Mayers Memorial Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Fall River Mills, California.
- Location
- 43563 Hwy 299 E, Fall River Mills, California 96028
- CMS Provider Number
- 056416
- Inspections on file
- 31
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Mayers Memorial Hospital during CMS and state inspections, most recent first.
A resident with paraplegia and COPD, who was cognitively intact, was transferred to an acute care hospital for respiratory issues and confusion, but the facility failed to follow its own policies for transfer and discharge. The resident did not receive or sign a 7‑day bed-hold form, there was no dual-nurse verification of verbal consent, and neither the resident nor family were informed of bed-hold provisions or the right to appeal the discharge. No discharge physician order was obtained, and there was no documented discussion with the resident or representative about discharge. Additionally, no change in condition assessment was completed, and the resident’s care plan was not updated to reflect the hospital transfer and change in health status.
Two residents were denied access to portable oxygen tanks due to repeated equipment failures, forcing them to use large, non-portable concentrators that restricted their movement and participation in activities. Both residents reported feeling embarrassed and confined, and staff confirmed ongoing issues with the oxygen supply system and the impact on residents' daily lives.
Surveyors found that multiple resident bathrooms had unsanitary conditions, including missing or damaged caulking around toilets, grime buildup, and floors in disrepair. Staff and a family member confirmed the bathrooms were not clean or homelike, and facility policies requiring daily cleaning and maintenance were not followed.
The facility did not prevent the use of unnecessary psychotropic medications or medications that could restrain a resident's ability to function, resulting in a deficiency related to medication management.
A controlled medication bin was found sealed with a zip tie whose number did not match the number recorded on the controlled count sheet. This discrepancy was confirmed by a nurse and acknowledged by the DON, indicating a failure to accurately document and secure controlled substances as required by facility policy.
Pharmacy recommendations for medication regimen reviews were not addressed by the physician, DON, or nursing staff for three residents, including those with dementia and complex medical histories. Recommendations regarding antipsychotic use, high-risk medication combinations, and the need for behavior documentation and dose reductions were left unanswered for several months, contrary to facility policy.
Two residents experienced medication errors when a nurse was unable to administer a prescribed antibiotic due to unavailability and another resident received omeprazole after breakfast instead of on an empty stomach as ordered. These incidents resulted in a medication error rate above 5%, with issues including lack of medication availability and discrepancies between the MAR and physician orders.
Surveyors found expired insulin lispro and tuberculin purified protein derivative vials in medication storage areas. Nursing staff and administration confirmed these medications were expired and should have been removed according to facility policy and manufacturer guidelines.
A licensed nurse used the same blood pressure monitor on multiple residents during medication pass without cleaning or disinfecting the device between uses. Both the nurse and DON acknowledged that the equipment should be sanitized between each resident, and facility policy as well as manufacturer instructions required cleaning after each use. This failure breached infection prevention and control protocols.
The facility did not ensure the pharmacist established and maintained records for controlled medications, leading to undetected diversion of narcotics. A nurse was observed removing narcotic cassettes, and an audit found thousands of missing narcotic tablets and vials, with missing documentation and lack of pharmacy tracking. The pharmacist was unaware of regulatory responsibilities and did not perform required audits or collaborate with staff to ensure safe handling of controlled substances.
Two residents with significant fall risk factors, including dementia and mobility issues, experienced avoidable falls resulting in hip fractures and hospitalizations after staff failed to follow care planned interventions. One resident was not assisted to bed or the bathroom as required, and another was not provided with non-skid footwear, leading to falls and injuries. The facility's policy and care plans were not followed, contributing to these incidents.
Two residents with severe cognitive impairment experienced physical and verbal abuse when one CNA was rough and pushed a resident, while another CNA cursed, pushed a resident, and threw personal care items onto the resident's chest. These actions were witnessed by staff and other residents, and resulted in emotional distress and fear for the affected residents.
A facility failed to thoroughly investigate an allegation of staff-to-resident abuse when a resident with severe cognitive impairment was allegedly mistreated by a CNA. Although a roommate witnessed the incident and confirmed she was not interviewed, the facility's investigation did not include her account, and the DON acknowledged this omission.
A resident with dementia was not promptly monitored or documented for changes in condition after experiencing abuse by a CNA. Required change in condition charting was not completed immediately, and alert charting to monitor the resident for 72 hours was initiated late, contrary to facility policy.
The facility did not follow its abuse reporting policy for several residents, including failing to send investigation results to CDPH after altercations between residents and not reporting a family member's verbal abuse of a resident within the required timeframe. These lapses involved residents with dementia, mood disorders, and other chronic conditions, and resulted in delayed or missing notifications to regulatory authorities.
A resident experienced verbal abuse from an RN who yelled and cursed at her, instructing her not to use her call light. The resident, with a BIMS score indicating good memory and decision-making skills, reported the incident, which was corroborated by CNAs. The facility's investigation substantiated the abuse, and the resident's medical history included COPD, cognitive decline, insomnia, diabetes, depression, and hypertension.
A CNA in an LTC facility verbally abused five residents, including those with dementia, stroke, and Parkinson's disease. The CNA refused to provide food to a resident in pain, made derogatory comments about another's size, and was described as unprofessional and disrespectful by others. These incidents were corroborated by staff and documented in facility records.
Two residents at an LTC facility eloped due to inadequate assessment and monitoring for wandering and elopement risks. One resident with severe cognitive impairment was found in the parking lot, while another with moderate impairment was located at a gas station by law enforcement. Risk assessments for both were completed only after the incidents.
The facility did not meet the required daily RN hours for PBJ staffing information submitted to CMS. The Quality Manager confirmed that RN coverage was not met for 20 days in the first Federal Quarter of 2024, with no RNs present on the schedule for these dates. The XML Submission Form showed specific dates with gaps in RN coverage, confirming the deficiency.
The facility failed to report abuse allegations in a timely manner for several residents. One resident was verbally and physically abused by the DON, and staff did not report the incident due to fear and lack of knowledge. Another incident involved two residents, where one hit the other, but the report was delayed. The facility lacked a culture that supported abuse reporting.
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Both residents had severe cognitive impairment and physician's orders for Wander guard devices, but their Care Plans lacked entries about elopement risk or the devices. The ADON confirmed the omission and mentioned that a new elopement policy was being drafted.
The facility failed to ensure the environment was free of accident hazards for two residents with orders for Wanderguard devices but lacked follow-up or monitoring. Both residents had severe cognitive impairments and were not wearing the Wanderguard devices as ordered, with no documentation in the MAR to monitor elopement behaviors. The ADON confirmed the lack of documentation and mentioned an unapproved new elopement policy.
The facility failed to protect a resident from physical and verbal abuse when the DON was observed yelling at and shaking the resident's wheelchair. The resident, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway when the incident occurred. This behavior violated the facility's policy on abuse and has caused the resident to feel afraid to leave her room.
The facility failed to ensure professional food safety and sanitation practices, as evidenced by an unclean microwave, expired food items, improperly labeled bagels, and a dented can of soup. These deficiencies were confirmed by the Certified Dietary Manager and had the potential to result in foodborne illness for the facility's 79 residents.
Failure to Provide Proper Bed-Hold Notice, Discharge Orders, and Care Plan Updates After Hospital Transfer
Penalty
Summary
The facility failed to ensure an appropriate transfer and discharge process for a resident who was transferred from the SNF to an acute care hospital for shortness of breath and confusion. The resident had paraplegia and COPD and had a BIMS score of 15/15, indicating intact decision-making ability. When the resident was sent to the hospital, the facility did not obtain a signed 7‑day bed hold form from the resident or her representative, nor did two nurses document a verified telephone agreement as required by facility policy. The DON confirmed that the bed-hold document in the record lacked the resident’s or responsible party’s signature and did not contain the required dual-nurse verification. The resident’s family member reported that neither the resident nor the family received the bed-hold information form or any information about appealing the discharge, and that the only communication received was that the resident’s belongings were packed and ready for pickup while the resident remained hospitalized. The facility also did not follow its transfer and discharge policy regarding physician orders and communication. Review of the resident’s order summary showed no discharge physician’s order, despite the resident not returning to the facility. Progress notes contained no documentation of any conversation with the resident or her responsible party about discharge from the facility, contrary to the policy requiring completion and review of a transfer/discharge summary and instructions with the resident and/or family. The DON confirmed the absence of a discharge order and the lack of documented discussion about discharge. In addition, the facility did not complete required assessments or update the care plan in response to the resident’s change in condition and transfer. The charting and documentation policy required recording any significant change in condition, but review of progress notes from the date of transfer through the survey date showed no change in condition assessment, which the DON confirmed. The care plan policy required review and revision of the care plan with changes in health status, yet the resident’s care plan, initiated previously, contained no updates related to the transfer to the acute care hospital for respiratory issues. These omissions resulted in the resident not being properly involved in or prepared for discharge and not being informed of the right to appeal the discharge, as stated in the report.
Failure to Provide Portable Oxygen Tanks Limits Resident Dignity and Mobility
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect by not providing access to portable oxygen tanks. Instead, residents were required to use large, noisy, non-portable oxygen concentrators that needed to be plugged into electrical outlets. This limitation prevented the residents from moving freely within the facility, going outdoors, attending appointments, or leaving with family, as the concentrators were cumbersome and required constant access to electricity. The issue was ongoing due to repeated malfunctions of the equipment used to fill portable tanks, and the facility's oxygen service provider was frequently called for repairs, but the problem persisted. Resident records indicated that one resident had severe cognitive impairment and was not their own representative, while the other had intact cognition and made their own medical decisions. Both residents expressed feelings of embarrassment, confinement, anger, and anxiety due to their restricted mobility and reliance on the concentrators. Staff interviews confirmed the recurring equipment failures, the need for staff assistance to move the concentrators, and the resulting impact on residents' ability to participate in activities and outings. The facility's own resident rights documentation emphasized the right to dignity and individuality, which was not upheld in this situation.
Unsanitary Resident Bathrooms and Lack of Homelike Environment
Penalty
Summary
Surveyors observed that 6 out of 8 resident bathrooms had unsanitary conditions, including gaps around toilet bases where caulking was torn or missing, resulting in grime and discolored buildup that resembled urine or fecal matter. The linoleum flooring in these bathrooms was described as old, scratched, and in disrepair, with additional observations of loose dirt debris, black scuff marks, and yellow staining. These conditions were confirmed by both family members and staff, who stated that the bathrooms were not in acceptable or sanitary condition. Facility documentation indicated that housekeeping procedures required daily and thorough cleaning of environmental surfaces, but these standards were not met in the observed bathrooms. Interviews with staff, including the Assistant Director of Nursing and Environmental Services Manager, acknowledged awareness of the maintenance and cleanliness issues in the resident restrooms. Both staff and family members expressed that the bathrooms were not maintained to a homelike or sanitary standard, with one family member stating they would not allow their home restroom to be in such a condition. The facility's own policies required a clean, sanitary environment, but observations and interviews confirmed that these expectations were not being fulfilled in the resident bathrooms at the time of the survey.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that could limit their functional abilities, contrary to regulatory requirements. The report does not provide specific details about the residents involved, their medical histories, or their conditions at the time of the deficiency.
Inaccurate Controlled Drug Record-Keeping
Penalty
Summary
The facility failed to maintain accurate pharmacy services for its census of 69 residents when the controlled drug record form was not properly filled out and signed. During an inspection of the controlled medication bin, it was observed that the bin was locked and sealed with a numbered zip tie that did not match the number recorded on the controlled count sheet. The discrepancy was confirmed by a charged nurse, who acknowledged the error, and the DON recognized the potential risk associated with mismatched tag numbers. Review of facility policy indicated that discontinued medications and controlled substances are to be handled securely, but the observed practice did not align with this requirement.
Failure to Respond to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
A deficiency occurred when pharmacy recommendations were not followed or responded to by the physician, DON, or nursing staff for three of six sampled residents over periods extending up to ten months. For one resident with dementia, chronic kidney disease, and emphysema, the physician failed to respond to the pharmacist's recommendations regarding the use of Rexulti for agitation for five months. Another resident with a history of stroke, dementia, and nerve pain had a high-risk medication combination of gabapentin and an opioid, with the pharmacist requesting a risk-benefit analysis and effectiveness documentation, but the physician did not respond for ten months. A third resident with dementia and aggressive behaviors was prescribed Zyprexa, and the pharmacist's repeated recommendations for a gradual dose reduction and improved behavior documentation went unaddressed for four consecutive months. The facility's policy required that the consultant pharmacist review medication regimens and that the physician respond to recommendations, documenting the rationale for continuing medications if indicated. However, clinical record reviews showed a lack of physician or nursing staff response to the pharmacist's recommendations in the medical records for the residents involved. The pharmacist confirmed that reminders were given to the DON and nursing staff regarding the need for specific behavior documentation and consideration of dose reductions, but these recommendations remained unaddressed.
Medication Error Rate Exceeds 5% Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two errors identified out of 31 opportunities during medication administration observations. For one resident, a licensed nurse was unable to administer doxycycline as ordered for bronchitis because the medication was not available at the time of administration. The nurse reported that the prescription had been extended by the provider, but the medication had not yet been received from the pharmacy, resulting in a missed dose. Facility policy requires that medications be administered as prescribed and available for administration. In another instance, a licensed nurse administered omeprazole to a resident after the resident had already consumed half of their breakfast, despite physician orders specifying that the medication should be given on an empty stomach before breakfast for gastrointestinal protection. The nurse acknowledged that the order summary on the MAR did not match the prescription label, and the MAR had not been updated to reflect the correct administration time. Facility policy requires that medications be administered at the correct time and as prescribed, with accurate reconciliation between the MAR and physician orders.
Expired Medications Found in Storage Areas
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and removal of expired medications. During an inspection of a medication cart, an expired insulin lispro pen was found with an expiration date that had already passed. The licensed nurse present acknowledged the medication was expired and confirmed it should have been removed. Review of the medication's provider information indicated that insulin lispro should not be used past its expiration date and that opened vials should be discarded after 28 days. The Director of Nursing stated that nurses are expected to check for expired medications each time they take over the cart, and that expired insulin pens should be dated and replaced. Additionally, an expired multi-dose vial of tuberculin purified protein derivative testing agent was found in a medication room refrigerator. The vial was labeled with an open date and a discard date that had already passed. The Assistant Director of Nursing confirmed the medication was expired and should have been removed from active storage. Facility policy and procedure documents reviewed by surveyors stated that outdated medications are to be removed from storage areas and are not to be available for patient use.
Failure to Disinfect Blood Pressure Monitor Between Resident Uses
Penalty
Summary
The facility failed to follow infection prevention and control practices when a blood pressure monitor was not disinfected according to the manufacturer's instructions after use during medication pass observations. On multiple occasions, a licensed nurse used the same blood pressure monitor to measure the blood pressure of different residents in their rooms and then placed the device back on the medication cart without cleaning or disinfecting it between uses. This practice was observed with several residents during the medication pass. During interviews, the licensed nurse acknowledged that the blood pressure monitor and cuffs were not cleaned or sanitized between residents, and the Director of Nursing confirmed that the equipment should be disinfected between each use to reduce infection risk. Review of the facility's policy and the manufacturer's cleaning recommendations indicated that both the monitor and cuff should be cleaned with a soft, moistened cloth and mild detergent after each use to maintain hygiene. The failure to adhere to these procedures constituted a breach of infection control protocols.
Failure to Maintain Controlled Substance Records and Oversight by Pharmacist
Penalty
Summary
The facility failed to ensure that the pharmacist was responsible for establishing and maintaining a system of records for the receipt and disposition of all controlled medications, as required by federal regulations. The facility's policy required consistent receiving and tracking of controlled substances to prevent and detect diversion, but this was not followed. A narcotic reconciliation issue was identified when an LVN requested additional narcotics for a resident before it was due, and video surveillance later showed the LVN removing narcotic cassettes from the locked medication room. An audit revealed that 2550 narcotic tablets and 2 vials of morphine were missing, with missing paperwork on 85 narcotic cassettes and 2 vials of liquid morphine. The facility identified contributing factors such as lack of overflow accountability and the pharmacy not tracking required control sheets, with leadership changes cited as a root cause for process failures. The pharmacist stated he was unaware of his federal responsibilities and had not established or maintained records of receipt and disposition of controlled medications, nor performed routine audits to reconcile narcotic drug usage or collaborated with facility staff to ensure safe and secure handling of these drugs. The pharmacist believed his responsibility ended once the narcotics were dispensed to nursing, and he relied on DEA software alerts to identify issues. This lack of oversight and failure to follow established procedures allowed narcotic medications to be diverted without detection.
Failure to Implement Care Planned Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement care planned fall prevention interventions for two residents who were identified as high risk for falls. For one resident with diagnoses including dementia, rheumatoid arthritis, prostate cancer, vision problems, and high blood pressure, the care plan required staff to follow the resident to his room and assist with toileting or lying down. Despite this intervention, the resident experienced multiple falls in his room, including an incident where he attempted to transfer himself from his wheelchair to his bed, resulting in a fractured right hip that required surgical repair. The Director of Nursing confirmed that staff did not follow the care plan intervention at the time of the fall. Another resident, also at high risk for falls due to conditions such as dementia, depression, anxiety, insomnia, repeated falls, chronic pain, heart failure, lung disease, incontinence, arthritis, osteoporosis, and prior fractures, had a care plan intervention to ensure the use of non-skid footwear when ambulating or mobilizing in a wheelchair. This intervention was not followed, and the resident was found wearing slippers that were not non-skid at the time of a fall. The resident attempted to self-transfer from a wheelchair to a recliner, slipped, and sustained a fractured left hip requiring surgical repair. A post-fall committee meeting identified inappropriate footwear as the root cause of the fall, and a nurse confirmed the care plan was not followed. Both residents had documented histories of falls and were assessed as high risk using the Morse Fall Scale. The facility's own policy required the implementation of evidence-based interventions for residents at risk for falls, including addressing fall risks in care plans and providing non-skid footwear. The failure to follow these care planned interventions directly resulted in avoidable falls and serious injuries for both residents.
Failure to Prevent Physical and Verbal Abuse of Residents
Penalty
Summary
The facility failed to prevent physical and verbal abuse for two residents with severe cognitive impairment. One resident, diagnosed with dementia, chronic pain, and weakness, was reported by her roommate to have been pushed and handled roughly by a CNA. A nursing note documented that this resident was emotional and distraught following the incident. Another resident, also with dementia and a severely impaired BIMS score, experienced an incident where a CNA cursed, pushed the resident, and threw personal care items onto the resident's chest. A witness CNA reported that the resident expressed fear of the CNA due to her aggressive behavior. The facility's policy prohibits all forms of abuse and mistreatment, but interviews and record reviews confirmed that staff members engaged in rough and aggressive conduct toward these residents. The incidents were directly observed or reported by other staff and residents, and the affected residents were noted to be emotionally distressed and fearful as a result of the staff's actions.
Failure to Interview Witness During Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of staff-to-resident abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. According to facility policy, all suspected incidents of abuse require obtaining written statements from all persons involved and conducting staff and resident interviews. However, despite a roommate witnessing the alleged abuse and confirming she was not interviewed, the facility's investigation records did not include an interview with this witness. The Director of Nursing confirmed that no interview was conducted with the roommate, despite her being a witness to the incident.
Failure to Timely Monitor and Document After Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that a resident who experienced abuse was properly monitored for any resulting problems. Specifically, after a Certified Nursing Assistant (CNA) was rough with the resident and threw personal care items at him, staff did not complete required change in condition charting immediately following the incident. Additionally, alert charting, which is meant to provide ongoing documentation and monitoring for 72 hours after such incidents, was not initiated until two days after the event. These actions were not in accordance with the facility's own policies, which require documentation of significant changes in condition and monitoring after abuse or unusual occurrences. The resident involved had a diagnosis of dementia, which affects memory and decision-making abilities. Review of the resident's progress notes confirmed the absence of timely change in condition documentation and a delay in starting alert charting. The Assistant Director of Nursing verified that these documentation requirements were not met as per policy following the incident of abuse.
Failure to Timely Report and Document Abuse Investigations
Penalty
Summary
The facility failed to follow its abuse reporting policy for six out of fourteen residents sampled for abuse. In multiple instances, altercations and allegations of abuse between residents, as well as an incident involving a family member verbally abusing a resident, were either not reported to the California Department of Public Health (CDPH) as required or were reported late. The facility's policy mandates that results of abuse investigations be reported to the appropriate authorities, including CDPH, with documentation of dates and times. For one incident, a resident with vascular dementia threw a plate at another resident with dementia and chronic pain. Although an initial report was made, the follow-up investigation results were not sent to CDPH as required by policy. In another case, a resident with dementia, stroke, and dysphagia was involved in altercations with two other residents, one involving physical contact and another involving verbal aggression. Investigations were conducted for both incidents, but there was no documentation that the results were reported to CDPH. Additionally, a resident with dementia, mood disturbance, and anxiety was verbally abused by a family member during a visit. Staff overheard the family member using profanity and belittling the resident. The incident was not reported to CDPH within the required 24-hour timeframe, instead being reported 46 hours after the event. These failures to report and document abuse investigations as per facility policy had the potential to subject residents to mistreatment, neglect, or abuse.
Verbal Abuse by RN Towards Resident
Penalty
Summary
The facility failed to prevent verbal abuse towards a resident by a registered nurse (RN A). The incident involved RN A yelling and cursing at the resident, instructing her not to use her call light, which caused the resident distress and feelings of unmet needs. The resident, who had a BIMS score indicating good memory and decision-making skills, reported the verbal abuse, which was corroborated by witness statements from certified nursing assistants (CNAs). These statements detailed RN A's frustration with the resident's frequent use of the call light and included instances of RN A turning off the call light and instructing CNAs to ignore the resident's calls unless it was an emergency. The resident's medical history included chronic obstructive pulmonary disease, age-related cognitive decline, insomnia, diabetes, depression, and hypertension. Despite these conditions, the resident expressed satisfaction with the facility overall. However, the verbal abuse incident was substantiated by the facility's investigation, which included a review of witness statements and an email from RN A acknowledging the difficulty in working with the resident. The Director of Nursing confirmed the findings of verbal abuse during an interview.
Verbal Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect five residents from verbal abuse by a Certified Nurse Assistant (CNA 1). Resident 1, who suffers from dementia, anxiety, spinal stenosis, and high blood pressure, reported that CNA 1 refused to provide food unless the resident sat up, despite the resident's pain. This incident was corroborated by another CNA and an Activities Aide, who both witnessed CNA 1's rude behavior. Additionally, CNA 1 was reported to have taken away Resident 1's dinner tray, causing distress to the resident. Resident 2, who has a history of stroke, obesity, hearing loss, and arthritis, was also subjected to verbal abuse. CNA 1 was overheard yelling that Resident 2 was too big to handle alone and made derogatory comments about the resident's size. This behavior was documented in the facility's progress notes and reported by other staff members. Resident 3, who is cognitively intact and has obesity, fibromyalgia, and diabetes, described CNA 1 as a bad CNA, although the resident did not provide further details. Resident 4, diagnosed with Parkinson's disease, cancer, and a history of falls, expressed that CNA 1 was unprofessional and disrespectful, making the resident feel belittled. The resident reported that CNA 1 did not listen and made dismissive comments. Similarly, Resident 5, who has Alzheimer's, a hip replacement, anxiety, and arthritis, stated that CNA 1 was bossy and rushed the resident, refusing assistance to the toilet. These incidents were documented in the facility's records and reported by the residents to the nursing staff.
Failure to Assess and Monitor Residents for Wandering and Elopement Risks
Penalty
Summary
The facility failed to ensure proper assessment and monitoring for two residents who were at risk for unsafe wandering and elopement. Resident 1, who had a severe cognitive impairment due to an anoxic brain injury, eloped from the facility and was found in the parking lot by a staff member. Despite wearing a Wander Guard, the resident's wandering and elopement risk assessments were only completed after the incident occurred, two months post-admission. Resident 2, with moderate cognitive impairment and medical diagnoses including cancer, depression, and anxiety, was found by law enforcement at a gas station after eloping from the facility. The resident's wandering and elopement risk assessments were not completed until nearly five months after the incident. Interviews with facility staff confirmed that the assessments for both residents were not conducted until after their respective elopements.
Failure to Meet Required RN Coverage
Penalty
Summary
The facility failed to meet the required daily Registered Nursing (RN) hours for Payroll Based Journaling (PBJ) staffing information submitted to the Centers for Medicare and Medicaid Services (CMS). During a concurrent record review and interview, the Quality Manager (QM) confirmed that the required RN coverage was not met for 20 days of the first Federal Quarter of 2024. The QM acknowledged that there were no RNs present on the schedule for these dates, although RNs were encouraged to clock in when providing resident care. The QM reviewed the XML Submission Form with the surveyor, pointing out specific dates where gaps in RN coverage were evident, confirming that no RNs were listed for resident care as required by CMS.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report abuse allegations in a timely manner for several residents. One resident, who was cognitively intact and had a history of high blood pressure, intellectual disability, and traumatic brain injury, was verbally and physically abused by the Director of Nursing (DON). The DON yelled at the resident and physically shook her wheelchair, causing the resident to feel embarrassed and in tears. Staff members were aware of the incident but did not report it due to fear of retaliation and a lack of understanding of reporting procedures. The incident was not reported to the California Department of Public Health as required by regulations. Another incident involved two residents, one with severe cognitive impairment and the other with behavioral disturbances. A Certified Nurse Assistant (CNA) witnessed one resident hitting the other in the hallway. The incident was documented in the clinical records but was reported late to the appropriate authorities. The facility's policy requires that such incidents be reported within two hours, but this was not adhered to. Interviews with staff revealed a lack of knowledge about the abuse coordinator and the proper procedures for reporting abuse. The Quality Manager acknowledged that the facility did not have a culture that supported reporting abuse, which contributed to the failure to report the incidents in a timely manner. The facility's training program on abuse reporting was reviewed, and it was confirmed that staff were educated to report suspected abuse within two hours, but this protocol was not followed in these cases.
Failure to Include Elopement Risk and Wander Guard Devices in Care Plans
Penalty
Summary
The facility failed to review and revise the Care Plans for two residents when information about their risk for elopement and exit alarm devices was not included. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, had a physician's order for a Wander guard device to be applied for safety. However, the Care Plan for Resident 27 did not include any entries about elopement risk or the Wander guard device. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, also had a physician's order for a Wander guard device. Yet, Resident 128's Care Plan also lacked entries about elopement risk or the Wander guard device. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that the elopement risk and Wander guard devices were not included in the Care Plans for Residents 27 and 128, and acknowledged that they should have been. The ADON mentioned that they usually discussed elopement risk during the resident's Care Conference and were in the process of drafting a new elopement policy, which had not yet been approved.
Failure to Monitor Wanderguard Devices for Residents
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards for two residents who had orders for Wanderguard placement but lacked follow-up or monitoring. Resident 27, who had severe cognitive impairment and a history of anoxic brain damage and a prior heart attack, was admitted with a physician's order for a Wanderguard device to be applied to their left ankle and checked every shift. However, there was no documentation in the Medication Administration Record (MAR) to monitor elopement behaviors, and during an observation, it was confirmed that Resident 27 was not wearing the Wanderguard device as ordered. Additionally, the Multidisciplinary Care Conference note did not mention the risk of elopement or the Wanderguard device, indicating a lack of proper documentation and follow-up on the resident's care plan. Similarly, Resident 128, who had severe cognitive impairment, dementia, anxiety, and legal blindness, had a physician's order for a Wanderguard device to be applied and checked twice a day. However, the MAR also showed no monitoring for elopement behaviors. During an interview, the Assistant Director of Nursing (ADON) confirmed that Resident 128 was not wearing the Wanderguard device as ordered and acknowledged the lack of documentation. The ADON mentioned that an initial elopement risk assessment is usually done on admission, but there was no documentation to support this for Resident 128. The facility was in the process of drafting a new elopement policy, which had not yet been approved, further highlighting the gap in ensuring resident safety from elopement risks.
Failure to Protect Resident from Physical and Verbal Abuse
Penalty
Summary
The facility failed to ensure that Resident 10 was free from physical and verbal abuse. The incident occurred when the Director of Nursing (DON) was observed by a confidential informant (CI1) yelling at and shaking Resident 10's wheelchair. Resident 10, who has a history of high blood pressure, intellectual disability, and traumatic brain injury, was wheeling herself backwards down the hallway due to weakness in her right side extremities. After accidentally bumping into another resident, the DON came out of her office, yelled at Resident 10, and physically shook her wheelchair, causing Resident 10 to feel embarrassed and cry. This incident was corroborated by interviews with Resident 10 and two confidential informants (CI1 and CI2), who confirmed the DON's inappropriate behavior and frequent yelling at residents. The facility's policy and procedure on abuse, dated 7/15/2022, clearly states that residents have the right to be free from all forms of abuse, including verbal and physical abuse. Despite this policy, the DON's actions violated these guidelines, resulting in physical and verbal abuse of Resident 10. The incident has led to Resident 10 feeling afraid to leave her room due to fear of being yelled at again. The failure to protect Resident 10 from abuse has the potential to negatively impact her psychosocial wellbeing and lead to isolation.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure professional food safety and sanitation practices were in place, as evidenced by several deficiencies observed during a kitchen inspection. The interior of the microwave oven used to prepare resident food was found to be unclean, with red-colored material splattered on its ceiling and sides. Additionally, two plastic bags containing grated cheese were found to be expired, and a sealed bottle of a nutritional shake had a printed expiration date that had passed. Furthermore, three bagels were stored in a plastic bag without a use-by date, and a large can of soup was dented along its seam, which should have been discarded. These deficiencies were confirmed by the Certified Dietary Manager (CDM) during the inspection. The presence of food debris or dirt on nonfood contact surfaces, such as the microwave, can provide a suitable environment for the growth of microorganisms, which employees may inadvertently transfer to food. The expired food items and the lack of proper labeling on the bagels also pose a risk of foodborne illness. The dented can of soup further increases the risk of physical contamination. These failures had the potential to result in foodborne illness for the facility's 79 residents who consumed food prepared in the facility.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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