencies, and facility policy required prompt repair or replacement of call systems.
The facility failed to maintain dignity and respect for three residents. A resident was humiliated by a CNA's demeaning comments about her use of a commode. Two residents with severe cognitive impairments were assisted with meals in a disrespectful manner, as CNAs stood over them instead of sitting. The inappropriate actions were acknowledged by the CNAs and confirmed by the Director of Nursing.
The facility failed to ensure accessible call light systems for three residents, leading to potential unmet needs. A resident with multiple sclerosis had a call light out of reach due to a contracted hand. Another resident with hemiplegia was without a call light while on a Geri chair, and a third resident with cerebral infarction had a call light on the floor. Staff confirmed these deficiencies, which contradicted care plans and facility policy.
The facility failed to provide a written transfer agreement with a local GACH, as required by federal regulations. The DON was unable to produce the agreement during multiple interviews, acknowledging the requirement but failing to locate it. This deficiency could potentially risk residents' continuity of care and treatment.
A resident's Foley catheter drainage bag was observed on the floor, contrary to the facility's infection control policy. Staff confirmed that this practice increases infection risk, as the policy requires the bag to be kept off the floor to prevent bacterial contamination.
The facility failed to ensure call lights were within reach for two residents, leading them to yell for help. Staff confirmed the call lights were inaccessible, which is against facility policy. The deficiency involved residents with muscle weakness, neuromuscular dysfunction, hyperlipidemia, and anemia.
A resident experienced a 22-day delay in UTI treatment, risking acute kidney failure, while three others missed critical medications due to pharmacy delays. One resident with respiratory issues was transferred to higher care after missing medications, and another with heart conditions missed doses for two days. The DON acknowledged failures in medication administration and pharmacy delivery adherence.
The facility failed to notify two residents and their Responsible Parties (RPs) of changes in their medical conditions or treatment plans. One resident with severe cognitive impairment was not informed about changes in skin condition, while another resident was not notified about the extension of intravenous antibiotic therapy. Staff interviews confirmed the facility did not follow its policy of notifying residents and RPs, violating their rights and potentially impacting care quality.
A facility failed to ensure timely administration of insulin for a diabetic resident and did not implement a nurse practitioner's treatment plan for another resident. The insulin was administered late on multiple occasions, and the NP's recommendations for pressure ulcer prevention were not followed. Staff interviews confirmed the importance of adhering to orders, but the facility's policies were not followed, leading to deficiencies in resident care.
A licensed nurse in an LTC facility reused an alcohol wipe on a resident's abdomen after administering insulin, contrary to infection control protocols. The resident, dependent on staff for care and with a history of diabetes, requested the site be wiped again, leading the nurse to reuse the wipe due to a lack of extras. Staff interviews confirmed this practice poses a risk of infection, violating the facility's infection prevention policy.
The facility failed to ensure all CNAs were CPR certified, as required by policy. Interviews revealed that four CNAs lacked CPR certification and were unfamiliar with emergency procedures, relying on licensed nurses for assistance during emergencies. The DSD confirmed the absence of a CPR team, and the facility's policy indicated that key clinical staff should maintain CPR certification.
A resident with a history of heart transplant did not receive Tacrolimus as prescribed, with a staff member administering an incorrect dose without a prescriber's order and failing to conduct required weekly lab tests. The facility's policy on medication orders was not followed, compromising safe care delivery.
A resident with severe cognitive impairment and high fall risk experienced a fall due to the facility's failure to consistently implement a non-skid mesh intervention on the wheelchair. Despite recommendations from the Director of Rehabilitation, the mesh was missing, and staff were unaware of its necessity, leading to the resident's fall and subsequent injuries.
A resident with cognitive impairment was physically assaulted by another resident, resulting in injuries. The incident was witnessed by a CNA, and the aggressor admitted to hitting the victim due to noise. The facility's policy states residents should be free from abuse, but the altercation occurred nonetheless.
A resident with heart failure and pressure ulcers experienced respiratory distress, indicating pneumonia onset. Despite a chest x-ray confirming pneumonia and orders for antibiotics and aspiration evaluation, the facility failed to implement a care plan with necessary interventions like oxygen administration and aspiration monitoring. The resident was transferred to the hospital without consistent intervention implementation, contrary to facility policies.
The facility failed to prevent and treat pressure ulcers for three residents, leading to the development and worsening of wounds. One resident developed a Deep Tissue Injury and a Stage 4 pressure ulcer due to improper monitoring and treatment. Another resident's left heel pressure ulcer was not identified or treated, causing pain and discomfort. A third resident did not receive wound dressing changes as ordered, and his heels were not floated, leading to a wound infection.
The facility failed to implement an effective fall management program for three residents with dementia, leading to multiple fall incidents and injuries. The facility did not follow care plans, address causal factors, or provide adequate supervision, resulting in falls that caused significant injuries, including a head contusion and femur fracture.
The facility failed to provide adequate pain management for four residents, leading to repeated pain and discomfort during care and treatment. Residents with severe contractures, pressure ulcers, and post-surgical conditions were not given pain medication as needed, resulting in visible signs of pain and inadequate pain relief.
The facility failed to assess, monitor, and provide necessary care for two residents, leading to severe health complications. One resident developed a deep tissue injury and an open wound that worsened, resulting in an above-the-knee amputation. Another resident experienced severe constipation and a small bowel obstruction, leading to an emergency hospital transfer.
The facility failed to post the contact information for the State Survey and Certification agency, leaving six residents uninformed about their right to file complaints about their care. Staff members confirmed the absence of this information, and residents expressed frustration and sadness over not knowing how to contact the State.
The facility failed to ensure that 28 out of 35 rooms met the required 80 square feet per resident in multiple-occupancy rooms. Rooms with two beds provided only 71.5 square feet per resident, and rooms with four beds also provided 71.5 square feet per resident. The Administrator admitted that the application for a room waiver had not been sent to the California Department of Public Health.
The facility failed to treat residents with respect and dignity, as evidenced by unlicensed staff neglecting residents' needs and displaying poor attitudes. Additionally, the facility did not follow its laundry policy, leading a resident to mistrust the service and wear only a patient gown due to lost personal clothes.
The facility failed to ensure accurate MDS assessments for two residents. One resident's right above-the-knee amputation was not documented, and another resident's healed pressure ulcer was inaccurately reported as unhealed. The MDS Coordinator confirmed these inaccuracies, emphasizing the importance of accurate assessments for proper care planning.
The facility failed to develop and implement person-centered care plans for two residents, leading to multiple falls for one resident and inadequate pain management for another post-amputation. The care plans were generic and did not address specific risks or provide necessary interventions, resulting in potential harm and discomfort.
The facility failed to meet professional nursing standards for five residents, leading to multiple deficiencies. Two residents with pressure ulcers had improperly inflated mattresses, one resident did not receive pain medication as prescribed, another resident's neurological condition was not adequately assessed, and a resident expressing suicidal ideations was not monitored as required.
A resident with multiple health conditions did not receive scheduled showers, leading to poor personal hygiene. Despite being scheduled for showers twice a week, the resident only received bed baths and partial baths during the review period. Staff admitted to not providing the showers, and no complaints were reported to the DSD.
The facility failed to provide activities to meet the needs and preferences of four residents, resulting in feelings of loneliness, isolation, and depression for one resident. Despite care plans indicating preferences for TV and music, these activities were not facilitated, leaving residents without interaction or entertainment.
The facility failed to provide appropriate ROM treatment for two residents, leading to pain and potential worsening of contractures. One resident did not have a hand roll applied as ordered, and the other did not consistently receive RNA services. Documentation and communication issues between departments contributed to these deficiencies.
The facility failed to provide appropriate respiratory care for two residents. One resident did not receive continuous oxygen therapy as ordered, and there was no documentation of respiratory assessments. Another resident received oxygen therapy above two liters per minute without a required humidifier, risking nasal dryness and bleeding.
The facility failed to maintain adequate staffing levels for CNAs and Licensed Nurses, leading to delayed care and resident complaints. Residents reported long wait times for assistance, and staff acknowledged the negative impact of short staffing on resident safety and care quality.
Failure to Initiate Emergency Response for Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate emergency treatment and care according to physician orders, resident preferences, and established policies when a resident experienced acute respiratory distress and altered mental status. The resident had been re-admitted with diagnoses including pneumonia and acute and chronic respiratory failure with hypoxia and had a POLST indicating full code status. An MDS assessment documented intact cognition at baseline. On the date of the incident, an SBAR noted hypoxia, altered level of consciousness, and shortness of breath. According to the nurse’s notes, at approximately 9 p.m. a licensed nurse entered the resident’s room to administer bedtime medications and found the resident awake, able to take medications, but repeatedly saying the same sentence. The nurse documented that when asked if he was okay, the resident opened his eyes and then closed them again. The resident’s O2 saturation was 84% on 3 L O2 via nasal cannula; the nurse increased the oxygen to 4 L, but the O2 saturation remained low at 82–83%. The nurse contacted the on-call physician at 9:30 p.m., obtained an order to send the resident to the emergency room for hypoxia, and arranged a non-emergency transport that arrived at 9:45 p.m., with transfer out at 10 p.m. There was no documentation that staff changed the nasal cannula to a non-rebreather mask. In interviews, the licensed nurse stated she noted the resident’s difficulty breathing, continuous oxygen use, low O2 saturation, and behavior not consistent with baseline, and that she called the on-call physician, who ordered transfer to the ER. The DON stated that respiratory distress with O2 saturation below 88% and decreased level of consciousness requires activation of the emergency response system by calling 911, and confirmed that the resident’s condition warranted a 911 transfer. The nurse practitioner, after reviewing the case and ER records, stated the resident should have been transferred via 911 due to hypoxia, altered responsiveness, and continued desaturation despite oxygen, and noted that ER records showed a GCS of 7 on arrival and subsequent intubation for acute respiratory failure. The facility’s policies on Emergency Procedures and Change of Condition require immediate medical care and initiation of emergency procedures, including calling 911 and providing first aid until emergency personnel arrive, and the California Nursing Practice Act requires initiation of emergency procedures based on observed abnormalities. The failure to call 911 and initiate an emergency response in accordance with these standards constituted the deficiency.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, in violation of federal requirements for permitting residents to return to the facility following a hospital stay or therapeutic leave. The resident, who had been admitted with multiple diagnoses including stroke, depression, and muscle weakness, was described as friendly but disoriented, requiring staff assistance for personal care, eating, transfer, and ambulation. After admission, the resident eloped from the facility and was found at another facility across the street. Upon return, the resident was placed on one-on-one supervision and later sent to the emergency room for evaluation. Despite repeated requests from the hospital, the facility refused to readmit the resident, citing concerns about the resident's safety due to confusion, agitation, and a tendency to attempt to leave the facility. Interviews with facility staff, including the Administrator and DON, revealed that the decision to refuse readmission was based on the belief that the resident was not safe at the facility, particularly given its proximity to a busy street. However, staff interviews and documentation indicated that the resident did not exhibit physical aggression, agitation, or behaviors that endangered herself or others. The resident was described as confused, talking about wanting new slippers, and attempting to get up from her wheelchair, but not combative or aggressive. The facility's own policies required that discharges or refusals to readmit be based on documented evidence that the resident's needs could not be met or that the resident posed a danger to themselves or others, with physician documentation supporting such decisions. In this case, there was no documentation from a physician indicating that the resident's needs could not be met or that transfer was necessary. The DON acknowledged the lack of clinical records supporting the decision and agreed that interventions such as a wander guard and adequate supervision might have prevented the elopement and subsequent transfer. The failure to permit the resident's return resulted in the resident remaining unnecessarily in the hospital while awaiting placement.
Failure to Prevent Resident Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including depression, muscle weakness, difficulty walking, and acute encephalopathy caused by stroke, was admitted to the facility. The resident was documented as confused, disoriented to time, place, and person, and required staff assistance for personal care, eating, transfer, and ambulation. Despite these factors, the facility's elopement assessment rated the resident as low risk for elopement, which was later acknowledged by the Director of Nursing to be inaccurate. On the day following admission, the resident was observed by a licensed nurse standing by her room door with a walker, expressing confusion and searching for slippers. Later that day, a concerned citizen notified facility staff that the resident had been found wandering in the parking lot of another facility across a busy street. The resident had left the facility without staff knowledge, crossed a dangerous roadway, and was found confused and wearing only socks, insisting she needed to buy new slippers. Interviews with facility staff, including the Administrator and Director of Nursing, confirmed that the resident had no wander guard in place due to the inaccurate elopement assessment. Staff acknowledged that the resident was confused, wandered frequently, and required significant redirection and supervision. The facility's own policy required identification and intervention for residents with exit-seeking behavior, but these procedures were not effectively implemented, resulting in the resident's unsupervised elopement and exposure to significant health hazards.
Failure to Maintain Emergency Power Supply System
Penalty
Summary
The facility failed to maintain its Emergency Power Supply System (EPSS) in accordance with regulatory requirements. During a tour and review of records, it was observed that the facility did not have a remote manual stop station for its five-kilowatt propane EPSS. The absence of this stop station was confirmed through observation and interview with the Maintenance Staff, who stated they were unaware of the requirement for such a device. Additionally, the facility was unable to provide documentation of a required four-hour load test for the EPSS when requested. The Maintenance Staff confirmed that no such documentation was available for review. This indicates that the facility did not perform or could not verify the performance of the four-hour load test as required by NFPA 110 standards. These deficiencies affected all 57 residents and three smoke compartments within the facility. The lack of a remote manual stop station and the absence of documentation for the four-hour load test were directly observed and confirmed through staff interviews and record review.
Plan Of Correction
K 918 - Electrical Systems - Essential Electric System. Continue A. 1. C. Bates Electric company installed the remote manual stop station for the five-kilowatt propane EPSS on 4/11/25. 2. The annual service and the four-hour load bank test for the generator is scheduled on 4/18/25 by the C and D Power company. B. There is only one generator in the building. No other concerns with this deficient practice. C. The Administrator provided an in-service on 4/14/25 to the Maintenance Staff regarding the requirements of the Life and Safety findings K 918 Electrical Systems - Essential Electric System including but not limited to: 1. Remote manual stop station for the five-kilowatt propane EPSS. 2. The Administrator provided an in-service to the Maintenance Staff regarding the annual service and the four-hour load bank test for the facility generator. D. Monitoring 1. Maintenance Staff will monitor and test the remote manual stop station for the five-kilowatt propane EPSS once a month during generator test and by the facility contracted vendor that provides service to do the four-hour load bank test for the generator. It will be recorded on the "Generator Log." 2. The Maintenance Staff and Administrator will monitor to make sure that the annual service and the four-hour load bank test for the generator is conducted annually by the facility contracted vendor for the generator preventative maintenance. A log will be maintained to record the annual generator service on the "Generator Log." The log will be kept by the Maintenance Staff and is available for inspection when requested. E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice of K 918 Electrical Systems and Essential Electric System; remote manual stop for the generator is maintained and the four-hour generator load test is performed annually. Completion Date: April 18, 2025
Improper Use of Relocatable Power Taps in Nursing Station
Penalty
Summary
During a facility tour, surveyors observed a deficiency related to the improper use of electrical equipment and wiring. Specifically, at the nursing station, a relocatable power tap was found connected to another relocatable power tap, which is not compliant with NFPA 101 and NFPA 70 standards. The maintenance staff, when interviewed, stated that he was not aware that the relocatable power taps were connected to each other. This non-compliant use of electrical equipment was found to affect 16 out of 57 residents and one of three smoke compartments. The report documents that the facility failed to ensure that electrical equipment, including power strips and extension cords, was used in accordance with applicable codes and standards. The improper connection of power taps was directly observed by surveyors, and the maintenance staff's lack of awareness contributed to the deficiency. No information about corrective actions or follow-up measures is included in the report.
Plan Of Correction
K 920 Electrical Equipment - Power Cords and Extensions A. The Maintenance Supervisor immediately removed the relocatable power tap that was connected to another relocatable power tap being used at the nursing station. The two relocatable power taps are now both connected directly to the electrical power outlet. The facility is now in compliance with the use of a relocatable power tap. B. The Maintenance Staff made rounds in the facility and checked the extension cords and electrical equipment in the building to ensure compliance. No other problems were identified, same as this deficient practice. C. The Administrator provided an in-service to the Maintenance Staff regarding compliance with this deficiency regarding proper use of extension/power cords and to ensure compliance with the use of relocatable power taps; (plug directly to the wall electrical outlet and not with another power tap). D. The Maintenance Staff will monitor appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. It will be documented on the "Extension Cord Monitoring Log." E. QUALITY ASSURANCE: The Administrator and the Quality Assurance Performance Improvement (QAPI) team members will discuss system effectiveness of the plan of correction for this deficient practice, such as appropriate use of extension cords and to ensure compliance with the use of the relocatable tap during his weekly maintenance rounds. Completion Date: April 18, 2025
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications for nine residents, leading to significant discomfort and potential health risks. Residents experienced delays in receiving prescribed medications due to late orders, lack of valid prescriptions, and administrative oversights. For instance, Resident 265 did not receive morphine sulfate on time, resulting in severe pain and sleep disturbances. Similarly, Resident 60 and Resident 267 faced delays in receiving their medications, which posed risks to their health conditions. The report highlights multiple instances where medication orders were either sent late to the pharmacy or lacked necessary authorizations, causing delays in delivery. Resident 264's pain medication was not administered for several days due to a missing valid prescription, leading to severe pain and limited daily activities. Resident 266 also experienced delays in receiving pain and respiratory medications, resulting in severe pain and potential breathing difficulties. Additionally, the facility's failure to administer medications as per physician's orders and professional standards was evident in the case of Resident 48, where a licensed nurse did not safely administer medications via a gastrostomy tube. These deficiencies indicate systemic issues in medication management and order processing within the facility, adversely affecting residents' well-being and comfort.
Failure to Provide Timely Pain Medication Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that four residents received their prescribed pain medications in accordance with physician orders, resulting in significant medication errors. For each resident, there were delays or omissions in administering pain medications such as morphine sulfate, pregabalin, Qulipta, and buprenorphine. These failures were due to issues such as delayed transcription and faxing of medication orders to the pharmacy, lack of valid prescription orders, and the absence of certain pain medications in the facility's emergency kit. In several cases, the pharmacy did not receive the necessary orders in a timely manner, which led to delays in medication delivery and administration. Residents affected by these deficiencies had medical histories that included fractures, neuralgia, neuritis, osteoarthritis, chronic pain, migraines, and diabetes with neuropathy. Upon admission, these residents experienced moderate to severe pain, as documented in their clinical records and pain assessments. The medication administration records (MARs) showed that scheduled doses of pain medications were marked as held and not given, and progress notes indicated that medications were not available or pending delivery from the pharmacy. Interviews with residents confirmed that they experienced severe pain, difficulty sleeping, and emotional distress due to not receiving their pain medications as ordered. Staff interviews and record reviews revealed that delays in processing and transmitting medication orders contributed to the problem. The admissions coordinator acknowledged that it could take several hours for nurses to transcribe and fax orders, and that issues with electronic transmission from hospitals further complicated timely medication access. The facility's policies required prompt verification, transcription, and communication of medication orders, but these procedures were not consistently followed, resulting in residents experiencing unnecessary pain and discomfort.
Improper Garbage Disposal
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during an inspection of the kitchen and garbage dumpster area. The dumpster was found to be overflowing, preventing the lid from closing, which was acknowledged by a kitchen staff member. This situation was confirmed during an interview with the facility's Registered Dietitian, who stated that dumpster lids should be closed to prevent attracting pests. A review of the facility's policy on food-related garbage disposal indicated that all garbage and food waste should be kept in containers and stored in a manner inaccessible to vermin, with outside dumpsters kept closed.
Improper Disposal of Resident Meal Tray Tickets
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical records by improperly disposing of meal tray tickets. During observations and interviews, it was noted that Dietary Aide 2 and Cook 2 routinely discarded used resident meal tray tickets into the regular kitchen trash, which was then taken to the dumpsters outside the facility. The dumpsters were observed to be overflowing and unsecured, posing a risk of unauthorized access to the residents' protected health information. The meal tray tickets contained sensitive information such as residents' names, room numbers, diet orders, and other personal details. The facility's policy required that resident meal tray tickets be shredded when no longer needed, but this procedure was not followed. The Registered Dietician confirmed that the tickets should be shredded to comply with HIPAA regulations. Observations on subsequent days revealed that identifiable information from residents was still being discarded improperly, indicating a systemic issue with the facility's handling of confidential information. This failure affected 54 out of 60 residents who consumed facility-prepared meals, exposing their personal and protected health information to potential unauthorized access.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management services for two residents, Resident 264 and Resident 265, as per professional standards, facility policy, and physician orders. Resident 264, who was admitted in February 2025, had multiple diagnoses including osteoarthritis, diabetes mellitus, neuropathy, chronic pain syndrome, and major depressive disorder. Despite having an intact cognition and experiencing frequent pain that affected her daily activities, Resident 264 did not receive her prescribed pain medications consistently upon admission. Her medication administration records indicated that she received oxycodone for moderate pain and hydrocodone-acetaminophen for severe pain, contrary to the physician's orders. Resident 265, admitted in February 2025, had a moderately impaired cognition and diagnoses including a fracture of the left humerus, neuralgia, and neuritis. Her care plan indicated a need for pain management due to her fracture. However, her medication administration records showed that she received hydrocodone-acetaminophen for moderate pain, although it was prescribed for severe pain. This inconsistency in medication administration was confirmed by a licensed nurse, who acknowledged the risk of over-medication or drug dependence when the medication was given for moderate pain. The Director of Nursing confirmed that staff should adhere to physician orders when administering medications. The facility's policies on pain management and medication administration emphasized the importance of following prescriber orders to ensure safe and effective pain management. The failure to adhere to these policies and physician orders resulted in unnecessary pain and emotional distress for the residents, affecting their physical comfort and psychosocial well-being.
Delayed Medication Administration and Policy Non-Compliance
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of its residents, as evidenced by multiple instances where residents did not receive their prescribed medications in accordance with physician orders. Residents, including those with diabetes mellitus, respiratory conditions, and other chronic illnesses, experienced delays in receiving critical medications such as metformin, insulin glargine, and various inhalers. These delays were often due to late receipt of medication orders by the pharmacy and subsequent delayed deliveries, which were not aligned with the facility's policy of timely medication administration. The report highlights specific cases where residents were adversely affected by these delays. For instance, a resident with diabetes did not receive metformin on time, posing a risk of elevated blood sugar levels. Another resident with chronic obstructive pulmonary disease did not receive their inhaler, leading to difficulty breathing. In several cases, the facility's emergency medication kit did not contain the necessary medications, further exacerbating the issue. Interviews with residents revealed dissatisfaction and discomfort due to the lack of timely medication administration. Additionally, the facility's procedures for medication delivery and accountability were not followed. Medication delivery manifests were not signed by two licensed staff members, which is a requirement for accountability. Furthermore, the facility did not adhere to its policies and procedures for the destruction of controlled medications, increasing the risk of drug diversion. These systemic issues contributed to unsafe and untimely medication use, as well as potential risks to resident health and safety.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 10%, which is above the acceptable threshold of 5%. During observations, it was noted that Licensed Nurse 2 and Licensed Nurse 3 did not follow the manufacturer's directions for reconstituting Polyethylene Glycol powder, as they used less than the recommended 4 to 8 ounces of water. This error affected Resident 48 and Resident 16, as the medication was not prepared according to the guidelines, potentially impacting its effectiveness. Additionally, during a medication administration observation, Licensed Nurse 2 administered four medications via a gastrostomy tube to Resident 48 without performing water flushes between medication boluses or after the final medication. The Director of Nursing and the Director of Staff Development confirmed that the facility's protocol and evidence-based practice require flushing the G tube with water between each medication to ensure proper medication delivery. This oversight in following the correct procedure for G tube medication administration contributed to the facility's high medication error rate.
Unsafe Medication Storage in Med Cart
Penalty
Summary
The facility failed to ensure the safe storage of medications, as observed during an inspection of Medication Cart C. Unused medications from a discharged resident were found stored in the bottom drawer of the cart, including Pantoprazole 40 mg tablets and Nifedipine 30 mg tablets. Additionally, an expired narcotic, Morphine Sulfate Oral Solution, was also found in the same drawer. Licensed Nurse 4 acknowledged that these medications should not have been stored there and proceeded to remove them immediately. The Director of Nursing stated that the expectation is for licensed nurses to check expiration dates during medication counts and to remove any expired medications or those belonging to discharged residents from the cart. The facility's policy on labeling and storing medications indicates that medications no longer in use or expired should be disposed of according to Federal and State Laws. These failures had the potential to contribute to unsafe medication use and storage, as well as the potential for diversion.
Inadequate Staffing in Dietary Management
Penalty
Summary
The facility failed to ensure that a full-time Dietary Manager/Supervisor position was filled appropriately when the current Dietary Manager went on medical leave in mid-November 2024. During this period, a kitchen staff member, who lacked the necessary training and qualifications, was placed in the role to cover for the Dietary Manager. This staff member, referred to as CK 1, acknowledged not having the regulatory training and certification required for the Dietary Manager/Supervisor position. The facility employs a part-time Registered Dietician (RD) who works on a consultant basis and is present at the facility only once a week. The RD confirmed that CK 1 was covering the Dietary Manager/Supervisor role without the required credentials, which could potentially risk the residents' nutritional status. Interviews with the facility Administrator (ADM) and the part-time RD revealed that the facility was aware of the absence of a qualified full-time Dietary Manager/Supervisor. The ADM acknowledged the differences in roles and qualifications between CK 1 and the Dietary Manager/Supervisor, and admitted that CK 1 did not have the necessary regulatory training and credentials. The facility's job descriptions outlined the qualifications required for the Dietary Supervisor role, which CK 1 did not meet. This situation had the potential to impact the nutritional needs of the facility's 60 residents adversely.
Sanitation Deficiencies in Kitchen Affecting Resident Safety
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting 54 out of 60 residents who received food from the kitchen. During an observation, it was found that the sanitizing solution used in the kitchen was below the manufacturer's minimum effective concentration, posing a risk for foodborne illness. The acting Dietary Manager confirmed the issue and acknowledged the need for a new solution. Additionally, a dietary aide was observed working in the kitchen without a beard cover, which was against the facility's policy and could negatively impact the kitchen's sanitary conditions. Further inspection revealed that food items were not stored properly. A clear plastic bin containing Jello was found with an unsealed lid, and an opened box of pancake mix was not tightly sealed. The facility's Registered Dietician acknowledged that these practices could compromise the kitchen's sanitary conditions. Moreover, food items were not labeled with use-by dates, including a partial loaf of bread and a box of pancake mix, which were only marked with the date they were opened or received. This lack of proper labeling was against the facility's policy and could lead to the use of expired food. The inspection also uncovered unsanitary conditions in the storage of dishware. Food preparation and storage bins were stored wet and stacked, preventing them from air drying and increasing the risk of bacterial growth. Cooking and baking pans were found with blackened debris that could not be removed, indicating they were unsanitary. The Registered Dietician confirmed that these practices could lead to foodborne illness and acknowledged the need for proper drying and replacement of cookware that could not be cleaned effectively.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Resident 13, who was on EBP due to an indwelling catheter and a wound on the left knee, received wound care from the Staff Development Director without the required gown. This was confirmed by the Infection Preventionist, who stated that proper PPE, including gowns, masks, and gloves, was necessary to prevent the spread of infection. Resident 17, who was on EBP due to a gastric tube, received care from his wife without the use of PPE. The Infection Preventionist confirmed that all caregivers, including family members, should wear PPE when providing direct care to residents on EBP. Additionally, Resident 53, who had a severe sepsis diagnosis and was on EBP due to a urinary catheter and feeding tube, was repositioned by staff without the required PPE. The Director of Nursing confirmed that staff should wear gowns and gloves when repositioning residents on EBP to prevent cross-contamination. Furthermore, several licensed nurses failed to perform hand hygiene before and after medication administration, as observed with multiple residents. The Director of Nursing and the Infection Preventionist emphasized the importance of hand hygiene in preventing infections. Additionally, a licensed nurse did not properly disinfect glucometers between uses, lacking understanding of the necessary dwell time for disinfectants to be effective. This oversight was acknowledged by the Infection Preventionist, who was unaware of the dwell time requirements and planned to address this issue with the nursing staff.
Failure to Conduct Mandatory Communication Training
Penalty
Summary
The facility failed to ensure that Effective Communications in-services were conducted as mandatory training for direct care staff, affecting a census of 60 residents. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield did not include any communication in-service training. The DSD acknowledged that no communication training had been conducted in 2024 or 2025. The facility's policy, revised in January 2025, stated that the in-service training program is intended for the development and improvement of staff skills, with classes scheduled by the in-service coordinator. However, the absence of communication training indicates a failure to adhere to this policy, potentially impacting the quality of care provided to residents.
Indirect Staff Not Trained on Resident Rights
Penalty
Summary
The facility failed to ensure that indirect staff members, who do not provide direct resident care, were educated on the rights of the residents and the responsibilities of the facility to properly care for its residents. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), where it was confirmed that the 2024/2025 in-service training calendar did not include training on resident rights and facility responsibilities for indirect staff. The facility's policy on in-service training, revised in January 2025, states that the training program is intended for the development and improvement of skills for all personnel, yet this training was not conducted for indirect staff members, affecting a census of 60 residents.
Failure to Conduct Mandatory QAPI Training
Penalty
Summary
The facility failed to conduct mandatory training for all staff on the elements and goals of its Quality Assurance and Performance Improvement (QAPI) program, which is essential for maintaining and improving safety and quality in nursing homes. During an interview and record review with the Director of Staff Development (DSD), it was confirmed that the 2024/2025 in-service calendar for the facility did not include any QAPI training sessions. Furthermore, the DSD admitted that no such training had been conducted in 2024 or 2025. The facility's policy on in-service training, revised in January 2025, emphasizes the importance of ongoing training programs for staff development and skill improvement, yet this policy was not adhered to in the case of QAPI training. This deficiency had the potential to result in poor communication among staff, a lack of awareness of facility updates, insufficient collaborative work, and compromised resident care, as the staff was not adequately informed about the QAPI program.
Failure to Conduct Behavioral Health Training
Penalty
Summary
The facility failed to conduct staff training on behavioral health, which was required as part of their facility assessment. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD). The review of the 2024/2025 In-Service Calendar for [NAME] Care Center of Fairfield revealed that an in-service training on the problems and needs of aged, chronically ill, acutely ill, and disabled patients was scheduled for April 2024 but was not conducted. The DSD confirmed this omission. Additionally, the facility's policy and procedure for the In-Service Training Program, revised in January 2025, stated that the facility is committed to developing an effective in-service training program to improve the skills of all personnel. However, the planned training was not executed, leading to a deficiency in staff preparedness to care for residents with behavioral health issues.
Failure to Provide Functional Call Light Systems for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for the needs of two residents by not ensuring they had access to appropriate and functional call light systems. One resident, who was dependent on staff for all activities of daily living and had severe cognitive and physical impairments, was provided with a standard call light button that he was unable to use due to his inability to move his fingers. Multiple staff members confirmed that the resident could not operate the call light and required an alternative system, such as a soft touch pad, but this was not provided. Another resident, who was bedbound and at high risk for falls and decline in activities of daily living, was moved to a new room where the call light system was broken. As an alternative, the resident was given a blue string to pull for assistance, but the string was tangled with bed wires and was not functional. The resident was unable to use this makeshift system to call for help, and staff confirmed that the alternative provided was not a functional call light system. Maintenance records indicated the call light was reported as broken, but the issue was not resolved at the time of observation. Facility policy required that residents be provided with a means of communication with nursing staff and that defective call lights be promptly reported and repaired or replaced. Despite these policies, both residents were left without effective means to request assistance, as confirmed by staff interviews and direct observation.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain dignity and respect for three residents. Resident 160, who had no cognitive impairment, was humiliated when CNA 2 made demeaning comments about her use of a commode instead of the restroom. CNA 2 acknowledged the inappropriate nature of her comments, which left Resident 160 feeling embarrassed and disrespected. The Director of Staff Development confirmed the interaction was inappropriate. Additionally, two residents with severe cognitive impairments, Resident 45 and Resident 6, were assisted with meals in a manner that lacked respect. Both residents were reclined in Geri chairs while CNAs stood over them during meal assistance. CNA 6 and CNA 3 admitted to standing over the residents, acknowledging that they should have been seated to promote respect. The Director of Nursing confirmed the inappropriate positioning of the CNAs, which was contrary to the facility's policy on treating residents with dignity and respect.
Inaccessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible for three residents, leading to potential unmet needs and communication barriers for assistance. Resident 13, who has multiple sclerosis and generalized muscle weakness, was observed with a call light button out of reach due to his contracted right hand. Both the resident and a licensed nurse confirmed the inaccessibility of the call light, which contradicted the care plan that required the call light to be within easy reach. Resident 48, diagnosed with hemiplegia, epilepsy, and dysphagia, was found without a call light within reach while lying on a Geri chair. The call light was tied to the bed's side rail, making it inaccessible. Both a family member and staff confirmed the resident's inability to reach the call light, emphasizing the need for it to be on the left side due to the resident's right-side paralysis. Resident 263, with cerebral infarction, diabetes mellitus, and atherosclerosis, was observed with the call light button on the floor, out of reach. The resident's care plan also required the call light to be within easy reach. Staff confirmed the call light's inaccessibility, which was against the facility's policy that mandates call lights to be within reach when residents are in bed.
Failure to Provide Written Transfer Agreement with Local Hospital
Penalty
Summary
The facility failed to ensure there was a written transfer agreement with a local General Acute Care Hospital (GACH), as required by federal regulations. During an interview on March 12, 2025, the Director of Nursing (DON) was unable to provide a copy of the facility's transfer agreement with a local hospital upon request. Despite multiple follow-up interviews on the same day and the following day, the DON confirmed that she was still unable to locate the transfer agreement. The DON acknowledged the requirement for such an agreement but was unable to produce it, potentially placing residents at risk for inadequate continuity of care and treatment.
Infection Control Lapse with Foley Catheter Management
Penalty
Summary
The facility failed to adhere to appropriate infection prevention and control measures for a resident with a Foley catheter. During an observation, it was noted that the resident's Foley catheter drainage bag was left on the floor, which is against the facility's policy. The resident confirmed that this was a recurring issue, indicating a lapse in maintaining proper infection control practices. Interviews with staff, including an unlicensed staff member, the Director of Staff Development, and the Director of Nursing, confirmed that the drainage bag should not be on the floor as it increases the risk of infection. The facility's policy explicitly states that catheter tubing and drainage bags should be kept off the floor to prevent bacterial contamination, yet this protocol was not followed, putting the resident at risk for a urinary tract infection.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that two out of six sampled residents had their call lights within reach, which is essential for residents to communicate with staff when they need assistance. Resident 1, admitted with muscle weakness and neuromuscular dysfunction of the bladder, did not have his call light within reach, as it was found on the floor by the foot of his bed. Resident 2, admitted with hyperlipidemia and anemia, had her call light wrapped around the left side rail of her bed, making it inaccessible. Both residents reported having to yell for help due to the unavailability of their call lights. During observations and interviews, staff members, including Unlicensed Staff A, Licensed Staff B, and the Director of Staff Development, acknowledged that the call lights were not within reach and confirmed that this was not acceptable practice. The facility's policy and procedure on call lights, revised in January 2024, states that call lights should only be out of reach during resident care and must be placed within reach immediately after care or when the resident is back in bed. The Director of Nursing also emphasized the importance of having call lights within reach to prevent delays in care and ensure resident safety.
Delayed Treatment and Medication Unavailability in LTC Facility
Penalty
Summary
The facility failed to provide timely and appropriate care for four residents, leading to significant health risks. One resident experienced a 22-day delay in the treatment of a urinary tract infection. The resident was admitted with a history of urinary tract infections, diabetes, acute kidney failure, and high blood pressure. A urinalysis with culture and sensitivity was ordered, but the antibiotic treatment was not prescribed until 11 days after the test results were available, despite the nurse practitioner visiting the facility multiple times during this period. This delay in treatment posed a risk of acute kidney failure for the resident. Three other residents did not receive their prescribed medications due to unavailability, which had the potential to result in serious health issues. One resident, with a history of respiratory failure and COPD, did not receive medications for high blood pressure, fluid overload, and breathing problems. This resident became anxious and was eventually transferred to a higher level of care. Another resident, with a history of atrial flutter and transient ischemic attack, missed doses of medications for high blood pressure and stroke prevention over two days. A third resident, with a history of high blood pressure and heart failure, did not receive medications for blood pressure and potassium supplementation due to pharmacy delivery delays. The Director of Nursing acknowledged the medication administration failures and the lack of timely delivery from the pharmacy. The facility's policies required timely specimen collection and medication administration, but these were not followed, leading to the deficiencies. The DON noted that the pharmacy had scheduled delivery times to ensure medications were available, but these were not adhered to, resulting in residents missing critical medications.
Failure to Notify Residents and RPs of Changes in Condition
Penalty
Summary
The facility failed to notify residents and their Responsible Parties (RP) of changes in their medical conditions or treatment plans, leading to deficiencies in care. For Resident 2, who has severe cognitive impairment and multiple health issues including Parkinson's Disease and Bipolar disorder, the facility did not inform the RP about changes in the resident's skin condition. Despite the presence of scattered scabs, open wounds, and other skin issues, there was no documentation or communication to the RP about these changes, which is a violation of the resident's rights as per facility policy. Similarly, Resident 3, who is cognitively intact and self-responsible, was not informed about the extension of his intravenous antibiotic therapy. The resident was initially supposed to receive the therapy until a certain date, but the treatment was extended without notifying him or explaining the reason for the extension. This lack of communication led to the resident feeling frustrated and upset, as he was unaware of the changes in his treatment plan. Interviews with various staff members, including the Director of Nursing and Licensed Nurses, confirmed that the facility did not follow its policy of notifying residents and their RPs about changes in condition or treatment. The facility's policy clearly states that it is the residents' right to be informed and involved in their care planning and treatment decisions. The failure to communicate these changes not only violated the residents' rights but also potentially impacted the quality of care they received.
Failure to Follow Physician and NP Orders
Penalty
Summary
The facility failed to ensure that a Licensed Nurse (LN A) followed the Physician's Order for administering long-acting insulin to a resident with diabetes mellitus. The insulin was supposed to be administered at 9 a.m., but LN A injected it at 11:18 a.m. on one occasion, and there were multiple instances where the insulin was administered late on other dates. During interviews, LN A admitted to not following the prescribed administration time, and other staff members, including LN B and the Infection Preventionist (IP), confirmed that administering medication late could pose a safety risk to the resident. The Director of Nursing (DON) also emphasized the importance of timely medication administration as per Physician's Orders. The facility also failed to follow the nurse practitioner's (NP) treatment plan and recommendations for another resident. The resident's Electronic Treatment Administration Record (ETAR) did not reflect the NP's treatment plan, which included the use of an alternating pressure pad (APP) and heel protectors to prevent pressure ulcers. Observations revealed that the resident was not using these devices, and interviews with staff, including LN B, the IP, and the DON, confirmed that the NP's treatment plan was not implemented. The DON acknowledged that the NP's recommendations should have been followed to prevent further skin breakdown. The facility's policy and procedure documents indicated that medications and treatments should be administered in accordance with prescriber orders. However, the failure to adhere to these policies resulted in deficiencies in the care provided to the residents. The staff, including the Director of Staff Development (DSD) and LN E, recognized that the NP's treatment plan and recommendations were considered valid orders and should have been followed, but they were not carried out as required.
Improper Reuse of Alcohol Wipe After Insulin Injection
Penalty
Summary
The facility failed to adhere to proper infection control protocols when a licensed nurse (LN) reused an alcohol wipe on a resident's abdomen after administering insulin. The resident, who was admitted with diagnoses including Diabetes Mellitus, chronic pain, and hyperlipidemia, was dependent on staff for all care. During an observation, LN A was seen using an alcohol wipe to clean the resident's abdomen before injecting insulin. After the injection, the resident requested the site be wiped again, and LN A reused the same alcohol wipe, acknowledging that it was not acceptable practice and citing a lack of extra wipes as the reason. Interviews with other staff members, including another licensed nurse, the infection preventionist, and the director of nursing, confirmed that reusing an alcohol wipe is against infection control protocols due to the risk of cross-contamination and infection. The facility's policy on infection prevention emphasizes the importance of educating staff and ensuring adherence to proper techniques, which was not followed in this instance.
Lack of CPR Certification Among CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nursing Assistants (CNAs) were trained and certified in Cardiopulmonary Resuscitation (CPR), which is a critical life-saving procedure. During interviews, it was revealed that four CNAs did not have CPR certifications and were not familiar with the facility's policy and procedure for CPR. The Director of Staff Development (DSD) acknowledged that some CNAs were not CPR certified and stated that these CNAs would seek a licensed nurse in the event of a resident experiencing a heart attack or breathing failure. The Director of Nursing (DON) confirmed that CNAs without CPR certification would be unable to assist residents during emergencies such as cardiac or respiratory arrest. Interviews with individual CNAs further highlighted the deficiency. CNA 2 admitted to not being CPR certified and unable to identify cardiac or respiratory arrest, indicating she would look for a licensed nurse or supervisor during an emergency. CNA 3 and CNA 4 also confirmed their lack of CPR certification and uncertainty about the facility's emergency procedures. The DSD confirmed the absence of a designated CPR team within the facility. A review of the facility's policy and procedure document indicated that key clinical staff, including non-licensed personnel, should obtain and maintain CPR certification, which was not adhered to in this case.
Failure to Adhere to Medication Orders and Monitoring Protocols
Penalty
Summary
The facility failed to ensure that services met professional standards for a resident who was admitted with multiple diagnoses, including dementia and a history of heart transplant. The resident was prescribed Tacrolimus to prevent organ transplant rejection, with specific instructions for dosage and weekly lab monitoring. However, Licensed Staff B administered Tacrolimus 0.5 mg without a prescriber's order and altered the prescribed dose without consulting the transplant coordinator, as required by the hospital discharge orders. Additionally, the facility did not conduct the weekly Tacrolimus lab tests as ordered, with only three lab results documented over a three-month period. Interviews with staff revealed that there was no documented evidence of a prescribed order for the 0.5 mg dose, and the Nurse Practitioner confirmed that she did not authorize such a change. The Director of Nursing acknowledged the absence of a written order and emphasized the expectation for verbal orders to be documented immediately. The facility's policy required medication orders to be recorded and signed by an authorized prescriber, which was not adhered to in this case. This oversight in medication administration and monitoring compromised the safe delivery of care to the resident.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to consistently implement a non-skid mesh intervention for a resident, who was at high risk for falls due to severe cognitive impairment, epilepsy, and muscle weakness. The resident, who mobilized using a wheelchair, experienced an unwitnessed fall resulting in injuries, including a skin tear and pain in the lower back and right knee. The fall risk assessment indicated a high risk for falls, and the resident's care plan did not include the recommended intervention of a non-skid mesh to prevent sliding from the wheelchair cushion. Interviews and observations revealed that the non-skid mesh was missing from the resident's wheelchair at the time of the fall and during subsequent checks. The Director of Rehabilitation had recommended the use of the non-skid mesh on multiple occasions, but it was not implemented. Staff members, including CNAs and the Director of Nursing, acknowledged the absence of the mesh and were unaware of its necessity, despite it being a bright blue and easily noticeable item. The facility's policy on fall management emphasized the importance of consistent intervention to minimize fall risks, which was not adhered to in this case.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect Resident 2 from abuse when Resident 1 physically assaulted him. Resident 1, who was cognitively intact, punched Resident 2 in the face while he was sleeping, resulting in a swollen upper lip, scratches on the right forearm, and scratches on the left-hand middle finger. This incident was witnessed by a Certified Nursing Assistant (CNA 1), who reported that Resident 1 was yelling at Resident 2 to stop making noise with his dentures before the altercation. The Director of Nursing (DON) confirmed that Resident 1 admitted to hitting Resident 2 because of the noise. Resident 2, who had severely impaired cognition due to conditions such as epilepsy, dementia, and depression, was unable to defend himself during the incident. The Social Services Director (SSD) acknowledged that the altercation was abusive. The facility's policy on abuse, neglect, and mistreatment clearly states that physical abuse includes hitting, and each resident should be free from abuse. Despite this policy, the facility did not prevent the altercation, resulting in Resident 2 being subjected to abuse.
Failure to Implement Care Plan for Resident with Pneumonia
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced a change in condition indicating the onset of pneumonia. The resident, who was admitted with diagnoses of heart failure and pressure ulcers, showed signs of respiratory distress on June 1, 2024. An SBAR Communication Form documented the resident's shortness of breath, and a chest x-ray confirmed mild airspace disease in the right lower lung, indicative of pneumonia. The resident's Nurse Practitioner was informed and ordered a chest x-ray and antibiotics, and recommended an evaluation by a speech language therapist for aspiration risk. Despite these actions, the facility did not create a care plan to address the resident's pneumonia, including necessary interventions such as administering supplemental oxygen, elevating the head of the bed, and monitoring for aspiration during meals. The Director of Nursing confirmed these interventions were appropriate but were not documented in the resident's care plan. The Medication Administration Record and Treatment Administration Record showed no consistent implementation of these interventions before the resident was transferred to the hospital on June 5, 2024. The facility's policies required individualized care plans and interventions for residents with pneumonia, which were not followed in this case.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, monitor, and provide wound care treatment to prevent the development and worsening of pressure ulcers for three residents. Resident 21 was not monitored properly while wearing a Pressure Relief Ankle Foot Orthosis (PRAFO), and there was no documentation to show that he was turned and repositioned every two hours as required. Additionally, the facility did not identify or treat Resident 21's pressure ulcer on his coccyx in a timely manner, leading to its progression from a Stage 2 to a Stage 4 ulcer. The facility also failed to ensure that Resident 21's low air loss mattress was set correctly according to his weight, which contributed to the development of a Deep Tissue Injury (DTI) on his right heel and a Stage 4 pressure ulcer on his coccyx. The facility's documentation was inconsistent and inaccurate, further complicating the treatment process for Resident 21's pressure ulcers. The Director of Nursing (DON) confirmed that the pressure ulcers were facility-acquired and that the lack of proper care and documentation contributed to their development and worsening. Resident 21 reported pain and discomfort due to the pressure ulcers and stated that he was not being turned and repositioned regularly, nor was he receiving consistent incontinence care. The facility's failure to follow its own policies and procedures for pressure ulcer prevention and treatment resulted in significant harm to Resident 21. Resident 33's left heel pressure ulcer was not identified or treated by the facility, leading to pain and discomfort for the resident. The facility did not have a doctor's order to treat the wound, and there was no documentation of a skin assessment for the left heel. The lack of monitoring and treatment had the potential to worsen the wound. Resident 33 was also not turned and repositioned every two hours as required, and his heels were not floated properly, which contributed to the development of the pressure ulcer. The facility's failure to implement appropriate interventions and monitor Resident 33's condition resulted in inadequate care and potential harm. Resident 122 did not receive wound dressing changes as ordered by the physician, and his heels were not floated to prevent pressure ulcers. The facility also failed to provide an appropriate pressure-reducing surface for his bed. These failures contributed to a wound infection and potentially prevented the healing of Resident 122's wounds. The facility's lack of adherence to physician orders and nursing standards of practice resulted in inadequate care and increased the risk of complications for Resident 122.
Failure to Implement Effective Fall Management Program
Penalty
Summary
The facility failed to develop and implement an effective fall management program for three residents with dementia. For Resident 38, the facility did not follow the fall care plan, failed to address causal factors such as poor balance and comprehension, and did not revise the care plan to reduce the likelihood of future falls. These failures led to six fall incidents between June 2023 and January 2024, with the most recent fall resulting in a head contusion and emergency department visit. Staff interviews revealed that Resident 38 was often unsupervised despite being a high fall risk, and the care plan was not individualized to address her specific needs. For Resident 13, the facility did not collaborate with the physician to identify pertinent interventions after falls on two occasions and did not have the pharmacist complete a Medication Regimen Review. The facility also failed to review and re-evaluate the fall care plan for effectiveness. These failures resulted in a fall that led to a hospitalization with a diagnosis of a laceration, bruise, and femur fracture. Staff interviews indicated that Resident 13 was not adequately supervised or provided with necessary incontinence care, contributing to the fall incidents. Resident 26 also experienced repeated falls due to the facility's failure to provide one-on-one supervision as part of the fall care plan. The report highlights that the facility's policies and procedures for fall risk intervention and monitoring were not consistently followed, leading to multiple fall incidents and injuries among the residents. Staff interviews consistently pointed out the lack of supervision and inadequate implementation of care plans as significant factors contributing to the residents' falls.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for four residents, leading to repeated pain and discomfort during care and treatment. Resident 33, who had severe contractures and pressure ulcers, was not given pain medication before receiving care, resulting in visible signs of pain such as grimacing and physical aggression. Despite reports from staff about the resident's pain, there was no routine order for pain medication, and the resident's pain was not adequately addressed during care and wound treatment. Resident 21, who had an above-the-knee amputation, was not offered pain medication after returning to the facility post-surgery. The resident reported feeling pain and discomfort but was scared to ask for pain medication due to a history of drug use. The facility's records showed that the resident did not receive scheduled pain medication, and the NP acknowledged that the resident could be experiencing phantom limb pain. Residents 35 and 122 were not given pain medication before wound treatment as ordered by their physicians. Resident 35 experienced pain during wound treatment, and the medication's effectiveness had worn off by the time of the procedure. Resident 122, who had a Stage 4 pressure ulcer, reported severe pain and was not pre-medicated before dressing changes. The facility's policies on pain management and pressure ulcer prevention were not followed, leading to inadequate pain relief for these residents.
Failure to Monitor and Provide Necessary Care for Residents
Penalty
Summary
The facility failed to assess, monitor, and provide necessary care and services for two residents, leading to severe health complications. Resident 21, who was at high risk for wounds due to Diabetes Mellitus, developed a facility-acquired deep tissue injury on his right heel and an open wound on his right lateral lower leg. Despite the identification of these wounds, nursing staff did not adequately assess and monitor the wounds, resulting in the worsening of the condition. This led to Resident 21 being transferred to the hospital, where he was diagnosed with Osteomyelitis and gangrene, ultimately requiring an above-the-knee amputation. Resident 61, who was nonverbal and had a history of stroke, hemiplegia, and hemiparesis, was dependent on staff for bowel management. Nursing staff failed to monitor for signs of constipation, did not administer medication per physician orders, and did not notify the physician or family about the constipation. This resulted in Resident 61 experiencing projectile vomiting and abdominal distention, leading to an emergency hospital transfer. At the hospital, Resident 61 was diagnosed with a small bowel obstruction, severe constipation, acute kidney injury, and hypernatremia. The deficiencies in care for both residents were evident through the lack of proper wound assessment and documentation for Resident 21 and the failure to follow bowel management protocols for Resident 61. These actions and inactions by the nursing staff directly contributed to the severe health outcomes experienced by both residents.
Failure to Inform Residents of State Complaint Procedures
Penalty
Summary
The facility failed to post the contact information for the State Survey and Certification agency, which is responsible for determining whether healthcare providers meet federal certification standards to participate in Medicaid and Medicare programs. This information was not made available to residents, as observed during interviews and record reviews. Six residents, including Resident 14 and Resident 34, were not informed of their right to file a complaint with the State about the care they were receiving at the facility. Anonymous Residents 1, 2, 3, and 4 also stated they did not know where the state information postings were located or how to formally complain to the State about their care. During interviews, various staff members, including Unlicensed Staff R, the Activity Director, Licensed Staff S, and the Infection Preventionist, confirmed that the State contact information was not posted anywhere in the building. They acknowledged the importance of this information being readily available to residents, as it is their right to know how to file a complaint about their care. The Administrator and the Director of Nursing (DON) also confirmed the absence of a policy and procedure on required notices and admitted that the State contact information was not posted in the facility. Resident 14 expressed anger and frustration over not being informed of his right to contact the State, while Resident 34 felt saddened by the lack of information. The failure to provide this essential information left residents feeling uninformed about their rights and how to address their concerns about the care they were receiving. This deficiency highlights a significant lapse in the facility's responsibility to ensure residents are aware of their rights and the proper channels to file complaints about their care.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that 28 out of 35 rooms met the required 80 square feet per resident in multiple-occupancy rooms. Specifically, 24 rooms with two beds each measured only 143 square feet, providing 71.5 square feet per resident, and four rooms with four beds each measured 286 square feet, also providing 71.5 square feet per resident. During an interview, the Administrator admitted that the application for a room waiver had not been sent to the California Department of Public Health. The Administrator also mentioned that some room adjustments had been made in the past, converting four-bed rooms to three-bed rooms. The deficiency was identified through observations, interviews, and record reviews, highlighting the potential impact on residents' personal space and mobility.
Failure to Treat Residents with Respect and Dignity and Follow Laundry Policy
Penalty
Summary
The facility failed to employ staff who treat residents with respect and dignity, as evidenced by multiple incidents involving unlicensed staff members. Resident 18's family member reported that an unlicensed staff member repeatedly failed to change Resident 18's soiled briefs despite being informed and called multiple times. Resident 31 indicated that an unlicensed staff member was combative, had a bad attitude, and did not clean her properly, and that complaints to leadership were ignored. Resident 12 experienced neglect when Unlicensed Staff Q turned off a bed alarm without acknowledging her or addressing her concerns, leading Resident 12 to avoid using the call light due to such interactions. The facility also failed to follow its policy regarding laundry services, resulting in Resident 7 refusing to wear anything other than a patient gown due to mistrust in the laundry services. Resident 7 reported that her personal clothes were not returned from the laundry, despite being labeled, and she often found other residents wearing her clothes. The Laundry Aide confirmed that clothes were supposed to be labeled by staff, but some clothes were found unlabeled, making it difficult to return them to the appropriate residents. The facility's policy required nursing staff to inventory and label residents' personal possessions upon admission and any additional items brought in after admission, but this was not consistently followed.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately completed for two residents. For Resident 21, the MDS dated [DATE] did not address his right above-the-knee amputation, which occurred on 1/28/24. Despite a 5-day assessment being completed on 2/07/24, the amputation was not captured in the MDS assessment. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that a Significant Change in Status Assessment was not completed to reflect Resident 21's current condition. For Resident 40, the MDS dated [DATE] inaccurately indicated the presence of an unhealed pressure ulcer without specifying its stage. The MDS Coordinator confirmed that the pressure ulcer on Resident 40's right ankle had healed on 12/03/23, making the assessment inaccurate. The MDS Coordinator emphasized the importance of accurate assessments in guiding staff to develop appropriate care plans for residents. The job description for the MDS Assessment Nurse also highlighted the necessity of complete and accurate documentation.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, leading to significant deficiencies in their care. For Resident 38, the facility did not address the causal factors of fall incidents and failed to implement relevant, consistent, and individualized interventions to prevent future falls. Despite multiple falls between June 2023 and January 2024, the care plans remained generic and did not provide specific interventions based on the resident's risk and cause of falls. Staff interviews confirmed that the fall care plans were not followed, and the resident was often unsupervised, leading to further falls and potential injuries. Resident 21's care plan did not address how the resident would be kept free from pain and discomfort after a right leg amputation. The care plan lacked interventions for pain management, and there was no scheduled pain medication ordered for the resident. Interviews with the MDS Coordinator and the DON revealed that the care plan did not include pain assessment and management, which could have resulted in the resident experiencing pain and discomfort post-amputation. The facility's policies and procedures for fall risk intervention and care planning were not adhered to, resulting in inadequate care for the residents. The fall care plans were not updated to address the root causes of falls, and the amputation care plan did not include necessary pain management interventions. These deficiencies highlight the facility's failure to provide individualized and effective care plans for its residents, leading to potential harm and discomfort.
Failure to Meet Professional Nursing Standards
Penalty
Summary
The facility failed to meet professional nursing standards for five residents, leading to multiple deficiencies. For Residents 35 and 33, who had pressure ulcers, the facility did not properly inflate their Low Air Loss (LAL) mattresses according to their weights. This oversight was confirmed during observations and interviews with staff, who admitted that the mattresses were not set correctly, potentially worsening the residents' pressure ulcers. Additionally, excessive linens were found under Resident 35, which defeated the purpose of the pressure-relieving mattress. Resident 35 also did not receive pain medication according to the doctor's orders. The resident was given a lower dose of Morphine Sulfate than prescribed for her reported pain levels, as verified through record reviews and staff interviews. This failure in pain management could have led to unnecessary pain and discomfort for the resident. For Resident 12, the facility's licensed nurses failed to appropriately assess a neurological condition related to an intracranial hemorrhage. Despite the resident's caregiver reporting significant changes in the resident's mental status, the nurses did not document or act on these changes adequately. The resident was eventually transferred to a higher level of care, where she was diagnosed with an intracranial hemorrhage requiring surgical intervention. Additionally, Resident 47, who expressed suicidal ideations, was not monitored every 15 minutes as per physician orders. The facility staff did not follow the policy for emergent transfer, placing the resident at risk of self-harm or death.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that Resident 21 received showers on his scheduled days, which were Tuesdays and Fridays. Despite being scheduled for showers twice a week, Resident 21 reported that he never received a shower and felt grimy and dirty as a result. Observations confirmed that Resident 21 had white flakes around his mouth, indicating poor personal hygiene. Interviews with the resident and staff revealed that the resident had not received his scheduled showers and instead received complete bed baths on four days and a partial bath on one day during the review period from 3/01/24 to 3/24/24. The staff admitted to not providing the showers and stated they would give a bed bath if they did not have time for a shower, but there was no record of any showers being given during this period. Resident 21, who has diagnoses including Diabetes Mellitus, morbid obesity, and hemiplegia, is dependent on staff for showering and personal hygiene. The Minimum Data Set (MDS) indicated that Resident 21 had a BIMS score of 15, showing he is cognitively intact and aware of his hygiene needs. Despite this, the facility's documentation and staff interviews confirmed that the resident's scheduled showers were not provided, and no complaints from the resident were reported to the Director of Staff Development (DSD). The facility's policy on showers, revised in January 2024, emphasizes the importance of promoting cleanliness and relaxation, but this policy was not followed in the case of Resident 21.
Failure to Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to provide activities to meet the needs and preferences of four residents, resulting in feelings of loneliness, isolation, and depression for Resident 12. Resident 12, who has a history of surgical amputation, major depression, and heart disease, requested a television in her room to alleviate her isolation. Despite her request, the facility did not provide a television, and the Activity Director indicated that residents must purchase their own if one is not already installed in their room. This lack of accommodation left Resident 12 without any interaction or entertainment, exacerbating her feelings of isolation and depression. Resident 21, who is cognitively intact and has diagnoses including diabetes mellitus and morbid obesity, was observed lying in bed with his television off and no other activities provided. Although his care plan indicated he enjoyed watching TV and listening to music, these preferences were not met. The Activity Director stated that Resident 21 preferred to stay in bed and received one-on-one visits, but there was no evidence of other activities being provided to him, such as books or magazines. Resident 33, who has severe cognitive impairment and a history of hemiplegia and contractures, was frequently observed lying in bed with his television and radio off. Despite his care plan indicating he enjoyed listening to the radio and watching TV, these activities were not facilitated by the staff. Similarly, Resident 40, who has a BIMS score of 5 and diagnoses including hemiplegia and congestive heart failure, was observed lying in bed with his television unplugged and no music playing. The lack of available power outlets for his TV further limited his access to preferred activities, contributing to his inactivity and potential social isolation.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to ensure that two residents, Resident 33 and Resident 5, received appropriate treatment and services to maintain joint mobility and prevent further decrease in Range of Motion (ROM). Resident 33, who was admitted with diagnoses including hemiplegia and contractures of the left hand and knee, did not have a hand roll applied to his left hand as ordered by the physician. Multiple observations confirmed the absence of the hand roll, and interviews with staff revealed inconsistencies in the application of the hand roll and the provision of passive ROM exercises. Resident 33 exhibited signs of pain during care, such as grimacing and physical aggression, indicating that the ROM exercises were causing discomfort and were not being managed appropriately by the staff. The Director of Rehabilitation acknowledged the importance of ROM exercises to prevent worsening contractures but noted that staff were instructed to stop if the resident showed signs of pain, which was not consistently followed. Resident 5, who had a history of paraplegia and multiple contractures, was supposed to receive restorative nursing assistant (RNA) services for passive ROM exercises and positioning to prevent further contractures. However, documentation revealed that Resident 5 had not been consistently receiving these services. The Director of Rehabilitation and the Director of Nursing both confirmed that Resident 5 should have been on the RNA program, but there was a lack of documentation to support that the services were provided. The RNA Weekly Assessments and Treatment Authorization Requests (TAR) showed inconsistencies, with some documents indicating that Resident 5 was not on the RNA program while others suggested that services were provided. The Director of Staff Development also confirmed that there was a disconnect in communication between the nursing and therapy departments, leading to missed orders and inconsistent documentation. The facility's policies and procedures for RNA referrals and joint mobility assessments were not followed, resulting in inadequate care for both residents. The failure to provide consistent and appropriate ROM exercises and positioning led to pain and the potential for further contractures. The discrepancies in documentation and communication between departments contributed to the deficiencies in care, highlighting a systemic issue within the facility's management of restorative nursing services.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident 33 and Resident 35. Resident 33, who had diagnoses including Hemiplegia, Hemiparesis, Congestive Heart Failure, and Anxiety Disorder, was not receiving oxygen therapy as per the doctor's order for continuous oxygen at two liters per minute. Multiple observations over several days showed Resident 33 without oxygen therapy, and there was no documentation of respiratory assessments by the nursing staff. The Director of Nursing confirmed that the nurses did not follow the doctor's order and failed to monitor and document signs of respiratory distress when Resident 33 was not on oxygen therapy. Resident 35, diagnosed with Dementia and Chronic Obstructive Pulmonary Disease, was observed receiving oxygen therapy at three liters per minute without a pre-filled humidifier attached to the oxygen concentrator. The facility's policy required a humidifier for oxygen flow above two liters per minute to prevent nasal discomfort and bleeding. Observations confirmed the absence of the humidifier, and the Infection Preventionist acknowledged the risk of nasal dryness and bleeding due to this oversight. The facility's failure to adhere to the prescribed oxygen therapy and lack of proper respiratory assessments for Resident 33, along with the omission of a required humidifier for Resident 35, demonstrated a significant lapse in providing appropriate respiratory care. These deficiencies were confirmed through observations, staff interviews, and record reviews, highlighting the facility's non-compliance with physician orders and internal policies regarding respiratory care.
Inadequate Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels for Certified Nursing Assistants (CNAs) and Licensed Nurses, resulting in complaints and potential risks to resident safety. For 20 out of 30 days in January 2024, the facility did not meet the required number of CNAs, and for two days, it did not meet the required number of Licensed Nurses. This inadequacy led to residents experiencing delays in care, with some residents having to wait for extended periods before their call lights were answered. One resident reported having to transfer herself to a wheelchair and seek help independently due to the lack of timely staff response during a COPD attack. Interviews with residents and staff highlighted the negative impact of short staffing. Residents expressed frustration and concern over frequent falls and long wait times for assistance. Staff members acknowledged the challenges posed by inadequate staffing, noting that it led to hurried care, increased risk of accidents, and delayed or missed care. One staff member mentioned that the facility's reluctance to offer overtime contributed to the staffing issues. The facility's staffing guidelines required a specific number of CNAs and Licensed Nurses based on the census, but these guidelines were not consistently met. The administrator confirmed the use of a staffing guideline but did not provide an explanation for the staffing shortfalls. The facility's policy stated the importance of adequate staffing to meet residents' needs, but the observed staffing levels did not align with this policy, leading to compromised resident care and safety.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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