San Francisco Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Francisco, California.
- Location
- 1477 Grove Street, San Francisco, California 94117
- CMS Provider Number
- 056272
- Inspections on file
- 26
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at San Francisco Health Care during CMS and state inspections, most recent first.
The facility failed to properly inventory and safeguard residents’ belongings and money, leading to missing items and inaccurate or absent inventory records. One hospice resident arrived with personal items documented by ambulance staff, but the facility’s admission inventory listed no belongings, and her representative later reported missing identification, a cell phone, and a debit card, along with unusual financial transactions and phone use after the resident’s death. The Administrator acknowledged a $1,200 monetary transaction between this resident and a CNA for an airline ticket but did not formally document or broaden the investigation. Another cognitively impaired resident was documented by the hospital as being discharged with $3,600 and jewelry, with instructions to facility admission staff to secure these valuables, yet the social worker later concluded the facility was not responsible when the items were reported missing and the admission staff did not recall the valuables. Additional audits found clothing labeled for another person among one resident’s belongings and a resident with multiple clothing items but no inventory sheet, despite a policy requiring admission inventories and safeguarding of valuables.
The facility failed to report allegations of misappropriation of personal property for two residents to appropriate agencies within the required 24-hour timeframe. One resident’s responsible party notified the Administrator by phone and text about missing items, including a cell phone, driver’s license, and debit card, and the Administrator later acknowledged not reporting the allegation within 24 hours. Another resident reported missing a large sum of money and jewelry, and the SW was informed by the resident’s family, but a review of CDPH electronic data showed no record that this allegation was reported. These actions were inconsistent with the facility’s policy requiring the Administrator or designee to notify appropriate persons or agencies within 24 hours of reported theft or misappropriation.
Two residents’ allegations of missing money and personal property were not thoroughly investigated. One hospice resident arrived with documented belongings, including a cell phone, but the admission inventory listed no items, and her representative later reported missing identification, a debit card, and unusual financial activity involving a CNA and post‑death phone and debit card use; the Administrator acknowledged the unusual monetary transaction but did not suspend the CNA, report the allegation, expand the review to other residents, or formally document the investigation. Another cognitively impaired resident was documented by the hospital as being discharged with cash and jewelry to be secured by admission staff, yet she was considered to have arrived without belongings, and the facility’s conclusion relied heavily on her inconsistent statement about giving valuables to a man not employed there, without contacting the transport company or expanding the investigation to other residents linked to the involved admission staff, despite a written policy outlining broader investigative steps for suspected theft or misappropriation.
Two residents in a facility suffered injuries due to inadequate safety measures and supervision. One resident tripped over a fall mat placed between beds, resulting in a hip fracture, while another resident was injured due to a missing armrest padding on her wheelchair, leading to a head injury. The facility failed to document and address these hazards, as well as update care plans and communicate maintenance needs, highlighting deficiencies in safety protocols.
A resident experienced a 24.4% weight loss over six months due to inadequate nutritional support and monitoring. The facility failed to provide 1:1 meal assistance as ordered, did not offer alternatives during poor intake, and had an inadequate meal monitoring system. The resident's food preferences were not assessed, and there was no documentation of supplement intake, hindering effective nutritional intervention evaluation.
The facility failed to maintain sanitary conditions in the kitchen, with issues including a dripping icemaker spout, an unreplaced water filter, and a greasy kitchen hood. The Maintenance Manager's claim of filter replacement lacked documentation, and the facility had no policies for icemaker maintenance. These deficiencies risked foodborne illnesses.
The facility failed to properly dispose of kitchen refuse as two garbage containers in the kitchen were found without lids. This was confirmed by a Dietary Aide and acknowledged by the Registered Dietitian, who agreed that all garbage containers should have lids. The facility's policy requires food waste to be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids could lead to contamination by flying insects.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, leading to potential cross-contamination risks. A resident with a feeding tube had an unlabeled syringe, another with a urinary catheter had an uncovered drainage bag, and a third with a central venous catheter had no special precautions. Additionally, a resident with a gastrostomy tube was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room.
The facility failed to maintain an effective pest control program, as flying insects were observed in a resident's room and during an interview with another resident. Despite having a subcontracted pest control company, the presence of insects indicated a lapse in the program's effectiveness. The facility's policy required the building to be free of insects, which was not achieved.
A facility was found to have a medication error rate of 25.9% due to several issues, including a nurse administering eye drops without consulting the MAR, a resident not receiving a critical cardiac medication due to unavailability, and inadequate documentation of medication issues. These errors involved multiple residents and contributed to the high error rate observed.
A facility failed to cover a resident's urinary catheter drainage bag with a privacy bag, compromising the resident's dignity and privacy. The bag was observed hanging exposed, with a reddish-brown discoloration and was unlabeled and undated. A CNA confirmed the absence of a dignity bag, and an RN acknowledged the need for privacy coverage.
A facility failed to develop a baseline care plan within 48 hours for a resident with heart failure, kidney disease, and dependence on dialysis. The resident missed a dialysis session due to unarranged transportation, and no care plan addressed his dialysis needs or CVC care. Staff interviews revealed the baseline care plan was incomplete, with no specific deadline for completion, potentially leading to inadequate care.
A facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, leading to the resident not receiving necessary physical and occupational therapy. The resident, who was on non-weight bearing status, was not evaluated by therapists upon readmission, and the facility's records lacked orders for weight-bearing as tolerated and therapy referrals. Miscommunication and lack of documentation resulted in inadequate care and treatment.
A facility failed to develop a coordinated care plan with a Hospice agency for a resident with end-stage dementia. The resident's care plan did not specify Hospice services or communication protocols, leading to potential gaps in care. Interviews revealed that while Hospice plans were in binders, the facility's care plan lacked documentation of Hospice's role. Staff described communication processes, but the facility's policy on collaboration with Hospice was not fully implemented.
A resident who underwent hip surgery was not provided with necessary physical and occupational therapy upon readmission to the facility. Despite hospital discharge instructions for rehabilitation, there were no therapy orders or interdisciplinary team meetings to address the resident's fall and care plan. The facility's failure to adhere to its fall management protocol and lack of communication led to this deficiency.
A resident was discharged from the facility without a documented discharge basis or summary, despite having multiple health issues. The Director of Social Worker confirmed the absence of necessary documentation, which is required by facility policy and the State Operations Manual.
A facility failed to prevent a resident from having unsupervised access to smoking materials, leading to multiple incidents of the resident smoking inside the facility and in non-designated areas. Despite multiple educations and reminders, the resident continued to violate the smoking policy, and staff were inconsistent in monitoring and enforcing the policy.
The facility failed to maintain clean and homelike shower rooms, with observations revealing peeling paint, rust, water damage, and visible stains. A resident expressed dissatisfaction with the cleanliness, and staff confirmed the deteriorating conditions. Despite attempts to address the issues, the shower rooms remained in poor condition.
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other waterborne pathogens could grow and spread. Despite having policies for Legionella surveillance, no risk assessment or water-flow diagram was completed. Multiple staff members, including the ADON, Maintenance Manager, previous DON, and CEO, confirmed the lack of a risk assessment and water testing.
The facility failed to ensure comprehensive care plans reflected all care needs for several residents, including accurate hospice provider information, clothing preferences, documented behaviors, and the use of an indwelling urinary catheter. Staff acknowledged these deficiencies during interviews.
The facility failed to ensure that residents' EHRs and physical medical charts accurately reflected their treatment wishes, including CPR decisions. This deficiency was identified for three residents, with discrepancies between POLST forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences.
The facility failed to ensure personal privacy for two residents during showers. One resident was left fully unclothed with the privacy curtain and door open, while another resident's backside was exposed during transport to and from the shower room. Staff interviews confirmed that privacy protocols were not followed.
The facility failed to include a diagnosis of schizophrenia on the PASRR Level I screening for a resident admitted with schizophrenia, epilepsy, and Parkinson's disease. The omission was identified during a review of the resident's records, and staff interviews confirmed the oversight.
A facility failed to meet professional standards when an RN reused a needle to administer an intramuscular injection to a resident, contrary to facility policy and CDC guidelines. The resident had a history of acute pyelonephritis and other medical conditions.
A resident with a feeding tube did not receive appropriate treatment as staff failed to check tube placement before administering water flushes and medications, and used a syringe plunger instead of gravity flow, contrary to facility policy and physician's orders.
The facility failed to maintain a medication error rate below 5%, resulting in a 5.8% error rate. A resident with a history of diabetes, heart failure, and dysphagia received incorrect medications due to RN misreading orders and failing to locate the correct medication. The DON confirmed the expectation for correct medication administration.
A facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. An RN left a medication cart unlocked and out of sight with medications on top, violating facility policy. Interviews with the ADON and DON confirmed the expectation for nurses to lock the cart and keep keys with them at all times.
The facility failed to maintain an effective pest control program, resulting in a cockroach infestation in a resident's room. Despite efforts to address the issue, including deep cleaning and sealing entry points, the presence of food in the room exacerbated the problem, leading to ongoing pest sightings and resident complaints.
Failure to Inventory and Safeguard Residents’ Belongings and Money
Penalty
Summary
The deficiency involves the facility’s failure to properly inventory and safeguard residents’ personal belongings and money, resulting in missing property and inaccurate or absent inventory documentation. For one resident admitted under hospice care, ambulance transport records showed she arrived with a bag of supplies, a cell phone, a wheelchair, and a backpack, while the facility’s admission inventory form documented “No Belongings upon arrival” and noted that donated clothes were provided. The resident’s responsible party later reported missing items including a cell phone, driver’s license, and debit card, and described abnormal financial activity and long-distance calls from the resident’s phone and withdrawals from her debit card after the resident’s death. The responsible party stated she had shared this information with the Administrator and requested help in investigating and retrieving the missing items, but reported that the facility had not taken responsibility for safeguarding the resident’s belongings. The Administrator acknowledged awareness of the responsible party’s concerns and confirmed that the resident had transferred $1,200 to a CNA to purchase an airline ticket to Zimbabwe, which he characterized as a highly unusual interaction between a resident and staff member. He stated that he determined the money was refunded when the resident was unable to take the trip and took no further action because there was nothing in the facility’s handbook or policy specifically prohibiting this type of transaction. The Administrator did not comment when presented with ambulance documentation indicating the resident arrived with belongings that were not reflected on the admission inventory, and he stated he did not expand his review to other residents under the CNA’s care and did not formally document the allegations or his investigation beyond some emails. For another resident with a BIMs score indicating severe cognitive impairment, the hospital discharge record documented that she was to be discharged with $3,600 in U.S. currency, a yellow necklace and bracelet, and two pendants, and that hospital staff had discussed these valuables with facility admission staff, who reportedly would document and secure them for safekeeping. The social worker reported that the resident’s family later raised concerns about missing money and jewelry and that, based on the resident arriving without belongings, she concluded the facility was not responsible. She stated she was aware of the hospital documentation and had interviewed the admission staff, who did not recall the conversation or valuables, and that the resident reported giving her money and jewelry to a Vietnamese man, although no such staff member worked at the facility at that time. Additional issues were identified during an inventory audit: one resident’s belongings included a housedress labeled with another woman’s name and room number, and another resident had multiple clothing items in his room but no inventory sheet in either the electronic or physical chart. These findings occurred despite a facility policy stating that residents have the right to be free from theft or misappropriation of personal property and that resident belongings are to be inventoried upon admission and safeguarded from easy public access.
Failure to Timely Report Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report allegations of misappropriation of personal property for two residents to the appropriate agencies within 24 hours, as required by its policy. Resident 1’s responsible party reported missing items, including a cell phone, driver’s license, and debit card, and provided evidence of having texted the Administrator about these concerns on March 17, 2026. In an interview, the Administrator acknowledged being aware of the responsible party’s concerns through phone calls and text messages and agreed that March 17, 2026, sounded like the date he was first made aware of the allegations. When asked if he reported the allegation within 24 hours of learning about it, the Administrator stated that he did not. A second allegation involved Resident 2, who reported missing approximately $3,000 and some jewelry. The Complainant stated that Resident 2 made this allegation, and the SW reported being informed of the missing money and jewelry by Resident 2’s family member on March 17, 2026. A review of CDPH electronic data for facility-reported incidents between March 17 and April 21 showed no evidence that the facility reported Resident 2’s allegation to CDPH. The facility’s policy on investigating incidents of theft and/or misappropriation of resident property, revised April 2017, states that the Administrator or designee will notify appropriate persons or agencies within 24 hours of such incidents, but this was not done for either resident’s allegation.
Failure to Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond appropriately to allegations of misappropriation of personal property for two residents. For the first resident, who was admitted under hospice for comfort-focused treatment, ambulance transport documentation showed she arrived with a bag of supplies, a cell phone, a wheelchair, and a backpack, while the facility’s admission inventory documented no belongings and indicated she was given donated clothes. The resident’s responsible party reported to the Administrator that the resident’s cell phone, driver’s license, and debit card were missing, and also reported abnormal financial activity, including the resident withdrawing $1,200 to give to a CNA to purchase an airline ticket to Zimbabwe, long-distance calls made from the resident’s cell phone after her death, and withdrawals from her debit card after death. The responsible party stated she shared all this information with the Administrator and requested help in investigating and retrieving the missing items, but the facility had not taken responsibility for safeguarding the resident’s belongings. During interview, the Administrator acknowledged awareness of the responsible party’s concerns and confirmed he looked into the issue of the resident transferring money to a CNA for an airline ticket, which he recognized as a highly unusual interaction between staff and resident. He stated he determined the money was refunded when the resident did not take the trip and took no further action because there was nothing in the facility’s handbook or policy specifically prohibiting this type of interaction. The Administrator did not comment when presented with ambulance documentation showing the resident arrived with belongings that were not reflected on the admission inventory. He also stated he did not suspend the CNA, did not report the allegation to appropriate agencies, did not expand the investigation to other residents under the CNA’s care, and did not formally document the allegations or his investigation beyond some emails, despite facility policy requiring investigation of incidents of theft or misappropriation. For the second resident, who had a BIMs score of 5/15 indicating severe memory and thinking problems, the hospital discharge record documented that she was to be discharged with $3,600 in U.S. currency, a yellow necklace and bracelet, and two pendants, and that the hospital social worker had discussed these valuables with facility admission staff, who agreed to document and secure them. The facility social worker reported she became aware of missing money and jewelry when informed by the resident’s family member and concluded the facility was not responsible because the resident allegedly arrived without belongings. She interviewed the admission staff, who did not recall the phone conversation or discussion of valuables, and relied heavily on the resident’s statement, translated by the ombudsman, that she gave her money and jewelry to a Vietnamese man on arrival, despite the facility having no Vietnamese male staff at that time and the resident’s documented severe cognitive impairment. There was no evidence the facility contacted the transport company to verify what items accompanied the resident, no documented follow-up when the resident arrived without the valuables the hospital had reported, and no expansion of the investigation to review other residents’ belongings associated with the admission staff involved, contrary to the facility’s written policy on investigating theft and misappropriation.
Failure to Prevent Accidents and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for two residents. Resident 25 experienced a fall due to a fall mat placed between his bed and his roommate's bed, obstructing safe passage. This resulted in Resident 25 tripping, falling, and sustaining a right hip fracture that required surgical repair. Despite being at high risk for falls, as indicated by his care plan and assessments, there was no documentation of an interdisciplinary team meeting to assess the cause of the fall or update his care plan. Additionally, there was no order for weight-bearing as tolerated or a physical therapy referral upon his readmission to the facility. Resident 73 suffered an injury due to a missing armrest padding on her wheelchair, which was not reported or replaced. This led to her sliding her right arm on the metal part of the wheelchair, hitting her head on the window, and sustaining a large hematoma on her forehead. Despite the incident, there was no documentation of a fall in her clinical record, and the missing padding was not reported to maintenance for repair or replacement. The facility's maintenance log did not contain any reports regarding the broken wheelchair, indicating a lack of communication and follow-up on safety hazards. The facility's policies and procedures for fall prevention and maintenance were not adequately followed. The interdisciplinary team and staff failed to identify and address environmental hazards and did not document or communicate necessary interventions to prevent further accidents. The lack of proper assessment, documentation, and maintenance contributed to the injuries sustained by both residents, highlighting deficiencies in the facility's safety protocols and supervision.
Inadequate Nutritional Support and Monitoring for Resident
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for Resident 3, who experienced a significant weight loss of 24.4% over six months. The resident, who had memory problems and sometimes understood others, was not provided with the 1:1 assistance during meals as ordered by the physician. Observations revealed that staff only set up the meal tray and did not assist the resident with eating, despite the resident's poor appetite and usual intake of only 20% of meals. Additionally, the facility did not offer alternatives or other interventions during poor meal intake, as required by their policy. The facility's meal monitoring system was inadequate, as it could not distinguish between 0-25% intake, which is critical for determining when to intervene. The Director of Nursing acknowledged this shortcoming and the importance of intervening even if a resident was on comfort measures. Furthermore, the facility did not document the percentage of nutritional supplements consumed by the resident, making it difficult to evaluate the effectiveness of nutritional interventions. Despite requests for this information, it was not provided by the time of the survey exit. The facility also failed to assess Resident 3's food preferences, which could have informed better meal planning and interventions. There was no evidence that the facility reached out to the resident's responsible parties or family members to assist with this assessment. The resident's records showed that she ate 51-100% of her food for only 24% of meals, with no analysis of whether higher intakes were related to specific food preferences. For 47.1% of meals, the resident ate between 0-25%, with no assessment of whether these low intakes were related to controllable factors such as menu items or meal timing.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during an inspection. Specifically, one of the icemaker's dispensing spouts was dripping water, and the icemaker had two water filters, one of which was not replaced. The Maintenance Manager claimed both filters were changed in December 2024, but there was no documentation to support this, as only one filter was purchased according to facility records. Additionally, the bottom of the kitchen hood was covered in a greasy film, with at least 30 spots where the substance was lumped into droplets, indicating a lack of regular cleaning. During interviews, it was revealed that the facility did not have policies regarding the replacement of icemaker water filters or maintenance to address drips. The facility's existing policy on hoods, filters, and vents required cleaning every two weeks to be free of dust and grease, which was not adhered to. These deficiencies in food storage, preparation, and service practices had the potential to put residents at risk for foodborne illnesses.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of kitchen refuse, as observed during an inspection. Two garbage containers in the kitchen were found without lids, which was confirmed by a Dietary Aide during the initial observation. This deficiency was further corroborated during an interview with the Registered Dietitian, who acknowledged that all garbage containers in the kitchen should have lids. The facility's policy, dated 2023, requires that all food waste be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids on the garbage containers had the potential to result in flying insects contaminating food items, food preparation areas, and utensils.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement its infection control program by not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 62, who was admitted with multiple diagnoses including stroke and diabetes, was observed with an unlabeled and undated irrigation syringe hanging on the feeding pump pole. The registered nurse confirmed that the syringe should have been labeled and dated, and acknowledged that Resident 62 was not on any precautions. The care plan for Resident 62 did not address infection control precautions. Resident 25, who was readmitted with a fracture and neuromuscular dysfunction of the bladder, was observed with an uncovered and unlabeled urinary catheter drainage bag. The certified nursing assistant acknowledged the lack of labeling and covering, and the registered nurse stated that contact precautions were followed during dressing changes. However, the care plan did not address infection control precautions for the suprapubic catheter. Resident 204, admitted with heart failure and kidney disease, had a central venous catheter for dialysis. The registered nurse supervisor stated that no special precautions were followed for this resident, and the care plan did not address infection control precautions. Additionally, Resident 256, who had a gastrostomy tube, was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room. The infection preventionist acknowledged the lack of signage and PPE setup for residents with catheters and tube feedings.
Failure in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flying insects within the premises. During an observation and interview in a resident's room, a family member pointed out a flying insect resting on the wall. Additionally, another flying insect was observed in the presence of the Kitchen Supervisor during an interview with another resident. The Maintenance Manager confirmed that the facility had subcontracted a pest control company as part of their pest management program. However, the presence of insects indicated a lapse in the effectiveness of this program. The facility's pest control policy, last revised in May 2008, stated that the building should be kept free of insects and rodents, which was not upheld in this instance.
High Medication Error Rate Due to Documentation and Availability Issues
Penalty
Summary
The facility was found to have a medication error rate of 25.9%, with seven medication errors occurring out of 27 opportunities during medication administration for four residents. One incident involved Resident 17, where a registered nurse (RN) crushed and mixed four oral medications with applesauce for administration, which was in accordance with the pharmacy protocol. However, the report does not specify if the medications were meant to be administered together or if there was an error in the dosage or timing. Another incident involved Resident 256, who has a gastrostomy tube and requires medications to be crushed and administered via the tube. The RN prepared six tablets, crushed them, and mixed them with water for administration through the gastrostomy tube. The RN noted that it takes time to dilute the tablets and sometimes requires additional effort, but the report does not indicate any specific error in this process. For Resident 63, the RN administered eye drops without consulting the medication administration record (MAR) due to a system outage, resulting in a deviation from the prescribed order of two drops in the left eye every four hours. Additionally, Resident 72 did not receive a critical cardiac medication, Vyndaquel, due to unavailability, and there was a lack of documentation regarding the medication's absence and the physician's notification. This oversight in documentation and medication availability contributed to the high medication error rate observed during the survey.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure the urinary catheter drainage bag of Resident 25 was covered with a privacy bag, which is necessary to maintain the resident's dignity and privacy. During an initial tour, the drainage bag was observed hanging on the side rail of the bed, partially filled and exposed, with a reddish-brown discoloration on the front of the bag and in the attached tube. The bag was also unlabeled and undated. A Certified Nursing Assistant (CNA) confirmed the absence of a dignity bag and acknowledged the lack of labeling and dating. A Registered Nurse (RN) later stated that the drainage bag should have been covered for privacy, indicating a lapse in maintaining the resident's right to a dignified existence and self-determination.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as Resident 204, who was admitted with multiple diagnoses including heart failure, acquired absence of the left leg below the knee, kidney disease, and dependence on renal dialysis. Upon review, it was found that Resident 204's care plan did not address his dialysis needs or the care of his central venous catheter (CVC), which is crucial for his dialysis treatment. Interviews with the resident and staff revealed that the resident missed a dialysis session due to a lack of arranged transportation, and no special precautions were being followed for his CVC care. Further investigation showed that the baseline care plan for Resident 204 had not been completed, contrary to the facility's practice of completing it within three days of admission. The Registered Nurse Supervisor confirmed that there was no dialysis care plan in place and that the nursing section of the care plan was incomplete. The supervisor also mentioned that there was no specific deadline for completing the baseline care plan, indicating a lack of urgency in addressing the resident's immediate care needs. This oversight had the potential to result in inadequate care and services for the resident.
Failure to Develop Comprehensive Care Plan for Resident with Hip Fracture
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, resulting in the resident not receiving necessary care and treatment such as physical and occupational therapy. The resident, who had a history of falls and was readmitted to the facility after hip surgery, was not evaluated by a physical therapist or occupational therapist upon his return. The resident reported being on non-weight bearing status and had not been out of bed since readmission. The facility's records did not include an order for weight-bearing as tolerated (WBAT) or a referral for physical therapy, and there was no documentation of an interdisciplinary team meeting to discuss the fall and update the care plan. The resident's care plan was outdated and did not reflect the recent fall and fracture. The facility's staff, including the Registered Nurse Supervisor and the Physical Therapist, were unaware of the resident's recent fall and fracture until several days after the incident. The lack of communication and documentation led to miscommunication between the staff and the resident regarding aftercare and weight-bearing activities. The resident's post-fall assessment and hospital discharge summary indicated the need for skilled nursing facility rehabilitation, but these were not incorporated into the resident's care plan, resulting in inadequate care and treatment.
Lack of Coordinated Care Plan with Hospice Agency
Penalty
Summary
The facility failed to develop a coordinated plan of care and communication process with the Hospice agency for a resident admitted under Hospice Services. The resident, who was admitted with an end-stage diagnosis of dementia, did not have a care plan that addressed the specific services Hospice would provide or when the facility should notify Hospice. This lack of coordination and documentation was identified during a review of the resident's records and interviews with facility staff, including the MDS Coordinator and the Director of Social Services. Interviews with facility staff revealed that while Hospice residents have binders containing the Hospice agency's plan of care, there was no mention of Hospice in the facility's care plan for the resident. The Director of Social Services acknowledged the absence of documentation regarding Hospice's role and the coordination process between the facility and Hospice. Additionally, the Director of Nursing and a Registered Nurse described the communication process with Hospice, but the facility's policy on collaboration with Hospice providers was not being fully implemented, as evidenced by the lack of documented collaboration efforts and care plan updates.
Failure to Provide Rehabilitative Services Post-Surgery
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required physical and occupational therapy following a right hip hemiarthroplasty. The resident, who had been readmitted to the facility after a fall that resulted in a hip fracture, was not evaluated by a physical therapist or occupational therapist upon return. Despite the resident's discharge summary from the hospital indicating the need for rehabilitation services, there was no documentation of orders for weight-bearing as tolerated or a referral for physical therapy. The resident, who had a history of falls, reported not being out of bed since readmission and stated that the therapy team was unaware of his recent fall and subsequent surgery. The facility's registered nurse supervisor confirmed the absence of documentation for therapy orders and noted that no interdisciplinary team meeting had occurred to address the resident's fall and update his care plan. The facility's policy on falls required assessment and intervention within 24 to 48 hours of a fall, which was not adhered to in this case. The physical therapist confirmed being unaware of the resident's recent fall and fracture until several days after the readmission. The facility's failure to follow its protocol for fall assessment and management, as well as the lack of communication and documentation regarding the resident's need for rehabilitative services, contributed to the deficiency in care provided to the resident.
Inadequate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure an appropriate discharge for a resident, identified as Resident 1, due to the absence of a documented discharge basis and discharge summary. Resident 1 was admitted with multiple health issues, including cachexia, severe protein-calorie malnutrition, iron deficiency, and unsteadiness on feet. Despite a doctor's order indicating a discharge to home with home health services, there was no evidence in the medical record of the basis for the discharge or a discharge summary from the doctor. Interviews with the Director of Social Worker (DoSW) confirmed the lack of documentation regarding the discharge. The DoSW acknowledged that there should have been a discharge note and a documented reason for the discharge, but these were missing from Resident 1's medical record. The facility's policy on discharging residents, as well as the State Operations Manual, require that the basis for discharge be documented, which was not adhered to in this case.
Failure to Prevent Unsupervised Access to Smoking Materials
Penalty
Summary
The facility failed to implement measures to prevent a resident from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This deficiency was observed when the resident was found in possession of smoking materials in the hallway and later smoking outside without supervision. Despite multiple educations and reminders to both the resident and a visitor, the non-compliance continued, leading to the resident smoking inside the facility and in non-designated areas, posing a significant safety risk. The resident had a history of tobacco use, senile degeneration of the brain, delirium, and muscle wasting. The resident's care plan required supervision while smoking and mandated that smoking materials be stored by the facility. However, the resident repeatedly violated the smoking policy, and the facility failed to enforce the necessary supervision and storage of smoking materials. The resident's smoking assessments were not updated regularly, and staff were inconsistent in monitoring and enforcing the smoking policy. Interviews with staff revealed a lack of clarity and consistency in the enforcement of the smoking policy. Some staff members were unaware of the resident's smoking restrictions, and others admitted to leaving the resident unsupervised while smoking. The facility's failure to reassess the resident's smoking safety and enforce the smoking policy led to multiple incidents of the resident smoking inside the facility and possessing smoking materials, creating a hazardous environment for all residents and staff.
Facility Fails to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain 4 of 4 resident shower rooms in a clean and homelike condition. Observations revealed that the shower rooms had peeling paint, rust, water damage, and visible stains. The third-floor shower room had worn tiles, rust stains, and a musty smell. The second-floor women's shower room had a hole in the wall, peeling paint, rusted fixtures, and visible water damage. The second-floor men's shower room had peeling paint, dirty tiles, and water stains. These conditions were confirmed by multiple staff members, including CNAs and the Maintenance Manager, who acknowledged the deteriorating state of the shower rooms and the challenges in maintaining them. Resident #79, who was cognitively intact and required moderate assistance with showering, expressed dissatisfaction with the cleanliness of the shower rooms, describing them as filthy and unclean. The resident mentioned that the shower rooms had feces in one of the stalls and appeared run down. Despite the resident's concerns, they had not complained to the facility, believing that the staff should be aware of the conditions without being told. Interviews with facility staff, including CNAs, the Maintenance Manager, the VP, the ADON/Infection Preventionist, and the DON, revealed that the shower rooms had been in poor condition for an extended period. The Maintenance Manager had attempted various methods to address the peeling paint and rust issues, but these efforts were unsuccessful. The VP and CEO acknowledged the repeated attempts to repaint the shower rooms, which only provided temporary improvements. Housekeeping staff confirmed that the shower rooms were cleaned daily, but the persistent issues with peeling paint and rust made it difficult to maintain a clean and homelike environment.
Failure to Conduct Legionella Risk Assessment
Penalty
Summary
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Despite having policies in place for Legionella surveillance and a water management program, the facility did not have a completed risk assessment or a water-flow diagram indicating areas at risk. This oversight was confirmed through multiple interviews with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Maintenance Manager, the previous Director of Nursing (DON), and the Chief Operating Officer (CEO), all of whom acknowledged that no risk assessment had been conducted. Additionally, the facility had not conducted any testing of standing water for Legionella detection, relying only on annual pH testing. The Maintenance Manager admitted to not knowing the layout of the water flow in the facility. The lack of a risk assessment and water testing was further corroborated by the ADON, the previous DON, and the CEO, who all stated that the facility staff were unaware of the requirement to complete a risk assessment of the water system. No previous positive cases of Legionella were reported, but the absence of a risk assessment and water testing posed a potential risk to all residents in the facility.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans reflected all care needs for several residents. Resident #400's care plan did not accurately reflect the current hospice provider and contact information, despite the resident receiving hospice services from a different provider than listed. This discrepancy was confirmed through observations and interviews with facility staff, including the RN/MDS coordinator, the Administrator, and the DON, all of whom acknowledged the care plan should have been updated to reflect the correct hospice provider information. Resident #15's care plan did not reflect the resident's preference to wear a hospital gown instead of personal clothing. Despite multiple observations of the resident in a hospital gown and interviews with CNAs and RNs who confirmed the resident's consistent refusal to wear personal clothing, the care plan was not updated to reflect this preference. The DON and other staff members acknowledged that the care plan should have included the resident's clothing preference and refusals. Resident #86's care plan failed to identify and address the resident's documented behaviors, such as flooding the bathroom, taking excessively long showers, and being combative with staff. Despite multiple progress notes documenting these behaviors and interviews with various staff members who were aware of these issues, the care plan did not include specific interventions to manage these behaviors. The Administrator, ADON, and other staff members confirmed that these behaviors should have been included in the care plan. Resident #49's care plan did not address the use of an indwelling urinary catheter or the specific care needs associated with it. Despite the resident having an active order for an indwelling urinary catheter and observations confirming its use, the care plan only mentioned a toileting deficit and incontinence. Interviews with the ADON, DON, and CEO confirmed that the care plan should have included details on the care of the indwelling urinary catheter.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that each resident's electronic health record (EHR) and physical medical chart accurately and consistently reflected their treatment wishes, including their decision regarding cardiopulmonary resuscitation (CPR). This deficiency was identified for three residents out of thirteen sampled. The discrepancies involved mismatched information between the residents' Physician Orders for Life-Sustaining Treatment (POLST) forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences. For Resident #39, the facility's records showed conflicting information regarding the resident's code status. The resident's POLST form dated a specific date indicated a Do Not Attempt Resuscitation (DNR) order, while another POLST form dated earlier indicated a full code status. The resident's EHR and physical chart contained inconsistent information, and staff interviews revealed that the discrepancies could result in mistakes, potentially leading to the resident's wishes not being followed. Resident #12's records also showed inconsistencies. The resident's POLST form prepared on one date indicated a DNR order with comfort-focused treatment, while another POLST form prepared later indicated selective treatment with a trial period of artificial nutrition. The EHR and physical chart did not consistently reflect these orders, and the responsible party confirmed that the resident should be listed as DNR. Similarly, Resident #92's records contained conflicting information, with the POLST form indicating an attempt resuscitation order, while the EHR and physical chart listed a DNR order. Staff interviews confirmed that these discrepancies were not always identified and corrected promptly, leading to potential risks of not following the residents' treatment wishes.
Failure to Ensure Resident Privacy During Showers
Penalty
Summary
The facility failed to ensure personal privacy for two residents during the provision of showers. Resident #301, who was admitted with diagnoses including cerebral infarction and essential hypertension, was observed sitting fully unclothed in a shower chair with the privacy curtain and door open. This allowed several people to see the resident as they passed by the shower room. The CNA attending to Resident #301 acknowledged the oversight but failed to completely close the privacy curtain, leaving the resident exposed to passers-by in the hallway. Resident #11, who had diagnoses including senile degeneration of the brain and peripheral vascular disease, was transported to and from the shower room in a shower chair with their backside exposed. Despite being covered with a sheet and bath blanket, gaps in the coverage left the resident's buttocks visible during transport. The CNA responsible for Resident #11 speculated that the resident's movements might have caused the blanket to shift, exposing the resident's backside. Interviews with the facility's staff, including the ADON and DON, confirmed that the expectation was for CNAs to ensure residents' privacy by closing the privacy curtain and door during showers and ensuring residents were fully covered during transport. The observations and interviews revealed that these protocols were not followed, resulting in a failure to maintain the residents' privacy during personal care activities.
Failure to Include Schizophrenia Diagnosis on PASRR Level I Screening
Penalty
Summary
The facility failed to include a diagnosis of schizophrenia on the Preadmission Screening and Resident Review (PASRR) Level I for Resident #26. The resident was admitted to the facility with a diagnosis of schizophrenia, epilepsy, and Parkinson's disease. However, the PASRR Level I screening document dated 07/03/2018 did not indicate the diagnosis of schizophrenia, and Section V-Mental Illness was left blank. This omission was identified during a review of the resident's records, including the Minimum Data Set (MDS) and care plan, which clearly documented the diagnosis of schizophrenia. Interviews with facility staff revealed that the PASRR Level I screenings were completed by the facility staff in 2018, and the Assistant Director of Nursing (ADON) or Registered Nurse (RN)-MDS was responsible for completing these screenings. The Administrator and ADON confirmed that the diagnosis of schizophrenia was not indicated on the PASRR Level I screening for Resident #26. The Director of Nursing (DON) and Chief Executive Officer (CEO) emphasized the importance of accurate and thorough PASRR Level I evaluations, noting that the facility's nurses used to complete these screenings, but now they are completed by hospital staff. The failure to include the diagnosis of schizophrenia on the PASRR Level I screening led to the deficiency identified by the surveyors.
Improper Injection Technique
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for a resident who required an intramuscular injection. Specifically, a Registered Nurse (RN) prepared the injection by reconstituting the medication and then used the same needle to administer the medication to the resident. The RN also stuck the resident with the needle, removed it prior to administering the medication, and then re-stuck the resident with the same needle to administer the medication. This action was against the facility's policy and CDC guidelines, which state that a needle should never be reused either from one patient to another or to withdraw medication from a vial. The resident involved had a medical history that included acute pyelonephritis, diabetes mellitus, atherosclerotic heart disease, chronic systolic heart failure, and benign prostatic hyperplasia. The resident was cognitively intact and had an active diagnosis of a urinary tract infection. The incident was observed during the administration of an antibiotic injection. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the needle should not have been reused, as it could be unclean and dull, increasing the risk of infection and causing pain during the injection.
Failure to Follow Feeding Tube Protocols
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services to prevent potential complications. Specifically, the staff did not check the placement of the resident's feeding tube before administering water flushes and medications, as required by the physician's order and the facility's policy. Additionally, the staff administered the water flushes and medications by using the plunger of a syringe to push them into the feeding tube, instead of administering them by gravity flow as directed by the facility's policy. The resident involved had a medical history that included dysphagia following a nontraumatic intracranial hemorrhage and required attention to a gastrostomy. The resident's comprehensive care plan indicated the need for tube feedings due to dysphagia, and the physician's orders specified checking the feeding tube placement before each use and flushing the tube with water before and after medication administration. However, during an observation, a registered nurse failed to check the tube placement and used a syringe with a plunger to push water flushes and medications into the feeding tube. Interviews with the registered nurse, the Director of Nursing, and the Assistant Director of Nursing confirmed that the proper procedure was not followed. The registered nurse admitted to not checking the tube placement and using the syringe plunger to ensure the medications entered the tube. Both the Director of Nursing and the Assistant Director of Nursing stated that the correct procedure involved auscultating the feeding tube before administration and using gravity flow to administer water and medications. The failure to follow these procedures could result in complications such as gastroesophageal reflux disease, ulcers, or pressure in the stomach.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than 5 percent, resulting in a medication error rate of 5.8%. This deficiency affected one resident who was observed during medication administration. The resident, who had a medical history including type two diabetes mellitus, congestive heart failure, and dysphagia, was admitted to the facility on 11/08/2023. The resident had active orders for aspirin 81 mg chewable tablet and oyster shell calcium with vitamin D 250 mg-3.125 mcg, both to be administered once daily at 9:00 AM. During an observation, RN #3 administered an 81 mg enteric coated aspirin instead of the prescribed chewable aspirin and gave oyster shell calcium 500 mg instead of the prescribed oyster shell calcium with vitamin D 250 mg-3.125 mcg. RN #3 acknowledged the errors during an interview, stating she misread the order and failed to locate the correct medication. The Director of Nursing confirmed that nursing staff are expected to administer medications correctly using the five rights of administration.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. Specifically, a Registered Nurse (RN) left the medication cart unlocked and not within their line of sight, with medications lying on top of the cart unsecured. The incident occurred when the RN parked the medication cart outside a resident's room to administer medications, prepared an intramuscular injection, and entered the room without locking the cart. The RN left a vial of antibiotic medication and a bottle of lidocaine on top of the cart and stepped behind the privacy curtain, leaving the cart unattended and out of sight. The RN then walked to the medication room to retrieve insulin, leaving the cart unlocked and unattended for an extended period. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the facility's policy required nurses to lock the medication cart and keep the keys with them at all times. The policy also stated that no medications should be left on top of the cart if the nurse could not see the cart. Both the ADON and DON reiterated that the expectation was for nurses to lock the medication cart when walking away and to ensure no medications or sharp items were left unsecured on top of the cart. The RN admitted to forgetting to lock the cart and leaving the medications on top of it, which was a clear violation of the facility's policy and professional principles for medication storage and security.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in Resident #76's room. The resident, who was cognitively intact with a BIMS score of 14, reported seeing bugs in their room frequently. Observations confirmed the presence of multiple cockroaches on the walls, floor, and furniture in the resident's room, including near food items left out in the open. The facility's pest control policy, revised in May 2008, mandates an ongoing pest control program, but the implementation was found lacking as evidenced by the recurring pest issue in the resident's room. Interviews with staff, including a CNA, RN, Director of Maintenance, ADON, and DON, revealed that the facility was aware of the cockroach problem. The CNA mentioned seeing cockroaches frequently, especially at night, and the RN had reported seeing a cockroach at the nurses' station months ago. The Director of Maintenance acknowledged the issue and described efforts to move residents, seal entry points, and conduct deep cleaning, but these measures were not consistently effective. The ADON and DON both expressed concerns about the pest problem and the need for regular pest control services and thorough cleaning to prevent recurrence. A review of the pest control vendor's monthly report from December 2023 indicated pest activity but did not specify the rooms treated. The facility's staff admitted that the presence of food in residents' rooms, like in Resident #76's case, exacerbated the problem. Despite efforts to address the issue, including deep cleaning and sealing entry points, the facility's pest control measures were insufficient to eliminate the cockroach infestation, leading to ongoing pest sightings and resident complaints.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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