River View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Modesto, California.
- Location
- 1611 Scenic Drive, Modesto, California 95355
- CMS Provider Number
- 055011
- Inspections on file
- 40
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at River View Post Acute during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including a stage 4 left ankle pressure ulcer and hemiparesis, developed a twisted, purple, cold left foot, prompting a STAT x‑ray of the left lower extremity. The STAT x‑ray later showed a distal leg fracture and osteomyelitis, and the results were transmitted to the facility the same evening. The nurse on duty did not re‑check for results after an initial review, did not contact the x‑ray provider to verify timing, and, once the abnormal report was received, notified the physician only by text without follow‑up phone calls or direct confirmation, despite facility policies requiring immediate, voice communication of new fracture findings and STAT results. This failure to follow established notification policies delayed physician awareness and subsequent hospital transfer orders.
A resident with hemiplegia, a stage 4 ankle pressure ulcer, DM2, PVD, and anemia was noted by staff to have a twisted left foot that was purple and cold, prompting a STAT x-ray of the left lower extremity. The x-ray later showed a fracture and acute osteomyelitis of the distal lower leg, and the physician was notified of these abnormal results. However, nursing staff did not complete or document a comprehensive reassessment of the resident’s left leg and foot, including pain and circulatory status, before or after notifying the physician, despite facility policy and job descriptions requiring detailed assessment and use of SBAR for significant changes in condition.
A resident with multiple complex medical conditions experienced a severe, unrecognized weight loss over several weeks. Facility staff failed to weigh the resident as required, did not notify the physician or implement interventions in a timely manner, and did not document the change of condition, despite facility policy requiring prompt action for significant weight changes.
A resident with a history of stroke and colon cancer, experiencing sadness and depression, did not receive a timely psychiatric evaluation after a referral order was entered. The Social Services Department failed to process the referral, and the resident reported not being offered counseling or therapy. Interviews confirmed the referral was not completed as required by facility policy.
A resident with anxiety and depression was administered PRN lorazepam without the required 14-day stop date or physician documentation explaining the omission. Facility staff and policy confirm that such medications must have a stop date to ensure ongoing evaluation, but the medication was given on multiple occasions without this safeguard.
A resident with documented intellectual disability and cerebral palsy was admitted without these conditions being accurately reflected on the PASRR Level I screening. The screening incorrectly indicated no need for further evaluation, and staff did not review the PASRR for accuracy, resulting in the resident not being properly evaluated for specialized services as required by facility policy.
A resident with adjustment disorder and anxiety did not receive two scheduled psychotherapy sessions as ordered, and facility staff failed to ensure timely follow-up or alternative interventions. Interviews confirmed that the missed visits were not communicated or addressed according to facility procedures.
A resident who required a mechanical lift and sling for transfers was unable to attend preferred activities on multiple occasions due to the facility's failure to provide an available sling. Staff confirmed that equipment shortages and uncharged lift batteries delayed care, and the resident had to use an inappropriate shower sling, resulting in skin irritation. The DON acknowledged the lack of equipment and its impact on the resident's ability to participate in activities, contrary to facility policy on resident autonomy and dignity.
A resident with bipolar disorder and intact cognition alleged that a CNA forcefully grabbed her legs, causing pain and bruising. Although two LNs and the CNA were aware of the allegation on the day it occurred, the incident was not documented or reported to the Department until five days later, contrary to facility policy requiring immediate reporting of suspected abuse. This delay resulted in a late investigation and reduced the facility's ability to protect residents from harm.
A resident with schizophrenia reported being hit on the head, but the facility did not notify the responsible party (RP) of this abuse allegation as required. The incident was documented in the resident's records and care plan, but the DON confirmed there was no evidence that the RP was informed, contrary to facility policy.
Two residents did not receive required alert charting following incidents—one after an allegation of physical harm and another after a verbal altercation. Despite care plans and facility policy mandating 72 hours of monitoring and documentation for psychosocial effects, licensed nurses did not complete the necessary charting for either resident.
Two residents with depression were unable to enjoy a safe and comfortable environment due to another resident's ongoing disruptive behavior, including yelling and cussing in hallways and activity areas. Staff confirmed that the disruptive resident, who has bipolar disorder, frequently caused distress, leading the affected residents to keep their doors closed and avoid activities. The facility's policy on maintaining comfortable sound levels was not met.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident was not provided with scheduled showers and instead had to use disposable wipes for hygiene, as staff did not accommodate the resident's preference for a female CNA. The care plan was not updated to reflect these preferences, and documentation did not indicate that the resident refused care. This failure to honor the resident's choices and provide routine care led to the resident's needs not being met and caused distress.
Two residents sharing a bathroom were exposed to an unsanitary environment when a toilet seat remained contaminated with fecal matter and urine for an extended period. A housekeeper confirmed the bathroom had not been cleaned during her shift, and the Director of Staff Development acknowledged the lapse, which was inconsistent with facility policies on cleanliness and infection control.
A resident with a history of repeated falls was found to have multiple wheelchairs, a recliner, and an overbed table stored in their room for several days, obstructing access and creating a potential fall hazard. The DSD confirmed these items should not have been stored in the room, as this violated facility policies on safety and a homelike environment.
The facility failed to maintain infection control practices, as personal care items like urinals, wash basins, and toothbrushes were found unlabeled and improperly stored in shared bathrooms. This increased the risk of cross-contamination among residents. Interviews with staff revealed that the facility's process required labeling and proper storage of these items, which was not followed, posing a significant infection control risk.
A resident discharged from the hospital with instructions for follow-up care with a podiatrist and interventional radiology did not receive these appointments from the facility. The resident, who had undergone a partial foot amputation due to gangrene, also required a surgical evaluation that was not communicated to the primary physician. This lack of follow-up and communication may have contributed to the resident's wound infection and subsequent leg amputation.
A CNA in an LTC facility failed to maintain infection control standards by wearing a loosened gauze dressing on her hand while caring for nine residents. The dressing, used to cover a burn, was not properly secured and was washed with the CNA's hands, posing a risk of infection spread. The facility's policies require strict hand hygiene to prevent such risks.
A facility failed to provide proper respiratory care for three residents receiving oxygen therapy. One resident received oxygen without a physician's order, and two residents lacked care plans for their oxygen use. Additionally, a resident's nasal cannula was expired, and the oxygen humidifier bottle was not labeled with a change date, posing an infection risk.
The facility failed to ensure safe medication storage practices, with expired, unlabeled, and undated medications found in two medication carts and two storage rooms. Observations included expired Atropine Sulfate and Latanoprost Ophthalmic Solutions, undated Ipratropium Bromide and Albuterol Sulfate inhalation solution, and a vial of Lorazepam belonging to a discharged resident. Over-the-counter medications with debris were also noted. Licensed nurses and the DON confirmed the need for proper labeling and disposal of medications.
The facility failed to ensure food safety and sanitation, affecting 91 residents. Opened food packages were unlabeled, spoiled and expired food was not removed, and kitchen equipment was not cleaned. A partially consumed water bottle was found in the dry food storage area, violating FDA guidelines.
A resident with physical limitations was denied the use of a personal device for communication and entertainment, despite it being important for their well-being. The facility unplugged the device due to concerns about the roommate, without providing alternatives, contrary to their policies on personal property and a homelike environment.
A resident with spastic diplegic cerebral palsy and adjustment disorder was unable to reach her call light due to contractures in her arms and hands, placing her at risk of falls and unmet care needs. A nurse confirmed the call light was out of reach, and the resident's care plan emphasized the importance of having the call light accessible. The DON expected call lights to be within reach, aligning with the facility's policy for timely responses to residents' needs.
A resident with a history of falls and fractures was observed in a Geri chair with the footrest elevated, preventing free movement and acting as a restraint. The DSD confirmed the chair should be upright when the resident is awake. The facility's policy states that restraints should only be used for medical symptoms, not for convenience or fall prevention.
The facility failed to develop and implement care plans for three residents, leading to potential unmet care needs. A resident with end-stage renal disease lacked a dialysis care plan, another with a splint had no care plan for its management, and a third involved in altercations had no behavioral care plan. These omissions were confirmed by staff and violated facility policies requiring comprehensive, person-centered care plans.
The facility failed to update care plans for two residents, one with new skin wounds and another who switched from smoking tobacco to vaping. The DON acknowledged the lack of a care plan for the resident with wounds, while the AD admitted to not updating the smoking care plan in a timely manner. This oversight could lead to inadequate care, as staff may not be aware of necessary interventions or changes in residents' conditions.
A resident with a left arm injury and chronic pain was not seen by an orthopedist for six months despite a referral from the facility's MD. The resident's splint, worn since admission, showed signs of neglect, and transportation issues were cited as the reason for the delay. Interviews with staff confirmed the oversight, and the MD emphasized the need for the referral.
A resident with worsening eyesight and specific symptoms was not assisted by the facility in obtaining an ophthalmology appointment, despite repeated requests and a care plan intervention. The Social Services Director acknowledged the oversight, and the Director of Nursing confirmed the lack of documentation and emphasized the risk of vision decline affecting mobility and fall risk.
A resident with pressure ulcers did not receive consistent treatment as ordered by their physician, specifically the use of heel protectors every shift. Observations confirmed the resident's heels were bare, and facility staff acknowledged the oversight, which was contrary to the facility's wound care policy.
A resident with quadriplegia did not receive ordered Restorative Nurse Assistant (RNA) services, including the use of orthotics and passive range of motion (PROM) exercises, due to a lack of communication and awareness among staff. Additionally, the facility failed to develop a care plan for the resident's arm and hand contractures, increasing the risk of further decline in range of motion.
A resident at high risk for falls did not have appropriate fall precautions in place, as fall mats were not positioned correctly and were not included in the care plan. Staff confirmed the mats were sometimes moved and not returned, and the resident's bedside table was out of reach, increasing fall risk. The need for fall mats was not documented, highlighting a lapse in care planning and staff education.
A facility failed to obtain a physician's order for a resident's indwelling foley catheter, despite the resident's diagnoses of urinary tract infection and acute kidney failure. The care plan required regular catheter care and infection monitoring, but the absence of a physician's order meant staff were not properly informed of the resident's needs, placing the resident at risk for complications.
A resident receiving IV therapy for MRSA had their IV tubing lying on the floor, and the infusion bag was not labeled with the date, time, or staff initials. The ADON confirmed these issues, acknowledging the risk of infection and physical hazards. The DON expected proper labeling and tubing management, as outlined in facility policies, but these standards were not met, resulting in a deficiency.
A resident's unlabeled urinal was found on the bedside table, posing a risk of infection if used by another resident. The CNA, LN, IP, and DON all confirmed that urinals should be labeled to prevent mix-ups. The facility's infection control policy requires maintaining a safe and sanitary environment, which was not followed in this case.
A resident with severe cognitive impairment was physically assaulted by another resident with a history of aggression in a common area. The incident was witnessed by a CNA who was unable to intervene due to attending to another resident. The facility's policies on monitoring and preventing abuse were not effectively implemented, leading to a deficiency.
A resident with osteoarthritis and osteoporosis fell and sustained fractures when a blanket caught in the wheel of a shower chair during transport, causing the chair to tip forward. The incident, witnessed by a CNA, resulted in severe pain and decreased mobility for the resident. The facility's policy required blankets to be secured during transport, which was not adhered to, leading to the preventable accident.
A resident with epilepsy did not receive his prescribed seizure medication for several days due to an insurance issue, and the physician was not informed. The resident experienced multiple seizures and was hospitalized. The facility's policy required notifying the physician and taking further steps if medication was unavailable, which was not followed.
Failure to Immediately Notify Physician of STAT X‑Ray Showing Fracture and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician of significant STAT x‑ray results showing a fracture and osteomyelitis. The resident had multiple serious diagnoses, including hemiplegia/hemiparesis after stroke, a stage 4 pressure ulcer of the left ankle, type 2 diabetes mellitus, peripheral vascular disease, and anemia. On the morning in question, a CNA alerted a nurse to check the resident’s left foot; the nurse and supervisor observed the left foot twisted downward from the ankle, with purple, cold skin and an existing stage 4 wound. A physician gave a verbal order for a STAT x‑ray of the left ankle, foot, and knee, which was entered into the record at 12:34 PM. The STAT x‑ray was completed and the radiology report, indicating a fracture and osteomyelitis of the distal left lower leg, was transmitted to the facility at 10:20 PM that same day. The facility’s process was that STAT x‑ray results would be uploaded into the electronic health record and faxed to a designated nurse’s station. The nurse on duty (LN 3) stated that during shift handoff, the pending x‑ray was discussed and that she checked the electronic record and fax machine around 8 PM but did not see results at that time. LN 3 did not check again for the remainder of the shift and did not call the x‑ray company to verify when results would be available. At approximately 1 AM, another nurse brought the faxed x‑ray report to LN 3, confirming the abnormal findings. Upon receiving the abnormal STAT x‑ray results, LN 3 notified the resident’s physician by text message at 1:40 AM and sent a picture of the report but did not make any additional attempts to contact the physician for the rest of the shift. LN 3 acknowledged that facility procedure required immediate reporting of abnormal x‑ray results and that notification several hours after the results were available did not meet the expectation of “immediate.” LN 3 also confirmed that no follow‑up phone call was made when the physician did not respond to the text message, and there was no direct confirmation that the physician had received the results. The DON stated that the nurse who received the STAT x‑ray results should have immediately notified the physician and, if there was no response within 30 minutes, should have called again, and that the lack of timely, direct voice communication delayed the order to transfer the resident to the hospital by approximately twelve hours, placing the resident at risk for pain and complications. Facility policies titled “Guidelines for Notifying Physician of Clinical Problems,” “General Guidelines for Reporting Abnormal Test Results to Physicians,” and “Lab and Diagnostic Test Results – Clinical Protocol” required immediate notification of physicians for sudden or marked changes in condition and for new or unsuspected x‑ray findings such as fractures, with direct voice communication identified as the preferred method for results requiring immediate notification. These policies specified that immediate notification meant contacting the physician as soon as possible, especially for STAT results and problematic abnormal findings. The events described show that the facility did not follow its own policies for immediate physician notification of a STAT x‑ray result revealing a fracture and osteomyelitis, resulting in delayed communication of critical diagnostic information.
Failure to Complete Comprehensive Assessment After Abnormal X-Ray Findings
Penalty
Summary
The deficiency involves the facility’s failure to complete and document a comprehensive assessment for a resident who experienced a significant change in condition involving the left lower extremity. The resident was admitted with multiple serious diagnoses, including hemiplegia/hemiparesis after a cerebral infarction affecting the left side, a stage 4 pressure ulcer of the left ankle, type 2 diabetes mellitus, peripheral vascular disease, and anemia. The resident’s BIMS score indicated moderate cognitive impairment. On the morning of 2/8/26, a CNA notified nursing staff that the resident’s left foot appeared twisted. A nurse’s note documented that the left foot was in a twisted position, with a stage 4 wound, purple skin color, and skin cold to touch. A physician was contacted and a STAT x-ray of the left ankle, foot, and knee was ordered and carried out. Later that day, radiology results were reported to the facility, indicating a fracture and acute osteomyelitis of the distal lower leg. The clinical record shows that the physician was notified of the abnormal x-ray results in the early morning hours of 2/9/26. However, there is no documentation that the resident’s left leg and foot were reassessed for changes in condition or for pain after the initial assessment at approximately 11:00 AM on 2/8/26 and before or after the physician was notified of the x-ray findings. During interview, the nurse who received the handoff report acknowledged that although she and another nurse viewed the resident’s foot, she did not complete a comprehensive assessment at that time. The DON’s review of the x-ray results and nursing progress notes confirmed that the assigned RN should have completed and documented a comprehensive assessment using the SBAR Communication Form in response to the significant change in the resident’s condition. The DON stated that the assessment should have included a detailed description of the leg and foot, circulation status, presence of bleeding, necrosis, or further twisting, and whether the resident expressed pain or discomfort. The facility’s policy on change in a resident’s condition requires nurses to make detailed observations and gather relevant information, prompted by the Interact SBAR form, prior to notifying the physician. Job descriptions for LVNs, RNs, and the Nursing Supervisor also require assessment and observation of residents with changes in condition. Despite these requirements, a comprehensive reassessment was not completed or documented around the time the abnormal x-ray results were obtained and communicated, constituting the cited deficiency.
Failure to Recognize and Address Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for a resident who experienced a significant, unrecognized weight loss. The resident, admitted with multiple diagnoses including colon cancer, dehydration, post-surgical aftercare, anemia, vitamin D deficiency, and muscle weakness, lost 21.4 pounds (15.7% of body weight) over a 10-day period, and a total of 31.8 pounds (23.3% of body weight) over five weeks. This weight loss was not identified, addressed, or reported to the physician in a timely manner, as required by facility policy. Observations and interviews revealed that the Restorative Nursing Assistant (RNA) was responsible for weighing residents and documenting the results, with the expectation to notify the DON or ADON of any weight change of 3 pounds or more. However, the RNA did not recall notifying anyone about the resident's severe weight loss. Licensed nursing staff and the DON confirmed that there was no documentation of physician notification or change of condition related to the weight loss during the critical period. The resident was not weighed weekly as required, and the significant weight loss was not recognized until more than four weeks after it occurred. Further review with the Registered Dietician (RD) and Medical Director (MD) confirmed that the resident met the criteria for severe weight loss, but interventions were not implemented until more than a month after the initial documented loss. The facility's own policies required prompt notification of significant changes in condition and unplanned weight loss, but these procedures were not followed. The delay in recognition and intervention was attributed in part to staff transitions, including changes in DON and RD positions during the period in question.
Failure to Process Psychiatric Referral for Resident with Depression
Penalty
Summary
A deficiency occurred when the facility failed to ensure the psychosocial well-being of a resident by not processing a psychiatric referral in a timely manner. The resident, who had a history of hemiplegia, hemiparesis following a stroke, malignant neoplasm of the colon, and recent colon surgery, was admitted with significant medical and emotional needs. An order for a psychiatric referral was entered by a Nurse Practitioner after the resident was observed with tears in her eyes and refusing therapy. However, the Social Services Department did not process this referral as required, and the resident did not receive the intended psychiatric evaluation. During interviews, the resident expressed feelings of sadness, loneliness, and depression related to her medical condition and stay at the facility, stating she had not been offered counseling or therapy. The Social Services Director confirmed that the referral process was not completed, and the DON acknowledged the importance of timely referrals for residents' mental health. The Nurse Practitioner who ordered the referral was unaware it had not been completed, and facility policy required social services to coordinate and document such referrals in collaboration with nursing staff.
Failure to Ensure Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
A deficiency occurred when a resident with diagnoses including anxiety disorder and depression was prescribed lorazepam, an anti-anxiety medication, on an as-needed basis without the required 14-day stop date or a documented rationale from the physician for omitting the stop date. The medication order, signed by the physician, instructed administration of lorazepam 0.5 mg every 6 hours as needed for anxiety or restlessness. Facility staff, including a licensed nurse and the Assistant Director of Nursing, confirmed that as-needed psychotropic medications are expected to have a 14-day stop date to ensure periodic evaluation of the medication's necessity and safety. However, the order for lorazepam did not include this stop date, and there was no documentation from the physician explaining the omission. Record review showed that the resident received lorazepam on three consecutive days without a stop date in place. The Minimum Data Set Coordinator and the facility pharmacist both confirmed that as-needed anti-anxiety medications require a specified duration or stop date to prompt re-evaluation before continuation. The facility's policy also states that PRN psychotropic drug orders, except for antipsychotics, are limited to 14 days unless the attending physician documents a rationale and indicates a duration for the order. In this case, the required documentation and stop date were missing, resulting in the administration of lorazepam without proper oversight.
Failure to Accurately Complete PASRR Screening for Resident with Intellectual Disability
Penalty
Summary
The facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for one resident who had documented diagnoses of mild intellectual disabilities and cerebral palsy. Upon review, the PASRR Level I screening did not indicate the presence or suspicion of intellectual or developmental disability or related conditions, despite these diagnoses being present in the resident's admission record. The Minimum Data Set Coordinator (MDSC) confirmed that the PASRR did not match the resident's diagnoses and stated that, had the intellectual disability been identified, it would have triggered a Level II evaluation. The PASRR was completed at the facility but was never reviewed for accuracy. Interviews with facility staff, including the MDSC and Assistant Director of Nursing (ADON), revealed that staff were expected to review completed PASRRs for accuracy, but this was not done in this case. The facility's policy required all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and to refer individuals for Level II evaluation if indicated. The failure to accurately complete and review the PASRR resulted in the resident not being properly evaluated for specialized services as required by policy.
Failure to Provide Scheduled Psychotherapy and Timely Follow-Up
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with adjustment disorder with depressed mood and anxiety disorder. The resident had a physician's order for psychotherapy sessions twice a week, as documented in the psychologist's progress notes and the doctor's order summary. However, both scheduled psychotherapy sessions during a specific week were missed, with no documentation indicating that services were provided or that alternative interventions were implemented. Licensed nursing staff confirmed the missed visits and acknowledged the absence of follow-up or backup plans. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that the process for handling missed psychotherapy appointments required communication and timely follow-up, which did not occur in this instance. The Social Services Department was responsible for managing psychology referrals and appointments, and staff were expected to notify appropriate personnel if a visit was missed. Despite these expectations, there was no evidence that the missed psychotherapy sessions were addressed, placing the resident at risk for negative psychosocial outcomes.
Failure to Provide Mechanical Lift Sling Prevents Resident Participation in Activities
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident who required a mechanical lift and sling for transfers, as documented in her care plan due to an ADL self-care deficit. On multiple occasions, the resident was unable to attend morning activities of her choice because the facility did not have a mechanical lift sling available. Documentation showed that transfers out of bed occurred at irregular times, often after scheduled activities, and staff interviews confirmed that a lack of available slings and uncharged lift batteries delayed care. On one occasion, the resident had to use a shower sling, which caused skin irritation, due to the shortage of regular slings. Interviews with staff and the resident confirmed that the absence of appropriate equipment directly prevented the resident from participating in preferred activities. The DON acknowledged that the facility should have the necessary equipment to meet the resident's needs and that missing activities could negatively affect the resident's psychosocial well-being. Facility policies reviewed emphasized the importance of resident autonomy, participation in activities, and dignity, all of which were not upheld in this instance due to the equipment shortage.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported to the Department in a timely manner. A resident with a diagnosis of bipolar disorder and intact cognitive function alleged that a certified nursing assistant (CNA) forcefully grabbed her legs, causing pain and bruising. The incident was initially reported by the resident to licensed nurses, who assessed her but did not observe visible marks and failed to document or report the allegation as required. Both nurses later acknowledged that they should have documented and reported the incident for the safety of the resident and others. The incident occurred on a Saturday evening, but the administrator did not become aware of the allegation until five days later, resulting in a delayed report to the Department. Interviews confirmed that two licensed nurses and the CNA involved were aware of the resident's allegations on the day of the incident, but no immediate action was taken to notify the administration or authorities. Facility policy required immediate reporting of suspected abuse within two hours, but this protocol was not followed, leading to a delay in the investigation process and a failure to protect the resident and others from potential harm.
Failure to Notify Responsible Party of Abuse Allegation
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's allegation of abuse. The resident, who had a diagnosis of schizophrenia, reported to staff that she had been hit on the head by a tall man with a stick during the early morning hours. This allegation was documented in the resident's progress notes, and the care plan was updated to address a potential psychosocial well-being problem related to the claim. The care plan included an intervention to increase communication between the resident, family, and caregivers. During an interview and record review with the Director of Nursing (DON), it was confirmed that there was no documentation indicating the RP had been informed of the abuse allegation. The DON acknowledged that the RP should have been notified and kept updated about the resident's situation. Facility policy requires that all reports of resident abuse be reported and that the resident's representative be notified immediately upon conclusion of the investigation, but this was not done in this case.
Failure to Implement and Document Required Alert Charting After Incidents
Penalty
Summary
The facility failed to implement care plan interventions for two residents following incidents that required monitoring for potential psychosocial effects. One resident, admitted with schizophrenia, reported being hit on the head and claimed to have lumps and bumps. The care plan for this resident included alert charting for 72 hours to monitor for possible psychosocial effects of the reported incident. However, documentation confirmed that alert charting was not completed by licensed nurses on two subsequent days as required. Another resident was involved in a verbal altercation with a peer, after which staff were instructed to monitor both individuals for behavioral changes. The care plan for this resident also required alert charting for 72 hours to assess for any adverse psychosocial effects. Record review and staff interviews confirmed that no alert charting was completed for this resident during the specified period. Facility policy mandates documentation of such incidents and subsequent care every shift for at least 72 hours, which was not followed in these cases.
Failure to Maintain Homelike Environment Due to Resident's Disruptive Behavior
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents who were negatively affected by the disruptive behavior of another resident diagnosed with bipolar disorder. Both affected residents, who had diagnoses including depression, requested that their room doors be kept closed due to the noise and verbal aggression occurring in the hallway outside their rooms. One of these residents also avoided participating in activities because the disruptive resident was present, yelling and cussing at others in the activities room. Multiple staff members, including CNAs and licensed nurses, confirmed that the disruptive resident frequently yelled and used profanities toward other residents, causing discomfort and distress among those exposed to the behavior. Review of the disruptive resident's care plan and progress notes revealed a history of sudden and abrupt episodes of verbal and physical aggression without warning, with documented incidents of yelling at both staff and residents. Staff interviews indicated that the behavior was ongoing and had a negative impact on the environment, with staff expressing concern and empathy for the affected residents. The facility's policy on maintaining a homelike environment emphasized the importance of comfortable sound levels, which was not upheld in this situation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Provide Scheduled Showers and Honor Resident Preferences
Penalty
Summary
A deficiency occurred when a resident was not provided with routine showers as scheduled, despite being cognitively intact and having a care plan that required assistance with bathing and shower transfers. The resident was scheduled to receive showers twice weekly, but documentation and interviews confirmed that showers were not provided on multiple scheduled dates. Instead, the resident resorted to using disposable wipes for personal hygiene, as staff did not offer showers outside of the assigned days and there was no documentation of refusal by the resident. Further investigation revealed that the resident preferred a female CNA to assist with showers and would decline when a male CNA offered assistance. This preference was reported to the licensed nurse several times, but the care plan was not updated to reflect the resident's needs or preferences. The facility's own policies and job descriptions emphasized the importance of honoring resident choices and promoting dignity, but these were not followed in this case, resulting in the resident's care needs not being met and causing distress.
Failure to Maintain Sanitary Shared Bathroom Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and sanitary environment for two residents who shared a bathroom. During an observation, a clump of brown bowel movement was found smeared on the toilet seat in the shared bathroom. The housekeeper assigned to clean the area confirmed that she had cleaned one of the resident's rooms earlier in her shift but had not yet cleaned the bathroom, stating she planned to do so later. At the time of the interview, the toilet remained soiled with both smeared feces and urine in the bowl. The Director of Staff Development acknowledged that the toilet should not have been left in such a condition and emphasized that it should have been cleaned to prevent injury or transmission of infection. Facility policies reviewed indicated that residents are to be provided with a safe, clean, and homelike environment, and that infection control practices are intended to maintain a sanitary environment and prevent disease transmission. The failure to promptly clean the soiled toilet created an unsanitary environment for the residents using the shared bathroom.
Unsafe Storage of Equipment in Resident Room Creates Fall Hazard
Penalty
Summary
The facility failed to provide a safe and hazard-free environment for one of three sampled residents when multiple items, including three standard wheelchairs, a high back wheelchair, an overbed table, and a reclining medical chair, were stored in the resident's bedroom. These items were placed on the side of the room closest to the door, while the resident's bed and personal belongings were on the opposite side. The resident reported that the items had been in the room for several days to clear the hallway. The resident involved had a history of repeated falls and was identified in the care plan as being at risk for falls due to poor safety awareness, with fall risk precautions indicated. During an interview, the Director of Staff Development confirmed that the items should not have been stored in the resident's room and acknowledged that their presence could create a trip or fall hazard. Facility policies reviewed emphasized the importance of maintaining a safe, clean, and homelike environment, free from accident hazards.
Inadequate Infection Control Practices in Shared Bathrooms
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for its 91 residents. During multiple observations of shared bathrooms, various personal care items such as urinals, wash basins, kidney basins, toothbrushes, and bedpans were found unlabeled and stored in unsanitary conditions. These items were often placed on the floor or on top of paper towel dispensers, increasing the risk of cross-contamination among residents. Certified Nurses Assistants (CNAs) confirmed that the items were not labeled and acknowledged the risk of cross-contamination due to improper labeling and storage. Interviews with the Infection Preventionist (IP), Director of Nursing (DON), and Administrator (ADM) revealed that the facility's process required staff to label personal care items with the resident's room number, first name, and last initial before use. After use, items were to be cleaned, dried, and stored in a bag in the resident's personal area, not in shared bathroom spaces. The IP, DON, and ADM all expressed that the condition of the bathrooms and the improper handling of personal care items did not meet the facility's expectations and posed a significant infection control risk.
Failure to Arrange Follow-Up Care Leads to Resident's Amputation
Penalty
Summary
The facility failed to provide necessary follow-up care for a resident who was discharged from the hospital with specific instructions for follow-up with a podiatrist and interventional radiology within 1-2 weeks. Despite these clear instructions, the facility did not arrange for these appointments, which were crucial for the resident's ongoing care following a partial amputation of the right foot due to gangrene. The resident's medical records indicated a lack of documentation regarding the condition of the surgical wound upon admission to the facility, and there was no evidence that the facility consulted with the physician about the removal of the surgical sutures. Additionally, the facility did not act on a recommendation from the wound care physician for a surgical evaluation of the resident's right foot. The wound care physician noted the need for a surgical examination for revision of the right TMA stump, but this recommendation was not communicated to the resident's primary physician or nurse practitioner. The facility's staff, including the Assistant Director of Nurses and the Social Services Director, acknowledged that the necessary follow-up appointments were not scheduled, and the resident was discharged without these critical consultations being arranged. The failure to ensure proper follow-up care and communication among the facility's staff and external healthcare providers may have contributed to the resident's wound infection and subsequent amputation of the right leg below the knee. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's follow-up needs, highlighting deficiencies in the facility's processes for managing and coordinating care for residents with complex medical needs.
Infection Control Breach Due to Improper Dressing Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control standards for nine residents when a Certified Nursing Assistant (CNA) wore a loosened gauze dressing on her right hand. The CNA had burned her hand at home and chose to cover it with a dressing rather than call in sick. During her shift, she washed her hands with the dressing on and changed it three times, which was observed to be dislodged near the thumb and top of the hand. This action posed a risk of spreading infection to the residents under her care and potentially to others she assisted. The Director of Staff Development (DSD) confirmed that the dressing was only partially covered with an occlusive dressing and was peeling away, which was against the facility's infection control policies. The facility's policy emphasized hand hygiene as the primary means to prevent infection spread, requiring all personnel to follow handwashing procedures. The Administrator also acknowledged that the CNA should have changed the dressing every time she washed her hands to prevent the risk of infection spread.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for three residents receiving oxygen therapy. Resident 53 was observed receiving oxygen therapy without a physician's order, which is necessary to determine the correct flow rate and monitor oxygen saturation levels. The Licensed Nurse confirmed the absence of an order and was unsure why the resident was receiving oxygen therapy. The Director of Nursing stated that a physician's order is expected for oxygen administration. Additionally, both Resident 53 and Resident 90 did not have care plans developed for their oxygen use. Resident 53's care plan was missing, which should have informed staff of the need for oxygen therapy. Similarly, Resident 90, who was diagnosed with chronic obstructive pulmonary disease, was observed using oxygen without a corresponding care plan. The Director of Nursing and the Director of Staff Development emphasized the importance of care plans to ensure staff are aware of and can meet the residents' needs. Resident 30's nasal cannula was found to be expired, and the oxygen humidifier bottle was not labeled with a change date. The Licensed Nurse confirmed that the nasal cannula was nine days old, exceeding the recommended seven-day change interval, which poses a risk of infection. The Director of Nursing and the Infection Preventionist both stated that oxygen tubing and humidification water should be changed weekly to prevent infection and ensure proper function.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure safe medication storage practices in two out of four medication carts and two medication storage rooms. Observations revealed expired, unlabeled, and undated prescription medications in the active storage areas of medication cart 2, including vials of Atropine Sulfate and Latanoprost Ophthalmic Solutions. Medication cart 4 contained an undated foil package of Ipratropium Bromide and Albuterol Sulfate inhalation solution. Additionally, the Station 1 medication room had an undated open foil package of Albuterol Sulfate Inhalation Solution, and the Station 2 medication room contained a vial of liquid Lorazepam belonging to a discharged resident. Over-the-counter liquid medications with dry, crusty debris were also found in medication carts 2 and 4. Licensed nurses confirmed that medications should be labeled, dated when opened, and disposed of after a specified period. The Director of Nursing stated that medications should be pulled for destruction when expired, undated, unlabeled, or belonging to discharged residents. The facility's policy indicated that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary manner, and that the dispensing pharmacy should be contacted for instructions regarding the return or destruction of discontinued, outdated, or improperly labeled medications.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure safe food production in accordance with professional standards for food safety, affecting 91 residents who received facility-prepared meals. During an inspection, it was observed that opened food packages and containers were not labeled with an open date. Specific instances included unlabeled containers of ground mustard, rubbed sage spice, baking powder, parsley flakes, oregano leaves, cream of wheat dry cereal, and a bin containing a white substance. The facility's policy required all food items to be labeled and dated, but this was not adhered to. Additionally, the facility did not remove spoiled and expired food products. An opened container of Italian seasoning was found to be expired, a red onion with mold growth was noted, and loaves of bread were expired. In the walk-in refrigerator, a flat of eggs contained a cracked egg. These observations were contrary to the facility's policy, which required produce to be fresh and free of spoilage, and bread to be used in the order delivered to ensure freshness. The facility also failed to maintain cleanliness of kitchen equipment and food contact surfaces. A can opener had a dried grayish substance on the blade, and the walk-in refrigerator had rust and substances on the walls. The oven had black, grimy build-up, and a metal strainer had a dried brownish substance. Other equipment, such as a toaster oven, commercial mixer, muffin tin, and metal rack, were also found with various residues. Furthermore, a partially consumed bottle of drinking water was found on a shelf with food items in the dry food storage area, which was against the FDA Food Code that requires designated areas for employee consumption to prevent contamination.
Failure to Provide Communication and Entertainment Alternatives
Penalty
Summary
The facility failed to provide a resident with alternative methods of communication and entertainment, despite the resident's physical limitations that prevented the use of a cell phone or tablet device. The resident, who was readmitted to the facility with spastic diplegic cerebral palsy and adjustment disorder with mixed anxiety and depressed mood, was provided with a device by their family to receive phone calls and listen to music. However, the facility repeatedly unplugged the device, citing concerns about it bothering the roommate and the potential for the family to overhear the roommate's conversations. Interviews with staff and family members revealed that the resident enjoyed listening to music and white noise, which helped them relax and feel less lonely. Despite this, the staff were instructed to unplug the device, and no alternative was provided. The facility's policies on personal property and creating a homelike environment emphasize the importance of allowing residents to use personal belongings to maintain comfort and independence, yet these policies were not adhered to in this case.
Resident's Call Light Inaccessible, Risking Unmet Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident when the resident's call light was not within reach, placing the resident at risk of falls and unmet care needs. The resident, who was readmitted to the facility with spastic diplegic cerebral palsy and adjustment disorder with mixed anxiety and depressed mood, was observed with contractures of both arms and hands, which were held against her chest. During an observation, the resident attempted to reach her call light but was unable to extend her arms enough to access it. The resident stated that if she could not reach the call light, she would yell for help. A licensed nurse confirmed that the resident was unable to reach her call light and stated that it should be within reach. The resident's care plan indicated that the resident was at risk for falls and required the call light to be within reach to request assistance. The Director of Nursing stated that it was her expectation that residents' call lights would be in reach at all times. A review of the facility's policy on answering call lights indicated that the call light should be accessible to the resident when in bed and that the resident call system should be answered immediately.
Improper Use of Geri Chair as Restraint
Penalty
Summary
The facility failed to ensure that Resident 19 was free from the use of physical restraints. Resident 19, who was admitted in 2023 with a history of falling, fractures, and altered mental status, was observed on multiple occasions sitting in a Geri chair that was reclined with the footrest elevated. This positioning prevented Resident 19 from freely getting out of the chair, effectively acting as a restraint. The Director of Staff Development (DSD) confirmed that the Geri chair should be upright with the footrest down when the resident is awake to avoid it being considered a restraint. Observations and interviews revealed that Resident 19 was awake and attempting to get out of the Geri chair, which was reclined and had the footrest elevated. The Director of Nursing (DON) stated that the expectation was for the footrest to be down to allow residents to get in and out of the chair easily. The facility's policy on the use of restraints indicated that restraints should only be used to treat medical symptoms and not for staff convenience or fall prevention. The policy also defined physical restraints as any device that restricts freedom of movement, which includes Geri chairs that residents cannot remove themselves.
Failure to Develop Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement resident-specific care plans for three residents, leading to potential unmet care needs. Resident 32, who was admitted with end-stage renal disease and dependent on dialysis, did not have a care plan addressing her dialysis treatment. Despite receiving dialysis three times a week, there was no documented care plan to guide staff in meeting her dialysis needs, as confirmed by a licensed nurse. This oversight was contrary to the facility's policy, which mandates a comprehensive care plan for residents with end-stage renal disease. Resident 197, admitted with chronic pain syndrome and a splint on her left arm, also lacked a care plan for her splint care. The Director of Nursing confirmed the absence of a care plan, which should have included interventions for monitoring the splint and preventing skin problems. The facility's policy requires regular review and management of splints as part of the resident's care plan, which was not adhered to in this case. Resident 46, involved in an altercation with another resident, did not have a behavioral care plan addressing her conflict with Resident 23. Despite multiple incidents and ongoing tension between the two residents, there was no care plan to guide staff in managing these behaviors. The Social Services Director and the Director of Nursing acknowledged the lack of a behavioral care plan, which was necessary to prevent escalation and ensure appropriate interventions were in place. This was in violation of the facility's policy on resident-to-resident altercations, which requires care plan updates following such incidents.
Failure to Update Care Plans for Residents with Changing Conditions
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for two residents, leading to potential inadequacies in their care. Resident 83 experienced a change in condition due to the development of multiple skin wounds or ulcers, as documented in the SBAR Summary for Providers Record. Despite the physician being notified and a wound care consult being ordered, the Director of Nursing (DON) acknowledged that no care plan was initiated for this change in condition. The facility's policy requires care plans to be updated with any significant change in a resident's condition, which was not adhered to in this case. Resident 71's care plan was also not updated in a timely manner regarding her smoking habits. Initially admitted with chronic obstructive pulmonary disease and centrilobular emphysema, Resident 71's smoking care plan was not revised to reflect her switch from tobacco to vape products until much later. The Activity Director (AD) admitted to not updating the care plan when Resident 71 began vaping, which led to confusion among staff about her smoking privileges and preferences. The Director of Staff Development (DSD) and Licensed Nurse (LN) 8 emphasized the importance of having updated smoking care plans to ensure staff are aware of residents' smoking preferences and necessary precautions. The facility's policy mandates that comprehensive, person-centered care plans be developed within seven days of a significant change in status and be revised as residents' conditions change. The failure to update the care plans for Residents 83 and 71 as required by the facility's policy and procedure potentially compromised their care and well-being, as staff may not have been aware of the necessary interventions or changes in their conditions.
Failure to Execute Orthopedic Referral for Resident
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as Resident 197, who was admitted with a splint on her left arm due to an injury. Despite a referral from the facility's Medical Director to see an orthopedist for persistent pain, the resident had not been seen by a specialist for six months. The resident's clinical records indicated a history of chronic pain syndrome and a previous injury requiring a splint, with multiple orders and notes confirming the need for an orthopedic consultation. However, the referral was not executed, and the resident continued to wear the same splint since admission. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that the referral was not carried out due to transportation issues, as the resident's wheelchair exceeded transport capacity, and the clinic could not accommodate her in a gurney. The splint was observed to have brown spots and a foul odor, indicating potential skin issues. The Medical Director confirmed the need for the referral and suggested that the resident should have been sent to the ER if transportation to the orthopedic clinic was not feasible. The facility's job description for Licensed Vocational Nurses emphasized the importance of following physician orders and meeting residents' individualized care needs.
Failure to Provide Vision Care for Resident
Penalty
Summary
The facility failed to provide necessary vision care for a resident who complained of worsening eyesight and requested to see an ophthalmologist. Despite the resident's repeated requests and the presence of a care plan intervention indicating the need for an ophthalmology referral, the facility did not assist in scheduling the required appointment. The resident, who had been admitted in 2022 with diagnoses including palliative care, history of falling, major depressive disorder, and anxiety disorder, expressed concerns about her vision deteriorating and reported specific symptoms such as her right eye fading to black and experiencing lightening flicks. The Social Services Director (SSD) acknowledged the responsibility for arranging ancillary care, including vision appointments, and confirmed that an appointment should have been made shortly after the care plan was created. However, there was no documentation in the resident's clinical record regarding her vision concerns or any follow-up appointments. The Director of Nursing (DON) also confirmed the lack of documentation and emphasized the risk of continued vision decline, which could affect the resident's mobility and increase the risk of falls. The facility's policy on visually impaired residents highlighted the responsibility to assist with scheduling appointments and arranging transportation, which was not fulfilled in this case.
Failure to Follow Heel Protector Order for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident received consistent treatment to promote the healing and prevention of pressure ulcers. The resident, who was admitted with diagnoses including pressure ulcers to the sacral region and left heel, had a physician's order for heel protectors to be worn on both feet every shift for pressure ulcer prevention. However, during observations and interviews, it was confirmed that the resident's feet and heels were bare and without protection, indicating that the treatment order was not followed. The Director of Staff Development and the Director of Nursing both acknowledged that the treatment order for heel protectors was not adhered to. The facility's policy and procedure for wound care, which includes applying treatments as indicated and using supportive devices as instructed, was not followed in this case. This oversight placed the resident at risk for worsening their current pressure ulcer and increased the chance for the development of new pressure ulcers.
Failure to Implement Restorative Services and Care Plan for Resident with Quadriplegia
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest level of range of motion (ROM) for a resident diagnosed with quadriplegia. The resident, identified as Resident 74, had an order for Restorative Nurse Assistant (RNA) services, which included donning and doffing bilateral orthotics and performing passive range of motion (PROM) exercises. However, these services were not implemented, as confirmed by the RNA staff who were unaware of the resident's needs. The Occupational Therapy Director also did not know what happened to the referral for the resident, and the Certified Nurse Assistants (CNA) and Licensed Nurse (LN) caring for the resident were not informed about the hand splints or the need for ROM exercises. Additionally, the facility did not develop a care plan for Resident 74's arm and hand contractures, which are conditions that could lead to deformity and rigidity of joints. The Medical Records staff confirmed the absence of a care plan, and the Director of Nursing (DON) acknowledged that a care plan was necessary to communicate the resident's care needs and ensure staff awareness. The lack of a care plan and the failure to implement RNA services placed Resident 74 at risk of a decline in ROM and worsening contractures.
Failure to Implement Fall Precautions for High-Risk Resident
Penalty
Summary
The facility failed to ensure appropriate fall precaution measures were in place for one resident, identified as Resident 12, who was at high risk for falls. During an observation, it was noted that Resident 12's bedside table was out of reach, and two fall mats intended to cushion falls were not properly positioned next to the resident's bed. One mat was found folded against the wall, and the other was under the bed. A Certified Nurse Assistant (CNA) confirmed that the fall mats were sometimes moved during feeding assistance and should have been placed back correctly. The CNA also noted that the resident might attempt to reach the table and fall, indicating a lack of adequate supervision and safety measures. Interviews with nursing staff revealed that Resident 12 was at risk for falls and should have had fall mats and padded side rails due to a risk of seizures. However, the need for fall mats was not documented in the resident's care plan or medical record, which was confirmed by a Licensed Nurse (LN) and the Director of Nurses (DON). The DON acknowledged that the resident's fall risk evaluation indicated a high fall risk, yet the care plan did not include fall mats as an intervention. This oversight in care planning and staff education contributed to the deficiency, as the necessary interventions to prevent falls were not implemented or communicated effectively.
Failure to Obtain Physician's Order for Indwelling Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling foley catheter for a resident who was admitted with diagnoses including urinary tract infection, acute kidney failure, and urine retention. The resident's care plan indicated the presence of an indwelling catheter and the need for regular catheter care and monitoring for signs of infection. However, the resident's nurses' weekly summaries did not reflect the presence of a catheter, and there was no physician order documented in the clinical record for its use. During interviews, both the Assistant Director of Nurses and the Director of Nursing confirmed the absence of a physician's order for the catheter, which is necessary to ensure proper care and monitoring by the nursing staff. The lack of an order meant that the staff was not adequately informed about the resident's catheter care needs, including monitoring for urine characteristics and signs of infection. This oversight placed the resident at risk for catheter-associated urinary tract infections and other complications.
Deficiency in IV Therapy Administration
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) therapy for a resident, identified as Resident 297, who was receiving treatment for a methicillin-resistant Staphylococcus aureus (MRSA) infection. During an observation, it was noted that the IV tubing connected to Resident 297's access site was lying on the floor, and the IV infusion bag was not labeled with the date, time, or initials of the staff who administered the medication. The Assistant Director of Nurses (ADON) confirmed these observations and acknowledged the importance of labeling the IV bag to track administration details and prevent expiration. The ADON also recognized the risk of infection and potential physical hazards posed by the tubing lying on the floor. The Director of Nursing (DON) stated that it was her expectation for IV infusion bags to be properly labeled and for IV tubing to be kept off the floor to prevent infection. The facility's policies and procedures, including those on preventing intravenous catheter-related infections and ensuring resident safety, were reviewed and indicated the importance of maintaining a safe environment and adhering to current standards of care. However, these standards were not met in the case of Resident 297, leading to a deficiency in the administration of IV therapy.
Unlabeled Urinal Poses Infection Risk
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures when a resident's urinal was found unlabeled. This incident involved a resident who was admitted with multiple diagnoses, including end-stage renal disease, dependence on renal dialysis, and anemia in chronic kidney disease. During an observation, the resident was seen resting in bed with an unlabeled urinal on the bedside table. Both a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN) confirmed the presence of the unlabeled urinal and acknowledged that urinals should be labeled to prevent confusion and potential misuse by other residents. The Infection Preventionist (IP) and the Director of Nursing (DON) both stated that urinals should be labeled with at least the resident's room number, last name, or initials to prevent mix-ups that could lead to infections. The facility's policy on infection control, dated October 2018, emphasized maintaining a safe and sanitary environment, which was not adhered to in this instance. The failure to label the urinal posed a risk of infection spread if it were used by another resident.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident 33, from physical abuse by another resident, identified as Resident 20. On August 3, 2024, Resident 20 pinched and hit Resident 33, an incident witnessed by CNA 7. Resident 33, who has severe cognitive impairment due to Alzheimer's Disease, was assaulted in a common area known as the Circle. Resident 20, who also has severe cognitive impairment and a history of physical aggression, was not adequately monitored despite existing care plans and interdisciplinary team notes indicating the need for close supervision due to her aggressive behavior. The incident occurred while CNA 7 was attending to another resident, and the licensed nurse was at the nurses' station, indicating a lapse in supervision. The Director of Nursing acknowledged that the interventions to monitor Resident 20's whereabouts were not followed as expected. The facility's policies on resident rights, resident-to-resident altercations, and abuse prevention emphasize the need to protect residents from abuse, yet these policies were not effectively implemented in this case, leading to the deficiency.
Resident Fall Due to Improper Transport Procedure
Penalty
Summary
The facility failed to provide a safe environment for a resident when a blanket became caught in the wheel of a shower chair during transport, causing the chair to stop abruptly and tip forward. This incident resulted in the resident falling and sustaining a fracture to her left medial malleolus and left fibula, leading to increased pain and decreased mobility. The resident was admitted to the facility in 2022 with diagnoses including bilateral osteoarthritis of the knee and age-related osteoporosis, conditions that made her more vulnerable to falls and fractures. The incident occurred when a CNA was transporting the resident from the shower room to her bedroom. The CNA had placed bath blankets over the resident, and during transport, one of the blankets became entangled in the wheel of the shower chair. This caused the chair to tilt forward, and despite the CNA's attempt to catch the resident, she fell onto her knees and hands. The fall was witnessed, and the resident immediately complained of severe pain in her left knee, with a pain score of 8 out of 10. The facility's policy on safety and supervision for residents emphasizes making the environment as free from accident hazards as possible. However, the Director of Nurses confirmed that the fall was due to the blanket becoming caught in the wheel, and it was expected that staff would ensure blankets were tucked in and not hanging below the resident's knees during transport. The Medical Director acknowledged that the fall was preventable and that the initial pain management was inadequate, leading to further complications for the resident.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to ensure professional standards of practice were followed for one resident when the resident did not receive his prescribed medication, and the physician was not informed that the medication was unavailable. The resident, who had a diagnosis of epilepsy, was admitted to the facility with a care plan that included administering seizure medication as ordered by the doctor. However, the medication administration record indicated that the resident did not receive his clobazam medication for several days due to an insurance issue, and the progress notes confirmed that the medication was pending delivery. Despite this, the nursing staff did not notify the physician about the unavailability of the medication. On the fifth day without the medication, the resident experienced multiple seizures and had to be hospitalized. Interviews with the licensed nurse and the Director of Nurses confirmed that the physician was not contacted about the medication issue, which was against the facility's policy. The policy required nursing staff to notify the physician and take further steps if the medication was unavailable. The failure to follow these procedures may have contributed to the resident's increased seizure activity and subsequent hospitalization.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
