Sherwood Oaks Post Acute Care, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Bragg, California.
- Location
- 130 Dana Street, Fort Bragg, California 95437
- CMS Provider Number
- 056483
- Inspections on file
- 30
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Sherwood Oaks Post Acute Care, Llc during CMS and state inspections, most recent first.
Failure to treat constipation and monitor bowel status: A resident with severe dementia, chronic constipation, and fecal impaction risk was receiving Percocet and Seroquel, both of which can cause constipation, yet nursing staff did not administer ordered PRN constipation meds, did not notify the MD when bowel movements were absent, and did not complete weekly nursing assessments. The resident developed a large fecal impaction with bladder outlet obstruction, required a Foley catheter and manual disimpaction, and was transferred to the hospital after nausea, abdominal pain, and vomiting.
The facility failed to ensure the acting Dietary Manager had the required CDM certification or documented Dietary Manager competencies. Manager J stated he had served in the role for two years, but record review showed his competency files were for cooks, not a Dietary Manager, and the Administrator confirmed he was not certified and was functioning more as a high-level cook. The facility’s consultant RD worked only about five hours per week, while facility records required a qualified FNS Director and identified the need for one RD and one Food Service Manager.
Failure to implement EBP and maintain Legionella water testing program. Three residents with indwelling devices, including a dialysis catheter, urinary catheter, and SP catheter, did not have EBP signage or PPE setup outside their rooms, and staff including the DON and ADM stated they were unfamiliar with EBP. The facility also lacked current Legionella water testing documentation, and the water management log showed no completed tasks after April 2024.
Failure to Employ an IPN for Infection Control Oversight: The facility did not have an IPN, and residents were not set up for EBP during the survey because no IPN was in place. The Administrator stated the facility had not had an IPN since early 10/2025, and the DON said there had never been a full-time IPN, only occasional fill-ins. Facility policies and the Infection Control Nurse job description identified the IPN role as part of the infection control program and committee.
Laundry Dryer Lint Traps Not Cleaned and Logged per Policy: Three dryer lint trap screens were observed full in the laundry room, and no logs were available to show when the lint traps had been cleaned. Laundry staff stated she had dried four loads in each dryer, was unaware of the logging requirement, and said she cleaned the traps twice a day rather than after two loads as required by policy. The DON/Administrator stated the required lint-removal logging had not occurred for at least two months.
Unsafe storage of medications and treatment supplies was observed when a medication cart and a treatment cart were left unlocked and unattended in a lounge area accessible to residents. An LPN and the DON were observed leaving carts unsecured, and a separate locked med cart had its keys, medications, and bandages left on top of it unattended in a hallway. The facility policy required medication compartments to be locked when not in use and carts not to be left unattended if open or otherwise available to others.
Overcooked vegetables and prolonged steam-table holding affected meal quality. Staff observed vegetables being cooked for an extended period and then held on the steam table before lunch service, and a taste test found green beans cold and mixed vegetables soggy. Residents reported poor food quality, runny eggs, and meals that were not appropriate for their medical conditions, with one RP stating the resident was eating less and might have lost weight. The dietary consultant and RD stated the cooking and holding process could diminish nutrition, flavor, color, and texture.
QAPI/QAA failed to identify system-wide issues involving infection prevention, dietary services, and environmental safety. The facility had no IPN, did not implement EBP for three residents with indwelling medical devices, lacked an updated Legionella water testing program, and had not employed a qualified DM for over a year. The Administrator confirmed the QAPI action plans did not address these systemic deficiencies.
The facility failed to meet QAPI membership requirements because the mandated IP was not present at the quarterly QA/QAPI meeting. The Adm stated the facility had no IP and that none had been in the building since 10/2025, even though the QAPI committee list included the IP. Sign-in sheets showed the IP did not attend the quarterly QA meeting.
Missing Informed Consent for Psychotropic Medications: Two residents received psychotropic medications without signed informed consent. One resident’s Seroquel dose was increased without a new consent, and another resident received trazodone for insomnia before any signed consent from the resident or RP was found. The DON acknowledged the missing documentation, and one resident was documented as having capacity to make medical decisions while the other was noted to have intact memory and to make daily decisions independently.
A resident with insomnia and diagnoses including cerebral infarction, borderline personality disorder, and circadian rhythm sleep disorder was receiving trazodone 50 mg nightly, but the DON acknowledged there were no care plans for insomnia management or for monitoring psychotropic medication use, including signs of overdose or unwanted side effects. The DON also stated there was no past or current care plan to address the resident’s insomnia or to consider non-pharmacological interventions.
Failure to care plan ongoing weight refusals. A resident with depression, severe protein-calorie malnutrition, anemia, delusional disorders, and severe cognitive impairment repeatedly refused weights, and the DON acknowledged the issue had been ongoing since the prior year. The record showed no comprehensive care plan was developed within the required timeframe, despite facility policy requiring documentation of refusal reasons, interventions taken, and care planning for monitoring and follow-up.
Failure to monitor psychotropic medication side effects: A resident with cerebral infarction, borderline personality disorder, and circadian rhythm sleep disorder received trazodone 50 mg qHS for insomnia, but the MAR did not show ordered monitoring for behaviors or adverse effects despite a consultant pharmacist’s recommendation. The DON acknowledged the monitoring task was not ordered and later stated nursing should have been watching for side effects such as serotonin syndrome, constipation, and suicidal ideations; the facility psychotropic medication policy required daily monitoring for adverse effects and target behaviors.
Surveyors found that the facility failed to keep the kitchen clean and sanitary for 31 residents, with dried liquids and food debris on floors under and around refrigerators and a stove, and a dust-covered fan blowing onto clean utensils in the dish room. The Dietary Manager acknowledged the floors did not meet cleanliness expectations and could attract pests and cause illness, but could not state when the floors were last cleaned. The kitchen cleaning log listed various equipment-cleaning tasks for dietary staff but did not include floor cleaning, and a staff member reported that floor cleaning was not her job, that the floors were not cleaned the previous night, and she did not know who was responsible, despite a facility policy requiring kitchen floors to be mopped at least once daily.
A resident at high risk for falls, with multiple medical conditions and cognitive impairment, fell and sustained a hip fracture due to inadequate supervision and preventive measures. The resident's care plan required staff assistance for transfers and close observation, but these were not effectively implemented. Contributing factors included the discontinuation of medication managing hallucinations and the family's decision to stop overnight supervision, leaving the resident without necessary support.
A resident with severe cognitive impairment was not protected from abuse when another resident with moderate cognitive impairment placed the first resident's hand on her genital area without consent. The incident was observed by a nurse who intervened, but the affected resident experienced emotional distress. The facility failed to document and monitor the situation adequately, and care plans were not updated as required.
A facility failed to submit a written report of an abuse investigation within 5 working days after an incident involving two residents with cognitive impairments. One resident attempted inappropriate contact with another, which was immediately addressed by staff. However, due to a lack of awareness of reporting requirements, the necessary documentation was not sent to the Department on time.
A resident with severe dementia and aggressive behaviors hit another resident on the thigh, causing pain. Despite having a care plan to manage her behavior, the resident was seated near another resident, leading to the incident. Staff intervened after the event, but the facility failed to prevent the abuse as per their policy.
The facility failed to immediately report an alleged abuse incident where a resident hit another resident. The incident was reported to the Department the following day, contrary to the requirement to report within two hours. The facility's abuse prevention policy lacked a specific reporting timeframe, and the DON was unaware of the two-hour reporting requirement.
The facility failed to have a dedicated full-time DON, with the current DON also serving as MDS coordinator and floor nurse. This compromised oversight and resident care, as the DON was responsible for medication administration and other duties. Interviews and record reviews showed the DON's extensive workload, with no active efforts to fill the vacant DON role since 2022.
The facility did not submit required PBJ data to CMS for the first quarter of 2024. The Administrator Assistant was unaware of the submission process, and the Director of Nursing was unfamiliar with PBJ reporting. The facility lacked a policy for PBJ reporting, and the Administrator could not confirm submission of the data.
The QAPI program at an LTC facility failed to identify several deficiencies, including a resident self-administering medications without assessment, missing narcotics not being investigated, and inadequate protocols for residents who are hard of hearing. Additionally, oral care was inconsistent, staffing requirements were not met, and significant weight changes in a resident were not reported. There was also a lack of staff training on care planning and infection control practices were inadequate.
The facility failed to identify and address multiple instances of abuse and neglect, including withholding food from a resident, neglecting to change soiled briefs, and verbal abuse by a staff member. Despite reports and observations of inappropriate behavior, the administration did not recognize these actions as abuse, creating an environment where residents' rights were violated and they were fearful of reporting further issues.
The facility failed to report multiple instances of abuse by an unlicensed staff member, who exhibited inappropriate behavior towards residents. Despite documented disciplinary actions, the Administrator did not notify the Department, creating an environment where residents were fearful of reporting negative behaviors. Interviews revealed that the staff member yelled at residents and acted unprofessionally, but the Administrator considered these incidents as personnel matters rather than abuse.
The facility failed to notify the Office of the State LTC Ombudsman about the discharge or transfer of four residents, including one discharged to home and three transferred to acute care facilities. The Social Services Assistant and Administrator showed confusion and lack of clarity regarding the notification process, and the facility's policies were outdated, leading to non-compliance with federal regulations.
The facility failed to ensure timely and collaborative completion of basic care plans (BCP) for residents, with the Director of Nursing (DON) being the sole individual involved in the process. The Interdisciplinary Team (IDT) did not review or implement the BCPs to meet residents' immediate care needs, and residents or their responsible parties were not involved or provided with BCP summaries. This lack of involvement and communication could compromise resident safety and care quality.
A resident with moderately impaired cognition did not receive regular oral care, as required by the facility's policy. Observations showed a buildup of material on the resident's tongue, and documentation confirmed that oral care was not provided after meals. Staff interviews verified the lack of oral care, which was not documented or performed consistently.
A resident experienced significant weight changes that were not reported to the physician or RD, contrary to facility policy. The resident, with severe cognitive impairment and dependency on staff for eating, lost 12.8 pounds and later gained 17.8 pounds over several months. Despite the facility's policy requiring re-weighing and reporting of such changes, these actions were not taken, posing potential health risks.
The facility failed to provide adequate staffing, leading to long wait times for residents needing assistance. Residents reported feeling scared and frustrated due to delayed responses to call lights. The facility did not meet the required DHPPD and CNA hours for most days in April and several days in May, impacting the quality of care. Staff acknowledged the short staffing and its potential risks, including delayed care and increased falls.
The facility failed to ensure staff competency in Baseline Care Plans (BCP) and Trauma Informed Care (TIC), as revealed through staff interviews. Key personnel, including the Director of Staff Development and various licensed and unlicensed staff, were unaware of BCP requirements and TIC principles. The facility's competency checklists and in-service training did not cover these areas, potentially compromising resident care and safety.
The facility failed to post nurse staffing information in a visible and accessible location, keeping it in a binder behind the nursing station counter. The staffing information was incomplete, lacking NHPPD data and signatures from the DON. Staff interviews revealed a lack of awareness about the requirement for visible posting and daily NHPPD calculations.
The facility failed to securely store discontinued controlled medications, leading to missing narcotics and unauthorized access. Additionally, medication labeling did not match doctor's orders, and a resident was allowed to self-administer OTC medications without proper assessment or physician's order, posing safety risks.
The facility failed to provide palatable food, as residents reported issues with taste, texture, and temperature. Observations confirmed mushy vegetables and tough meat, leading to potential nutritional problems if residents declined meals.
The facility failed to maintain proper infection control and hygiene practices. Clean linens were transported uncovered, exposing them to contamination. Staff did not consistently perform or offer hand hygiene before and after meals, risking cross-contamination. Additionally, urinals with urine were improperly managed, affecting infection control and resident dignity.
A facility failed to coordinate a Level II PASARR for a resident with mental illness after a positive Level I PASARR result, leading to a delay in necessary medical evaluation and care. The oversight involved not adhering to federal requirements to ensure proper placement and care planning for individuals with mental disorders.
A resident in a LTC facility was not assisted with using his CPAP machine every night, as staff failed to help him with the mask due to his hand dexterity issues. The resident's room setup made it difficult for him to access the CPAP, and a planned room transfer had not occurred. Additionally, there was no physician order specifying the CPAP settings, and a no smoking sign was missing from the resident's room, contrary to facility policy.
A resident with intact cognition and multiple diagnoses, including diabetes and muscle weakness, was not provided access to necessary hearing services. Despite requests, no audiologist referral was made, and hearing aids were not checked, leading to communication difficulties. Staff interviews revealed a lack of protocol for addressing hearing impairments, contributing to the oversight.
A resident with Multiple Sclerosis and contractures in both ankles did not receive the ordered ROM exercises due to the absence of a Restorative Nursing Assistant (RNA) for about two months. The facility's Restorative Nursing Program requires daily services to maintain patients' function, but interviews confirmed that no ROM exercises were conducted, potentially worsening the resident's condition.
Failure to Treat Constipation and Monitor Bowel Status
Penalty
Summary
The facility failed to provide resident-centered nursing care for a 90-year-old resident with severe dementia, delusional disorder, and a history of fecal impaction when she developed intermittent constipation and then a large fecal impaction. Her record showed she was always incontinent of urine and stool, required substantial to maximal assistance with toileting hygiene, and had a care plan addressing constipation risks related to Percocet and Seroquel. The CNA bowel elimination flow sheet documented multiple days without bowel movements, including an eight-day gap early in December and another five-day gap immediately before her transfer to the hospital. Although the resident had physician-ordered PRN constipation medications available, including Milk of Magnesia, Dulcolax suppository, Fleet enema, and Senna, nursing staff did not document giving any of those medications during the period reviewed. The DON confirmed that the PRN constipation medications were not administered and stated the nurses should have given Milk of Magnesia after two days without a bowel movement, a Fleet enema on the third day, and then called the physician if there was still no bowel movement. The record also showed the resident was receiving scheduled Polyethylene Glycol 3350 for constipation and was taking Percocet and Seroquel, both of which can cause constipation. Nursing staff also did not notify the physician when the resident remained constipated, despite the ongoing bowel pattern and the use of medications associated with constipation. The physician later stated the constipation had not been brought to his attention and that he expected nursing staff to manage it with the ordered PRN medication and call him if those measures were not effective. In addition, weekly nursing assessments were not completed after 8/31/25 through 2/28/26, and the DON confirmed the assessments were missing from the record during that period. The resident was transferred to the hospital on 1/3/26 after nausea, abdominal pain, and projectile vomiting, where imaging showed a very large fecal impaction compressing the bladder neck, causing a distended bladder and requiring a Foley catheter and manual disimpaction.
Unqualified Dietary Manager and Missing Competency Documentation
Penalty
Summary
The facility failed to ensure dietary staff had the required competencies and certifications to carry out food and nutrition services when the acting Dietary Manager, Manager J, was not certified to function in that position and did not have documented Dietary Manager competencies in his employee file. During an interview on 3/03/2026, Manager J stated he had been the Dietary Manager for two years. However, during record review, Dietary Consultant K reviewed prior RD Q’s kitchen inspection documentation, which stated that the dietary manager needed to be a CDM or the facility needed a full-time RD, and confirmed that Manager J was not certified as a dietary manager. Further review showed the competency documents in Manager J’s file were for cooks, not for a Dietary Manager. The Administrator later confirmed that Manager J was not certified to work as a Dietary Manager and described him as a high-level cook. The Administrator also stated the facility’s current consultant RD worked about five hours per week and was not employed full-time at the facility. Facility policy required a qualified FNS Director to oversee the total operation of the Food & Nutrition Services Department, and the facility assessment identified the need for one RD and one Food Service Manager.
Failure to Implement Enhanced Barrier Precautions and Maintain Legionella Water Testing Program
Penalty
Summary
Enhanced Barrier Precautions were not implemented for three sampled residents with indwelling medical devices. Resident 4 had diagnoses including end stage renal disease, dependence on renal dialysis, immunodeficiency, and urinary tract infection, and his record showed a 2-lumen dialysis catheter requiring care and monitoring. During observation, no enhanced barrier precaution signage was posted outside his room and no clean PPE was present immediately outside the door. Resident 29 was observed lying in bed, and there were no infection control precaution signs inside or outside the room and no PPE located outside the room. Her MDS indicated she had an indwelling catheter. Resident 35 had diagnoses including neuromuscular dysfunction of the bladder and cystostomy, and his record showed an order for routine suprapubic catheter changes. His care plan noted recurring UTIs related to poor hygiene techniques of his SP catheter. During observation, his SP catheter bag was on the floor, he stated he thought it was still hanging on his wheelchair, and there was no signage outside his room to indicate EBP or any PPE setup outside the room. The DON stated he was not familiar with EBP and did not know the standard of practice was to have signage posted and PPE carts set up for residents with indwelling devices and wound care. He stated nurses and CNAs had not been in-serviced on EBP and the IPN had not been setting up residents' rooms for EBP. The Administrator also stated she did not realize residents with indwelling medical devices and/or wound care should have EBP implemented, and CNAs stated they had not heard of EBP and had never seen signage or PPE carts for this purpose. The facility policy titled Enhanced Barrier Precautions stated that residents with wounds, indwelling medical devices, or invasive lines should have EBP and that staff must wear gloves and gowns during high-contact care activities, with door signage indicating required PPE.
Failure to Employ an Infection Prevention Nurse
Penalty
Summary
The facility failed to employ an Infection Prevention Nurse (IPN) from early 10/2025 through 3/06/26, and during the Recertification Survey from 3/03/26-3/06/26 residents were not set up for Enhanced [NAME] Precautions (EBP) because there was no IPN. The deficiency was identified through observation, interview, and record review, including reference to Federal Tag F880. During interviews, the Administrator stated on 3/05/26 at 4:50 p.m. that the facility did not have an IPN. On 3/06/26 at 8:45 a.m., the DON stated he could not recall when there had been a full-time IPN and said there had been a few IPNs who filled in once in a while over the past year, but never a full-time IPN. On 3/06/26 at 9:15 a.m., the Administrator stated there had not been an IPN in the facility since early 10/2025. Record review showed the facility's Infection Control Overview policy listed an Infection Preventionist as a member of the Infection Control Committee, and the Monitoring Compliance with Infection Control policy stated the Infection Preventionist or designee shall monitor infection control work practices and protective equipment. The job description for Infection Control Nurse stated the role was to plan, organize, develop, coordinate, and direct the infection control program and attend Infection Control Committee meetings.
Laundry Dryer Lint Traps Not Cleaned and Logged per Policy
Penalty
Summary
The facility failed to ensure that three dryer lint traps in the laundry room were cleaned after two uses, as required by the facility's Laundry Dryer Operation and Lint Removal Policy. During a concurrent observation and interview on 3/06/26 at 10:48 a.m., all three dryer lint trap screens were full, and there were no logs available to show how often the lint traps had been cleaned. Laundry Staff C stated she had already dried four loads of laundry in each dryer, said she cleaned the lint traps twice a day, and said she was just about to clean them and would clean them one more time before leaving around 3:30 to 4 p.m. She also stated she was not aware of needing to log the time she cleaned the lint traps or how often she was supposed to clean them, and said the staff member who trained her had quit after training her. During an interview on 3/6/2026 at 12:35 p.m., the Administrator stated laundry staff should clean the dryer lint traps after two loads and log the time they were cleaned, and stated that logging had not occurred for at least the past two months. No logs were presented. The Administrator also stated Maintenance should deep clean the dryers once a month and log when all dryers were deep cleaned. The facility policy stated that dryer lint traps and surrounding areas shall be cleaned regularly, that lint shall be removed after two dryer loads and at the end of each shift, and that a Dryer Lint Removal Log shall be maintained in the laundry area documenting the date, time, and staff initials.
Unsafe Storage of Medications and Treatment Supplies
Penalty
Summary
Drugs and biologicals were not stored safely when a medication cart and a treatment cart were left unlocked and unattended in the facility lounge area, which was accessible to residents. During an observation, LN L was preparing morning medications at medication cart #1 while the DON unlocked medication cart #2, placed medications inside it, and then walked out without relocking it. LN L then locked cart #1 and left the room, leaving cart #2 and one treatment cart unattended; the treatment cart contained topical medications, scissors, and other sharp instruments and equipment. LN L stated residents were allowed to come into the lounge area to sit and look out the windows, and later acknowledged that all carts should have been locked before staff left them unattended in any area accessible to residents. The treatment cart was observed again later that day in the lounge area, still unlocked and unattended, and LN L stated it should always be locked because residents could open drawers and remove items that could harm them. On another observation, a locked medication cart was seen in a hallway outside a resident’s room with the keys, along with some medications and bandages, left on top of the cart and unattended for about five minutes. The DON confirmed that leaving keys on an unattended medication cart was unsafe and against facility policy. The facility policy stated that compartments containing drugs and biologicals must be locked when not in use and that trays or carts used to transport such items must not be left unattended if open or otherwise available to others.
Overcooked vegetables and prolonged steam-table holding affected meal quality
Penalty
Summary
Food was not prepared in a manner that maintained nutritive value and palatability for four sampled residents when vegetables were cooked for approximately one hour and then held on a steam table for about one additional hour. During a concurrent observation on 3/03/26, the food on the steam table included meat and vegetable lasagna, green beans, mashed potatoes, and gravy, and dietary staff stated the food had been set on the steam table at 11:00 a.m. for a noon lunch service. Resident 4 stated she was unhappy with facility food and reported being served runny eggs every day without being offered substitutions after she complained. Resident 35 stated the food was institutional-like and said the green beans were overcooked that day. Resident 5's RP stated facility food had not been good since 2024 and that Resident 5 did not eat much of it, with concern that she might have lost weight because of the poor food quality. Resident 27 stated she was often served food she should not eat because of her medical conditions, that facility food often gave her diarrhea, and that she was not offered substitutions when she complained. On 3/05/26, mixed vegetables and green beans were observed cooking in water on the stovetop for an extended period, with the green beans boiling and later being drained and placed on the steam table at 11:05 a.m.; lunch plating began at 11:50 a.m. During a taste test at 12:15 p.m., the fish was described as a little fishy-tasting and seeming room temperature, the green beans were described as cold, and the mixed vegetables were described as soggy. The dietary consultant and RD stated that cooking vegetables for about one hour and then holding them on the steam table for another hour could overcook them and diminish nutrition, flavor, color, and texture, and the facility's recipes and policy directed that vegetables be served at recommended temperatures and not held on the steam table for long periods.
QAPI/QAA Failed to Address Systemic Infection Control and Staffing Deficiencies
Penalty
Summary
The facility’s QAPI/QAA program failed to identify and address system-wide problems related to infection prevention, dietary services, and environmental safety. During the survey, the facility had not employed an Infection Prevention Nurse since 10/26 through 3/06/26, and the QAPI action plans did not address the absence of that role, insufficient staff in-service training regarding Enhanced Barrier Precautions, or the lack of implementation of measures to prevent Legionella growth. The Administrator confirmed that the QAPI/QAA plans did not include these systemic issues. The survey also found that Enhanced Barrier Precautions were not implemented for three of 15 sampled residents who had indwelling medical devices. In addition, the facility did not maintain an updated Legionella Water Test Program, and it had not employed a qualified Dietary Manager for more than a year. A review of the facility’s QAPI Plan dated 7/26/25 showed guiding principles stating that QAPI focuses on systems and processes, uses data, and sets goals for performance and progress, but the identified deficiencies were not addressed in the facility’s QAPI/QAA program.
QAPI Committee Missing Required Infection Preventionist
Penalty
Summary
The facility failed to comply with its QAPI program by not having the mandated Infection Preventionist present at the quarterly QA/QAPI meeting, resulting in the required committee membership not being met. During interviews, the Administrator stated the facility did not have an Infection Preventionist and later stated there had not been an Infection Preventionist in the facility since 10/2025. The Administrator also stated the Infection Preventionist should have been attending the quarterly QAPI committee meetings. Review of the QAPI document titled "QA/QAPI Committee Members: Quarterly," revised 3/01/26, showed the Infection Preventionist was listed on the committee, but review of the quarterly QA meeting sign-in sheets dated 4/29/25, 8/12/25, 12/9/25, and 2/24/26 showed the Infection Preventionist was not in attendance at the 2/24/26 quarterly QA meeting.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed informed consents for two residents who were receiving psychotropic medications. One resident was prescribed Seroquel, and the dose was increased from 25 mg to 50 mg in the morning and from 75 mg to 100 mg in the evening without a new informed consent being completed. The DON reviewed the record and acknowledged that a new informed consent should have been completed when the Seroquel dose was increased. The resident’s record also indicated the resident had capacity to make medical decisions. A second resident, who had diagnoses including alcohol use, alcohol induced dementia, delusional disorder, and bipolar disorder, was receiving trazodone 50 mg nightly for insomnia starting on 2/26/26. Review of the resident’s MDS indicated memory was intact and the resident was able to independently make decisions about daily life. During record review with the DON, no informed consent document signed by the resident or the RP was found in either the electronic record or the hardcopy binder, and the DON acknowledged it was not completed.
Failure to Develop Care Plans for Insomnia and Psychotropic Monitoring
Penalty
Summary
The facility failed to develop care plans for one sampled resident who had insomnia and was receiving trazodone 50 mg nightly for insomnia. The resident was admitted with diagnoses including cerebral infarction, borderline personality disorder, and circadian rhythm sleep disorder. Her MDS dated 2/21/26 indicated her memory was intact and that she was able to independently make decisions about daily life. Her MAR dated 3/05/26 showed trazodone HCl was started on 2/26/26 for insomnia. During a concurrent interview and record review on 3/06/26, the DON reviewed the resident’s care plans and acknowledged there were no nursing care plans initiated for monitoring the psychotropic medication administration, including monitoring for signs and symptoms of overdose and/or unwanted side effects. The DON also acknowledged there was no past or current care plan for the management and treatment of the resident’s insomnia. The DON stated these care plans should have been started to monitor treatment, consider non-pharmacological interventions, and prevent harm.
Failure to Care Plan Ongoing Weight Refusals
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of the comprehensive assessment for Resident 5 regarding repeated refusals to be weighed. Resident 5 was admitted with diagnoses including depression, severe protein-calorie malnutrition, anemia, delusional disorders, and muscle weakness. The MDS dated 1/02/26 indicated severe cognitive impairment, delusions, and occasional rejection of treatment or care. A progress note dated 2/04/26 documented that the resident again refused to be weighed and that this was an ongoing issue. During interview and record review, the DON acknowledged that Resident 5 had been refusing weights since last year and agreed that care planning had not been implemented for these refusals. When asked what should have been care planned, the DON stated, "what should I have care planned?" The DON also stated that education, counseling, or family involvement could have been part of a care plan for this problem. The resident's last recorded weight was 145 lbs. on 11/13/25. Facility policy on weighing and measuring residents required documentation of the reasons for refusal and interventions taken, and the care area assessment policy directed staff to evaluate goals, design interventions, document interventions, and include monitoring and follow-up timeframes.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor the side effects of trazodone, a psychotropic medication, for one resident despite a consultant pharmacist’s recommendation and a later review by the facility physician. The resident was admitted with diagnoses including cerebral infarction, borderline personality disorder, and circadian rhythm sleep disorder. The resident’s MDS dated 2/21/26 indicated memory was intact, the resident was attentive, and the resident could independently make decisions about daily life. The resident’s MAR dated 3/5/26 showed trazodone HCl 50 mg by mouth nightly for insomnia, with a start date of 2/26/26. The consultant pharmacist’s medication regimen review dated 1/07/26 identified the current trazodone order and recommended monitoring for side effects and behaviors for the psychotropic medication. During interview and record review, the DON agreed that monitoring for behaviors and side effects of trazodone was not ordered and therefore could not be assumed to have been completed by nursing staff. In a later interview, the DON stated nurses should have been monitoring for side effects of trazodone, including serotonin syndrome, constipation, and suicidal ideations. The facility’s psychotropic medication policy stated nursing monitors psychotropic drug use daily for adverse side effects such as increased somnolence or functional decline and monitors for target behaviors daily.
Unsanitary Kitchen Conditions and Inadequate Floor-Cleaning Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen in a clean and sanitary condition for a census of 31 residents. During a kitchen observation, surveyors noted dried liquids on the floor in front of the refrigerator and visible food crumbs and dried food debris under the refrigerators, stove, and along the baseboards, with debris extending along the wall-floor seam into multiple areas. In the dish room, a fan with a buildup of dark-colored dust was observed blowing directly onto clean utensils and other clean dishes on the clean side of the dishwasher deck. The Dietary Manager, when shown the debris under the refrigerators and stove, stated that evening staff were supposed to clean the floor but was unable to say when the floor was last cleaned and acknowledged the floor did not meet his expectations of cleanliness. The Infection Preventionist also acknowledged the visibly soiled floors and observed the fan blowing toward clean utensils. A review of the kitchen cleaning assignment and log for the month showed daily cleaning tasks for morning and evening cooks and a dietary aide, including cleaning equipment such as the coffee machine, refrigerators, microwave, housekeeping closet, utility carts, trash cans, and stove, but did not list cleaning the kitchen floors. During an interview, a staff member stated that cleaning the floors was not her job and confirmed the floors were not cleaned the previous night, and she could not identify who was responsible for regular floor cleaning. The facility’s policy titled “General Cleaning of Food & Nutrition Services Department,” dated 2023, required that kitchen floors be mopped at least once per day and described the correct sweeping and mopping procedure. The Dietary Manager stated that floors that were not clean and sanitary could attract pests and cause illness to residents.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to prevent an avoidable fall for Resident 3, who was assessed as high risk for falls. Resident 3 was found on the floor by the bathroom after attempting to transfer and ambulate without staff assistance and supervision. This incident resulted in Resident 3 sustaining a left femoral neck fracture, requiring surgical repair. The deficiency was identified through interviews and record reviews, highlighting the lack of adequate supervision and preventive measures for a resident with known fall risks. Resident 3 was admitted to the facility with multiple diagnoses, including hemiplegia, hemiparesis, schizoaffective disorder, heart failure, and diabetes. The Minimum Data Set indicated that Resident 3 was moderately cognitively impaired and required one-person staff assistance for toileting and mobility. Despite being identified as a high fall risk, the facility's interventions, such as keeping the bed in the lowest position and using fracture mats, were insufficient to prevent the fall. The resident's care plan included staff assistance for transfers and close observation for unsafe actions, but these measures were not effectively implemented. Several factors contributed to the fall, including the discontinuation of Seroquel, which managed Resident 3's hallucinations and delusions, and the family's decision to stop providing overnight supervision. The Director of Nursing acknowledged that Resident 3 had a history of climbing out of bed and was moved closer to the nurse's station after the family ceased their overnight presence. However, the facility did not provide a one-to-one sitter due to staffing limitations, leaving Resident 3 without the necessary supervision to prevent the fall.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident placed the first resident's hand on her genital area without consent. This incident involved two residents, both with cognitive impairments. The first resident, who was admitted with severe cognitive impairment due to dementia and other medical conditions, was seated in a hallway when the second resident, who also had dementia and moderate cognitive impairment, engaged in inappropriate behavior. The incident was observed by a licensed nurse who intervened immediately to separate the residents. Despite the intervention, the first resident experienced emotional distress, as evidenced by tears in his eyes. The facility's documentation revealed that the first resident had a BIMS score indicating severe cognitive impairment, while the second resident had a BIMS score indicating moderate cognitive impairment. The second resident's care plan included interventions to prevent inappropriate sexual touching, but these measures were not effectively implemented at the time of the incident. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, revealed that there was a lack of documentation and monitoring for emotional distress and behaviors following the incident. The facility's policies and procedures for abuse prevention, investigation, and documentation were not adequately followed, contributing to the deficiency. The Director of Nursing acknowledged that a care plan for the first resident should have been created following the incident, but it was not, highlighting a gap in the facility's response to the event.
Failure to Timely Report Abuse Investigation
Penalty
Summary
The facility failed to provide a written report of the results of an abuse investigation to the Department within 5 working days following an incident involving two residents. Resident 1, who was admitted with severe cognitive impairment and other medical conditions, was involved in an incident where Resident 2, who also had cognitive impairments, attempted to place Resident 1's hand on her genital area. This incident was observed by a licensed nurse who intervened immediately. Resident 1, who has dementia and severe cognitive impairment, was unable to recall the incident when questioned. Similarly, Resident 2, who has moderate cognitive impairment, did not remember the incident and showed no distress when interviewed. Despite the immediate separation of the residents and notification of relevant parties, the facility did not submit the required investigation report to the Department within the stipulated timeframe. The Director of Staff Development, acting as the licensed nurse during the incident, and the Social Services Director, who completed the investigation report, were both unaware of the requirement to submit the report within 5 working days. This lack of awareness led to the failure to comply with the facility's policy and procedure on abuse investigations, which mandates timely reporting to the state survey and certification agency.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when Resident 1, who had severe memory issues and exhibited aggressive behaviors, hit Resident 2 on the thigh with her fist. Resident 1's medical records indicated she had severe dementia with agitation and was on antipsychotic medication. Her care plan included interventions to manage her aggressive behavior, such as redirecting her away from others and ensuring she was not in a position to strike other residents. Despite these measures, Resident 1 was seated near Resident 2 in the hallway, leading to the incident where she struck Resident 2 after a verbal exchange. Resident 2, who also had severe cognitive impairments and was easily distracted, was seated in her wheelchair near Resident 1. During the incident, Resident 1 verbally engaged Resident 2 and, upon not receiving a response, hit her, causing Resident 2 to express pain. Unlicensed Staff A witnessed the event and intervened by telling Resident 1 not to hit others and taking her back to her room. The facility's policy aimed to maintain an abuse-free environment by assessing and addressing behavior problems, but this incident indicates a failure to implement these measures effectively.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged resident abuse incident immediately, which involved a resident hitting another resident who was sitting nearby. The incident occurred on 11/10/24 at 4:18 p.m., but the report was not sent to the Department until 11/11/24 at 4:52 p.m. and received on 11/12/24 at 8:00 a.m. During a review of records and an interview on 12/23/24, it was found that the facility's abuse prevention policy did not specify a timeframe for reporting suspected abuse incidents. The Director of Nursing (DON) was unaware of the requirement to report alleged abuse incidents within two hours after the allegation is made, as informed by the Department. The facility's policy stated that all suspected violations of abuse should be immediately reported to appropriate state agencies as required by law.
Lack of Dedicated Full-Time Director of Nursing
Penalty
Summary
The facility failed to have a dedicated full-time Director of Nursing (DON), which is a requirement for ensuring proper oversight and management of nursing staff and resident care. The current DON was also fulfilling multiple roles, including that of the MDS coordinator and a floor nurse responsible for administering medications. This multi-faceted role compromised the ability to provide dedicated oversight as a full-time DON, potentially putting residents at risk. Interviews with the DON and the Director of Staff Development (DSD) revealed that the DON was responsible for passing medications to residents every weekday, in addition to handling pharmacy-related tasks, admissions, and discharges. The DON had been in this position since 2022, with no active efforts observed to fill the vacant DON role. The DSD occasionally assisted with medication administration to allow the DON to focus on other duties, but the workload remained overwhelming. A review of multiple residents' MDS records and Medication Administration Records showed that the DON was consistently involved in medication administration and MDS documentation over an extended period. This included administering medications to several residents on numerous days each month, further highlighting the extensive responsibilities shouldered by the DON. The facility was unable to provide a policy on the DON job description, indicating a lack of formal guidance for the role.
Failure to Submit PBJ Data to CMS
Penalty
Summary
The facility failed to electronically submit Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services (CMS) as required every quarter. The Certification and Survey Provider Enhanced Reporting system (CASPER) report indicated that there was no staffing information submitted for the first quarter of 2024. During interviews, the Administrator Assistant (AA) admitted to not knowing how to submit the PBJ report and mentioned that another staff member from a sister facility was responsible for submitting the facility's PBJ information. The Administrator confirmed that PBJ staffing information should be reported quarterly but was unable to provide evidence that the information was submitted for the first quarter. Additionally, the facility lacked a policy for PBJ reporting, and the Director of Nursing (DON) was unaware of PBJ reporting requirements. The AA acknowledged the importance of PBJ reporting for monitoring nursing hours but did not understand the implications of failing to report to CMS timely.
QAPI Program Fails to Identify Multiple Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Program (QAPI) failed to identify several quality deficiencies. One resident was found to be self-administering and storing medications in his room without a self-administration assessment or physician notification. Additionally, there was a lack of management oversight regarding missing narcotics, which were not investigated or reported to the appropriate agencies until discovered by a surveyor. The facility also lacked protocols for addressing residents who were hard of hearing, as evidenced by a resident who had not been referred to an audiologist. Oral care was not consistently provided, with one resident found to have poor oral hygiene. The facility failed to meet the required direct care staffing hours for several days, and there was no Restorative Nursing Assistant program for over two months. Significant weight fluctuations in a resident were not properly monitored or reported to the physician or dietitian. Furthermore, there was a lack of staff training on baseline care planning and trauma-informed care, and the interdisciplinary team did not collaborate effectively on care plans. Hand hygiene protocols were not followed, and infection control practices were inadequate, as evidenced by improper handling of residents' urinals. These deficiencies were not discussed in the QAPI meetings, preventing the committee from addressing and developing corrective plans.
Failure to Identify and Address Abuse and Neglect
Penalty
Summary
The facility failed to identify and address multiple instances of abuse and neglect involving residents. One incident involved an unlicensed staff member withholding food from a resident due to the resident's behavior. Another incident involved staff neglecting to change soiled briefs, resulting in skin breakdown for an unidentified resident. Additionally, a staff member verbally abused a resident, identified as Resident 19, by yelling at them in a hostile and angry tone. Interviews with various staff members and a complainant revealed a culture of fear and intimidation within the facility. The complainant indicated that residents and staff were reluctant to report issues due to fear of retaliation and the potential closure of the facility. High staff turnover and a lack of advocacy for residents were also noted. Despite multiple reports and observations of inappropriate behavior by Unlicensed Staff C, including yelling at residents and neglecting their care, the facility's administration did not recognize these actions as abuse or neglect. The facility's policy on reporting abuse was not effectively implemented, as evidenced by the failure to address the reported incidents. The Administrator and other staff members, including the DON and DSD, were aware of the issues but did not take appropriate action to protect the residents. The Administrator's investigation concluded that the incidents were personnel matters rather than abuse, despite evidence to the contrary. This lack of action and failure to recognize abuse created an environment where residents' rights were violated, and they were fearful of reporting further abusive behaviors.
Failure to Report Abuse by Unlicensed Staff
Penalty
Summary
The facility failed to identify and report three instances of abuse involving an unlicensed staff member, referred to as Unlicensed Staff C, who exhibited inappropriate behavior towards residents. Despite documented disciplinary actions on specific dates, the Administrator did not notify the Department of these incidents. This failure to report created an environment where residents' rights were violated, and they were fearful of reporting negative behaviors due to potential retaliation. Interviews and record reviews revealed multiple instances of misconduct by Unlicensed Staff C. A complainant reported that there were ongoing issues between staff and residents, with a specific incident occurring around late January. Resident 87, who had no cognitive impairment, was aware of staff incidents but chose not to discuss them. Unlicensed Staff A overheard Unlicensed Staff C yelling at a resident, and Licensed Staff B reported that Unlicensed Staff C's behavior was unprofessional and disrespectful towards residents and visitors. Despite these reports, the Administrator did not consider these actions as abuse or neglect. The facility's policy on reporting abuse was not followed, as the Administrator failed to report the incidents to the appropriate authorities. The policy clearly defines verbal and mental abuse and mandates immediate reporting of any suspected abuse. However, the Administrator deemed the incidents as personnel matters rather than abuse, leading to a lack of proper investigation and reporting. This oversight resulted in a failure to protect residents from potential harm and maintain a safe environment.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman regarding the discharge or transfer of four residents, which is a requirement to ensure residents are informed of their rights and options. Specifically, Resident 85 was discharged to home, while Residents 86, 87, and 88 were transferred to acute care facilities. The Social Services Assistant (SSA) expressed confusion about which discharges required notification to the Ombudsman, indicating a lack of clarity in the facility's procedures. The Administrator also failed to ensure proper notification, particularly in cases where residents were transferred to a higher level of care, such as Resident 86, who was transferred and returned on different dates without Ombudsman notification. The facility's policy and procedure documents were outdated and did not clearly indicate the requirement to notify the Ombudsman office. The Administrator acknowledged the oversight and mentioned that weekend discharges and transfers to higher levels of care posed challenges due to limited staff availability. The report highlights that the facility's current practices and policies did not align with federal regulations, as evidenced by the outdated reference tag in their policy documents. This lack of compliance with notification requirements potentially deprived residents of advocacy and information about their rights during transfers and discharges.
Deficiencies in Timely and Collaborative Care Planning
Penalty
Summary
The facility failed to ensure timely completion of basic care plans (BCP) for residents, which are essential for promoting continuity of care and communication among staff to enhance resident safety. Specifically, the BCPs were not completed in a timely manner for one out of four sampled residents, and the Interdisciplinary Team (IDT) did not review the physician's orders or implement the BCP to meet the residents' immediate care needs for all four sampled residents. This lack of timely and collaborative care planning had the potential to compromise resident safety and the quality of care provided. The report highlights that the Director of Nursing (DON) was the sole individual involved in completing the BCPs for the residents, without the collaboration of the IDT, which includes various healthcare professionals. Additionally, the residents or their responsible parties were not involved in the development of the BCPs, nor were they provided with a summary of the BCPs. This lack of involvement and communication could lead to residents not receiving the necessary care tailored to their specific needs and conditions. The report provides specific examples of residents affected by these deficiencies. For instance, one resident with severe cognitive impairment and dependency on staff for eating had a BCP completed late and without IDT collaboration. Another resident, who required maximum assistance with activities of daily living, also had a BCP completed solely by the DON, without input from the IDT or the resident's responsible party. These failures in care planning processes were confirmed through interviews with facility staff, who acknowledged the importance of IDT involvement and the provision of BCP summaries to residents and their representatives.
Failure to Provide Regular Oral Care
Penalty
Summary
The facility failed to ensure regular oral care for Resident 31, who was dependent on staff for oral hygiene due to moderately impaired cognition. Observations revealed a buildup of whitish yellowish material on Resident 31's tongue, indicating a lack of oral care. Interviews with the Director of Staff Development (DSD) and other staff confirmed that oral care was not documented or provided after meals, as required by the facility's policy. The absence of oral care documentation suggested that the care was not performed, which was verified by multiple staff members. Resident 31's point of care documentation from early May to late May showed that oral care was not provided after breakfast. The Director of Nursing (DON) confirmed that oral care should be performed every shift, but the documentation indicated otherwise. The facility's policy on Activities of Daily Living (ADL) required appropriate support and assistance with hygiene for residents unable to perform ADLs independently, which was not adhered to in this case.
Failure to Report Significant Weight Changes
Penalty
Summary
The facility failed to report significant weight changes of a resident to the physician and Registered Dietician (RD), which is a deficiency in maintaining the resident's health. Resident 6 experienced a weight loss of 12.8 pounds or 7.6% between April and May 2023, and a weight gain of 17.8 pounds or 11.5% between May and September 2023. These changes were not communicated to the physician or RD, which could have put the resident at risk for adverse health outcomes. The Director of Nursing (DON) acknowledged the lack of notification and the absence of documentation for re-weighing the resident to confirm the weight changes. Resident 6, who was admitted with diagnoses including Parkinsonism, feeding difficulties, and muscle weakness, was dependent on staff assistance during meals. The Minimum Data Sheet Assessment indicated severely impaired cognition. Despite the facility's policy requiring weight changes of 5% or more to be rechecked and reported, the significant weight changes were not addressed promptly. Interviews with the DON, Administrator, and licensed staff confirmed the oversight and the potential health risks associated with unreported weight changes. The facility's policy on weight assessment and intervention, revised in 2008, outlines the need for multidisciplinary care planning involving the physician, nursing staff, and dietician for significant weight changes. However, the policy was not followed in this case, as evidenced by the lack of immediate re-weighing and notification to the physician and RD. The Administrator and staff interviews highlighted the importance of reporting such changes to prevent health risks, yet the necessary actions were not taken for Resident 6.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by complaints from six sampled residents and a review of staffing records. Residents reported long wait times for assistance, with some waiting up to an hour for staff to respond to call lights. The facility did not meet the required direct care service hours per patient per day (DHPPD) and Certified Nursing Assistant (CNA) hours for the majority of days in April and several days in May 2024. This shortfall in staffing led to residents feeling scared and frustrated, fearing that no one would be available to assist them in case of a medical emergency. Interviews with residents and staff further highlighted the impact of inadequate staffing. Residents expressed concerns about the lack of timely assistance, with some stating that they had to go to the nursing station to find help. Staff members, including licensed and unlicensed personnel, acknowledged the short staffing and its potential consequences, such as delayed care, increased risk of falls, and late responses to call lights. The Director of Nursing and other staff members confirmed that the facility was not meeting the minimum DHPPD requirements, which could compromise the quality of care provided to residents. The facility's policy on emergency staffing situations was reviewed, but it was undated and did not appear to be effectively implemented. The policy aimed to ensure appropriate nursing staff levels to care for residents, but the consistent failure to meet staffing requirements suggests that the policy was not adequately addressing the staffing issues. The deficiency in staffing was a significant concern, as it directly affected the residents' safety and well-being, leading to a decrease in the quality of care provided at the facility.
Lack of Staff Competency in Baseline Care Plans and Trauma Informed Care
Penalty
Summary
The facility failed to ensure that its staff possessed the necessary competencies and skills to meet the needs of residents, specifically in the areas of Baseline Care Plans (BCP) and Trauma Informed Care (TIC). Interviews with various staff members, including the Director of Staff Development (DSD), licensed and unlicensed staff, the Infection Preventionist (IP), and the Activity Director (AD), revealed a lack of awareness and understanding of BCPs and TIC. The DSD admitted to not knowing what a BCP was or the required timeframe for its completion, which should be within 24 hours of admission. Similarly, the DSD and other staff members were unaware of TIC and had not received any in-service training on the subject. The deficiency was further highlighted by the absence of BCP and TIC in the facility's Registered Nurse and Certified Nursing Competency Checklists, as well as in the DSD's mandatory in-service topics. Staff members expressed a desire for training on TIC to provide safe and effective care for residents with trauma histories. The lack of knowledge and training in these critical areas could potentially compromise the safety and well-being of residents, as staff are not equipped to develop timely care plans or provide trauma-informed care.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Observations and interviews revealed that the staffing information was kept in a binder behind the counter at the nursing station, making it inaccessible. Additionally, the staffing information was found to be incomplete, as it lacked the nursing home patient per day (NHPPD) data and was not signed by the Director of Nursing (DON) or a designee. Staff members, including the Director of Staff Development (DSD) and Licensed Staff, confirmed the absence of visible staffing information and the lack of daily NHPPD calculations. Interviews with various staff members, including the Administrator Assistant (AA) and the DON, indicated a lack of awareness regarding the requirement to post staffing information visibly and the necessity of daily NHPPD calculations. The AA admitted to calculating NHPPD only every two weeks during the pay period and keeping the information in a binder behind the nursing station counter. The DON was unaware of the need for visible posting and did not sign off on NHPPD information. The facility's policy and procedure for nurse staffing posting were requested but not provided, further highlighting the deficiency in compliance with staffing information regulations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all controlled discontinued medications were stored securely and that only authorized licensed staff, such as the Director of Nursing (DON), had access to the storage. During an observation, it was found that discontinued controlled medications, including narcotics, were not properly secured, and an unauthorized licensed staff nurse had direct access to the locked storage for discontinued medication. The DON admitted to storing discontinued controlled medications in a black tin can box that was not securely vaulted, and discrepancies were found in the reconciliation sheets for medications like Norco and Percocet, indicating missing tablets. Additionally, the facility did not accurately label individual medications according to the doctor's orders. The labels from the pharmacy did not indicate the route and duration as ordered by the doctor, which could lead to medication administration errors. The Pharmacist Manager acknowledged the labeling issue but did not provide a policy or procedure for medication labeling. Furthermore, the facility failed to ensure the safety of a resident who was self-administering medications. The resident had over-the-counter (OTC) medications stored in his room without a physician's order or a self-administration assessment. The DON and other staff members confirmed that there was no assessment or physician's order for the resident to self-administer or store medications, posing a safety risk to the resident and others in the facility.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide residents with palatable food, as evidenced by multiple resident interviews and observations. Residents reported that the food was often mushy, lacked taste, and was sometimes served cold. Specific complaints included canned vegetables being mushy, a lack of fresh food, and meals primarily consisting of frozen items and pasta dishes. These issues were corroborated by a test tray evaluation conducted by surveyors, who found the zucchini mushy and the barbecued beef tough in texture. Further interviews with residents revealed dissatisfaction with the texture and quality of the meat served, with descriptions comparing it to leather and noting difficulty in cutting and chewing. The deficiency in food quality had the potential to lead to nutritional problems if residents chose not to eat the meals provided by the facility.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that clean linens were transported in a manner that promoted cleanliness and protection from dust and soil. During an observation, an unlicensed staff member was seen transporting clean bed linens and towels using an uncovered laundry cart, leaving them exposed to potential contamination. The staff member acknowledged the requirement to use a covered cart but admitted to forgetting in this instance. The facility's Infection Preventionist and Administrator confirmed the expectation that linens should be covered during transport, aligning with CDC guidelines for handling clean linen. The facility also failed to ensure proper hand hygiene practices were followed by staff and offered to residents before and after meals. Observations revealed that staff did not perform hand hygiene before assisting residents with meals, nor did they offer hand hygiene to residents. Interviews with residents and staff confirmed inconsistencies in hand hygiene practices, which were not in compliance with the facility's policy. The Director of Staff Development and other staff members emphasized the importance of hand hygiene to prevent cross-contamination and infection. Additionally, the facility did not appropriately manage urinals containing urine, which were found hung on a resident's walker and left on a bedside table. This practice was identified as inappropriate for infection control and resident dignity. Staff interviews confirmed that leaving urinals in such locations was not acceptable and posed risks for spillage and infection. The facility's policy indicated that if a resident preferred to keep a urinal at the bedside, it should be checked frequently and noted in the care plan, which was not done in these cases.
Failure to Coordinate Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate the Level II Preadmission Screening and Resident Review (PASARR) for a resident after a positive result from the Level I PASARR. This oversight involved Resident 17, who was admitted with a mental illness. The Level I PASARR evaluation, dated 08/10/21, indicated the need for a Level II PASARR mental health evaluation from the Department of Health Services, which was not coordinated by the facility. As a result of this failure, there was a delay in the evaluation by a medical doctor for mental illness, leading to a delay in the necessary care and services for Resident 17. The report highlights the federal requirement for Level II PASARR to ensure individuals with mental disorders or intellectual disabilities are not inappropriately placed in long-term care facilities. The regulatory health and safety codes emphasize the importance of incorporating PASARR recommendations into resident assessments and care planning, which was not adhered to in this case.
Failure to Assist Resident with CPAP Use and Lack of No Smoking Signage
Penalty
Summary
The facility failed to ensure that a resident was using his continuous positive airway pressure (CPAP) machine every night as prescribed. The resident, who had intact cognition and required maximum assistance with activities of daily living, reported that he had not used his CPAP regularly for months because staff did not assist him in wearing the CPAP mask. The resident had difficulty putting on the mask due to issues with hand strength and dexterity, and the CPAP machine's location in his room made it challenging for him to access it. Despite a plan for a room transfer to facilitate easier access to the CPAP, this had not occurred, and staff often told the resident to put on the mask himself. The Director of Nursing (DON) confirmed that the resident had a CPAP machine and acknowledged that nurses should have assisted him in using it every night. The DON was unaware of the resident's non-compliance with CPAP use and could not explain why the room change had not been implemented. Licensed staff and the Infection Preventionist (IP) emphasized the importance of having a physician order specifying the CPAP settings and assisting the resident with the CPAP mask if requested. The absence of a physician order with the correct CPAP settings was noted, and the DON verified that the order lacked essential components such as oxygen concentration and flow settings. Additionally, the facility failed to post a no smoking sign in the resident's room, despite the use of a CPAP machine. Both licensed staff and the IP confirmed the absence of the signage and highlighted its importance in preventing accidents and fire risks. The facility's policy and procedure for CPAP/BiPAP support required reviewing the physician's order for oxygen concentration and flow and posting a no smoking sign in the resident's room, which was not followed in this case.
Failure to Provide Hearing Services for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 1, gained access to necessary hearing services. Despite Resident 1's repeated requests to see an audiologist, no referral was made, and no appointment was scheduled. The resident's hearing aids were not checked for functionality, leading to difficulties in hearing spoken words. This oversight was confirmed through observations and interviews with the resident, who expressed frustration over the lack of action taken to address her hearing issues. Resident 1 was admitted to the facility with diagnoses including hyperlipidemia, type 2 diabetes mellitus, and muscle weakness. Her cognitive status was intact, as indicated by a BIMS score of 14. Despite needing assistance with activities of daily living, the resident was not provided with the necessary support to address her hearing impairment. Interviews with various staff members, including the Director of Nursing, Social Services Director, and other licensed staff, revealed a lack of protocol and action regarding the resident's hearing needs. The staff acknowledged the resident's hard of hearing condition and the associated risks of miscommunication, frustration, and potential safety issues. However, there was no evidence of a referral to an audiologist or any attempt to ensure the resident's hearing aids were functioning. The facility's policy on supporting activities of daily living did not specifically address the needs of residents with hearing impairments, contributing to the oversight in Resident 1's care.
Failure to Provide Ordered ROM Exercises for a Resident
Penalty
Summary
The facility failed to provide Range of Motion (ROM) exercises for one of the sampled residents, Resident 23, as ordered by her physician and outlined in her comprehensive care plan. Resident 23, who has a principal diagnosis of Multiple Sclerosis and suffers from contractures in both ankles and paraplegia, was supposed to receive passive ROM exercises with her upper extremities 2-3 times per week. However, due to the absence of a Restorative Nursing Assistant (RNA) for approximately two months, these exercises were not performed. Interviews with staff and the resident confirmed that no ROM exercises had been conducted during this period. The deficiency was further highlighted by the facility's own Restorative Nursing Program document, which mandates daily performance of such services to maintain patients' optimum level of function. Despite this requirement, the facility did not have an RNA available, and the Director of Nursing could not recall the duration of this absence. Resident 23 expressed that neither the former RNA nor the Certified Nursing Assistants (CNAs) had been performing the ROM exercises, and she noted that the CNAs lacked the knowledge and time to do so. This oversight had the potential to lead to the development or worsening of contractures, affecting the resident's health and well-being.
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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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