Upland Rehabilitation And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Upland, California.
- Location
- 1221 E Arrow Hwy, Upland, California 91786
- CMS Provider Number
- 055374
- Inspections on file
- 33
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Upland Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness and mobility issues was not provided with restorative nursing assistance for ambulation after completing physical therapy, despite care plan requirements and recommendations from rehab staff. Staff interviews confirmed that only upper body RNA was performed, and the resident was not assisted with walking, contrary to facility policy.
Surveyors identified that the facility did not maintain required fire sprinkler system records and had an illegible Auxiliary Drain information sign. The Maintenance Director could not provide documentation of the annual sprinkler inspection, and the only available record was from a previous five-year inspection. This deficiency affected all staff and residents in the facility.
Surveyors observed several cigarette butts on the ground in the designated smoking area, and the Maintenance Director was unaware of their presence or duration. This failure to maintain the smoking area in accordance with regulations affected all residents in the facility.
A penetration in the wall beneath a restroom sink in one room created a seven-inch opening, compromising the fire barrier and potentially allowing smoke and gases to pass between areas. The Maintenance Director was unaware of how long the issue had existed, and this deficiency affected 32 residents in one smoke compartment.
A corridor kitchen door equipped with a self-closing device was found not to latch when tested during a facility tour, as confirmed by the Maintenance Director. This deficiency impacted 32 residents in one smoke compartment and resulted in noncompliance with NFPA 101 standards for self-closing doors.
A box of sponge cakes belonging to a housekeeper was found stored in a refrigerator designated for residents' food only, despite clear signage and facility policy prohibiting employee food storage in that area. Staff interviews confirmed the food's ownership and revealed lapses in daily monitoring, resulting in a failure to follow food safety standards and facility policy.
A resident requiring one-on-one meal assistance, with multiple medical conditions, was assisted by a CNA who stood over them during feeding, contrary to both the resident's preference and facility policy. Leadership and facility documents confirmed that staff are expected to be seated at eye level to promote dignity and safe feeding, but this procedure was not followed.
The facility did not consistently provide or document opportunities for residents or their representatives to formulate Advance Directives. In several cases, forms were incomplete, missing, or not followed up, affecting residents with both impaired and intact decision-making capacity. Staff interviews confirmed that required processes for offering and recording Advance Directive information were not reliably implemented.
A resident with chronic respiratory failure received PRN clonazepam for anxiety, and the order was extended beyond the initial period without documented rationale from the prescriber in the medical record. The DON confirmed that this extension lacked the required documentation, which did not comply with facility policy on psychoactive drug monitoring.
A resident admitted for orthopedic aftercare following a left below-the-knee amputation was discharged without the required advance notification to the State LTC Ombudsman. The facility's policy and federal regulations require that the Ombudsman be notified at least 30 days before discharge, but staff confirmed the notification was sent after the resident had already left. Both the DON and Administrator acknowledged the failure to meet the notification timeframe.
Three residents did not have appropriate individualized care plans developed or implemented for their specific needs, including anticoagulant medication management and dental care. One resident on apixaban lacked a care plan for anticoagulant use, another resident with lost dentures and dental issues had no dental care plan, and a third resident on Lovenox did not have care plan interventions for monitoring bruising implemented after a fall. Staff confirmed the absence or lack of implementation of these care plans.
A resident with functional quadriplegia, fully dependent on staff for personal hygiene, was found with untrimmed and dirty fingernails. Staff acknowledged that nail care was not provided as required by facility policy, which mandates daily cleaning and regular trimming during ADL care. The DON confirmed that the facility's expectations and procedures for grooming were not followed.
A resident with MASD on the buttocks did not receive consistent weekly wound assessments as required by facility policy, despite ongoing physician-ordered treatment. Nursing staff confirmed missing documentation for two weeks, which is necessary to monitor wound progression and guide care.
A resident with obstructive sleep apnea who used a CPAP machine nightly did not have the machine's filter replaced according to manufacturer guidelines. Staff observed the filter was discolored and could not identify who was responsible for its maintenance. There was no documentation of filter inspection or replacement, despite the manufacturer's recommendation for regular checks and changes.
A resident with end stage renal disease who received regular dialysis had a bandage left on their dialysis access site for more than four hours after treatment, contrary to facility policy. Both an LVN and the DON observed the bandage the morning after dialysis, and records confirmed it should have been removed within three to four hours as part of post-dialysis care.
A resident with contractures and impaired upper extremity mobility was assessed as able to use bed rails for mobility, despite being fully dependent on staff and unable to utilize the rails. Documentation and staff interviews confirmed inconsistencies between the resident's actual abilities and the bed rail assessment, resulting in improper use of side rails.
A resident with chronic heart failure and on dialysis did not receive a prescribed dose of furosemide after an LVN withheld the medication due to an unclear order to hold all blood pressure meds on dialysis days. The nurse did not clarify whether the diuretic, ordered for heart failure, should be held, resulting in a missed dose. The DON confirmed that facility policy requires clarification of any questionable orders.
Surveyors identified that medications in one medication room were stored at temperatures exceeding manufacturer recommendations, with the room temperature recorded at 78°F on two days. Multiple medications requiring storage at or below 77°F were found in this room, and both the ADON and DON acknowledged the facility's policy to follow manufacturer guidelines for medication storage.
A resident with osteoarthritis and a history of stroke had physician orders for daily RNA services for ambulation, but documentation was incomplete, with only a few entries in one month and none in the following month. The RNA and DON confirmed that services provided or refused should have been documented, and facility policy requires complete documentation of care.
A single-dose acetic acid container was not discarded after opening and was stored in a treatment cart for several days, contrary to manufacturer instructions and facility policy. Additionally, a non-laundry staff member entered the clean area of the laundry department and removed clean linens, despite facility protocols restricting this area to laundry staff only. Both actions were inconsistent with infection control procedures.
A resident with limited mobility was left uncovered in bed by a CNA, violating privacy standards. Another CNA delayed attending to the resident for a change, failing to request assistance. These actions did not adhere to the facility's policy on resident dignity and timely care.
A LTC facility failed to provide a resident's medical records to their legal representative after a written request. The resident, with multiple health conditions, had a legal representative who claimed to have successfully faxed a request for the records. However, the facility's staff denied receiving the fax until a follow-up call was made. This failure potentially violated the resident's rights to access their medical records.
A resident's dignity and rights were compromised when an LVN entered her room without permission and removed her oxygen tubing, mistaking it for another resident's. The resident, who was cognitively intact and required assistance for daily activities, was left confused and upset. The facility's policy on resident rights, emphasizing respect and dignity, was not followed, as confirmed by the DON.
A resident with multiple serious health conditions developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. Despite being assessed as high risk for pressure sores, preventive measures such as turning and repositioning and the use of a low air loss mattress were implemented only after the ulcer developed. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
A resident with limited mobility was not provided a bedside commode or assisted to the bathroom, despite the facility's policy to assess and assist residents with toileting needs. This failure potentially impacted the resident's dignity and psychological well-being.
Failure to Provide Restorative Ambulation Services After PT Discharge
Penalty
Summary
A resident with diagnoses including muscle weakness, type 2 diabetes, hypertension, and gait abnormalities was admitted to the facility and required assistance to maintain or improve mobility. The resident's care plan indicated a need to improve functional mobility and reduce fall risk, with interventions to address limited physical mobility. After the resident completed physical therapy, facility staff failed to continue restorative nursing assistance (RNA) exercises for ambulation, despite the care plan and recommendations from the rehab staff that the resident should have been placed on an RNA program for walking. Observations and interviews revealed that the resident remained in bed and only received RNA for the upper body, with no ambulation exercises provided. The CNA and LVN confirmed the resident stayed in her room and had not been observed walking, while the restorative nursing assistant stated that only upper body RNA was performed. The facility administrator acknowledged that there was no continuation of therapy for RNA after physical therapy ended, and the resident was not placed on the RNA program for ambulation as required by facility policy.
Failure to Maintain and Document Fire Sprinkler System Inspections
Penalty
Summary
The facility failed to maintain the automatic fire sprinkler system in accordance with regulatory requirements. During a document review and interview, surveyors found that the Auxiliary Drain information sign located on the west outside wall near the generator was faded and illegible. The Maintenance Director stated that the contractor responsible for replacing sprinkler system signs during the semi-annual inspection had been informed about the need for replacement approximately two months prior, but the sign had not yet been replaced. Additionally, the facility was unable to provide records of the required annual sprinkler system inspection and testing. The only documentation available was from a five-year sprinkler inspection/test conducted previously. The Maintenance Director indicated that the facility was under contract with a sprinkler company that was supposed to conduct annual inspections automatically, but no records for the most recent annual inspection could be located. This deficiency affected all staff and all 192 residents across six smoke compartments.
Plan Of Correction
K353 NFPA 101 Sprinkler System - Maintenance and Testing How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. The automatic fire sprinkler system inspection and testing was immediately scheduled and completed on 5/27/25. The auxiliary Drain Information sign was replaced on 5/27/25. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by this finding. Maintenance director completed audit to ensure all inspections and testing are up to date. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on 5/27/25 by the Administrator regarding policy on ensuring that all sprinkler inspections and testing are completed to ensure compliance. Maintenance director will ensure that all logs are reviewed monthly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or designee will review inspection and testing records for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 353
Failure to Maintain Smoking Area Cleanliness
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed approximately five cigarette butts on the ground near the designated smoking area. The Maintenance Director stated that he was unaware of the cigarette butts being present and did not know how long they had been there. This observation indicated that the facility failed to properly maintain the smoking area as required by regulations, specifically regarding the disposal of cigarette butts. The deficiency affected all 192 residents across six smoke compartments. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Plan Of Correction
K741 NFPA 101 Smoking Regulations How corrective action will be accomplished for those residents found to have been affected by the identified practice: All cigarette butts were immediately picked up from the smoking area ground. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to have been affected by the practice. Housekeeping staff will ensure that all smoking areas are cleaned daily, ash trays are emptied out, and any cigarette butts are picked up daily. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Housekeeping staff were in serviced on 5/27/25 by the Administrator regarding keeping smoking areas free of smoking debris on the floor. Housekeeping supervisor or designee will check smoking areas to ensure compliance weekly for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: The Administrator or Designee will do rounds weekly and for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: Імие 9, 2025.
Unsealed Wall Penetration Compromises Fire Barrier
Penalty
Summary
During a facility tour and interview with the Maintenance Director, surveyors observed a deficiency related to the building's construction. Specifically, in Room 203, there was a drain cap underneath the restroom sink that was not flush with the wall, resulting in an approximately seven-inch crescent-shaped penetration. This opening was identified as a potential pathway for smoke and gases to travel between different parts of the building, which is not in compliance with fire safety requirements for health care occupancies. The Maintenance Director was interviewed at the time of the observation and stated that he was unsure how long the penetration had been present. This deficiency affected 32 out of 192 residents in one of the six smoke compartments within the facility. The report does not provide additional details about the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations and is intended to serve as a credible allegation of our intent to correct the practices identified as deficient. The Plan of correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in Medicare/Medicaid program(s). K161 NFPA 101 Building Construction type and height. How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The Penetration in Room 203 was immediately fixed. No residents were affected by this finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken. All residents have the potential to have been affected by the practice. Maintenance director and assistant checked all other drain caps in all restrooms and no issues were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur. Maintenance Staff were in serviced on June 2, 2025 by administrator regarding the policy penetrations in the facility. Maintenance Director or designee will check all storage rooms and hallways to ensure there are no penetrations weekly for the next 3 months. Dept heads or designee will check their Guardian Angel rooms weekly for any penetrations for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or designee will do rounds weekly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025. K 161
Failure to Maintain Self-Closing Door Latching Mechanism
Penalty
Summary
During a facility tour and interview with the Maintenance Director, it was observed that a corridor kitchen door equipped with a self-closing device did not latch when tested. The Maintenance Director acknowledged at the time of observation that he had just realized the door was not latching. This deficiency affected 32 out of 192 residents in one of six smoke compartments. The report documents that the door's failure to latch could allow the passage of smoke and gases from one part of the building to another, as the door was not maintained in accordance with NFPA 101 requirements for self-closing devices.
Plan Of Correction
K223 NFPA 101 Doors with self-closing devices How corrective action will be accomplished for those residents found to have been affected by the identified practice: Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: The door with self-closing device that did not latch when released was immediately fixed by maintenance staff. No residents were affected by the finding. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: All residents have the potential to be affected by this practice. Maintenance director and assistant conducted a sweep of all self-closing doors to ensure they latch upon release. No other findings identified. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: Maintenance staff were in serviced on June 2, 2025 by the administrator regarding policy on self-closing devices. Maintenance Director or Designee will check all self-closing devices biweekly to ensure compliance for the next 3 months. How the facility plans to monitor its performance to make sure that solutions are sustained: The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. The Administrator or Designee will do rounds monthly for the next 3 months to monitor for compliance. Any issues will be reported to the Quality Assurance committee for review and recommendations. Completion date of corrective actions: June 9, 2025
Employee Food Improperly Stored in Residents' Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety when an employee's food was found inside a refrigerator designated for residents' food only. During an observation, a box of sponge cakes labeled with a name and date was discovered in the residents' refrigerator on Station 1, which had signage indicating it was for residents' food only and not for employee use. Staff interviews revealed uncertainty about the ownership of the food, and it was later confirmed that the food belonged to a housekeeper working at night. The administrator acknowledged that staff should not have placed their food in the residents' refrigerator and that the facility's policy required daily monitoring of these refrigerators by designated staff. A review of facility records showed that Station 1 had 56 residents, with 50 on oral diets, making them potentially susceptible to cross-contamination from improper food storage. The facility's policy on resident/personal food storage required monitoring for food safety, but this policy was not followed in this instance. The FDA Food Code was also referenced, indicating that ready-to-eat food potentially contaminated by an employee should be discarded. The failure to adhere to these standards and policies resulted in a deficiency related to food storage and safety.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
A deficiency was identified when a Certified Nurse Assistant (CNA) failed to treat a resident with dignity during a meal. The resident, who had diagnoses including unstable angina, atherosclerosis, hypertension, and diabetes, required one-on-one assistance during meals. During an observation, the CNA was seen standing over the resident while assisting with feeding, despite the resident expressing a preference for the CNA to be seated. The CNA acknowledged that the correct procedure was to be seated facing the resident during feeding. Further interviews with facility leadership confirmed that the expectation and facility policy required CNAs to be seated at eye level with residents during feeding to promote dignity and ensure safe feeding practices. Review of the facility's feeding techniques document also specified that staff should never stand above or lean over residents while feeding them. The Director of Nursing confirmed that the CNA did not follow the facility's established procedure in this instance.
Failure to Document and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to honor residents' rights to formulate Advance Directives for five sampled residents. For three residents, the Advance Directives Checklist forms did not indicate whether they were provided an opportunity to formulate an Advance Directive. Specifically, one resident's form acknowledged receipt of information but did not document whether the resident wished to formulate an Advance Directive, and the resident reported not being offered assistance. Another resident's form was incomplete, with unchecked boxes and a responsible party who was unsure what an Advance Directive was or if it had been offered. A third resident's form was undated, unsigned, and did not indicate whether the responsible party was provided with information, despite the resident being severely cognitively impaired and unable to follow commands. For another resident with severe cognitive impairment and no decision-making capacity, the Advance Directives Checklist was faxed to the responsible party for signature, but the form remained unsigned and there was no documentation that the responsible party received the information or was given the opportunity to complete the Advance Directive. In the case of a fifth resident, who had full decision-making capacity, there was no Advance Directives Checklist in the medical record, and the POLST form was incomplete regarding the Advance Directive section. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, confirmed that the process for providing and documenting Advance Directive information was not consistently followed. The facility's policy required that residents or their representatives be provided with written information about Advance Directives upon admission and that this be documented in the health record, but this was not done for the affected residents.
Lack of Documentation for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that the medical record contained documentation demonstrating the rationale for extending a PRN (as needed) psychotropic medication order for a resident. Specifically, a resident with chronic respiratory failure had a PRN order for hydroxyzine for anxiety, which was later changed to a scheduled dose, and subsequently, clonazepam was started as a PRN medication for anxiety. The clonazepam PRN order was extended beyond the initial 14-day period without documentation from the prescribing practitioner explaining the medical necessity for this extension in the resident's medical record. Review of the resident's records showed that the medication was administered as ordered, and observations confirmed the resident was sleeping after receiving the medication. During interviews and record reviews with the DON, it was acknowledged that the required documentation for the rationale behind the continued PRN use of clonazepam was missing, which was not in accordance with the facility's own policy on psychoactive drug monitoring. The policy requires that the medical necessity for psychoactive medications be documented and regularly reassessed, with any continuation clearly indicated in the medical record.
Failure to Notify Ombudsman Prior to Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman prior to the discharge of a resident who had been admitted for orthopedic aftercare following a left below-the-knee amputation. The resident was determined to have the capacity to understand and make decisions. According to the facility's own policy and federal requirements, the Ombudsman should be notified at least 30 days before a resident is transferred or discharged, or as soon as practicable before the event. Record review and staff interviews revealed that the Notice of Proposed Transfer/Discharge for the resident was faxed to the Ombudsman's office after the resident had already been discharged. The Director of Social Services confirmed the late notification, and both the Director of Nursing and the Administrator acknowledged that the required notification timeframe was not met. The facility's policy was reviewed and found to be consistent with the regulatory requirement for advance notification.
Failure to Develop and Implement Individualized Care Plans for Medication and Dental Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for three residents, resulting in deficiencies related to medication management and dental care. For one resident with atrial fibrillation who was prescribed apixaban, there was no care plan developed to address the use of this anticoagulant, despite documentation confirming the medication was being administered as ordered. Staff interviews confirmed the absence of a care plan and acknowledged the necessity of such a plan to guide monitoring and care. Another resident, who was cognitively intact and had both upper and lower dentures upon admission, experienced the loss of their dentures while at the facility. Despite dental assessments, recommendations for tooth extraction, and ongoing issues with eating and appearance, there was no care plan developed to address the resident's dental care needs. Staff and social services confirmed awareness of the dental issues and the lack of a corresponding care plan. A third resident, with a history of stroke and on anticoagulant therapy (Lovenox), had a care plan that included interventions for daily skin inspections and monitoring for complications such as bruising. However, after the resident sustained a fall and developed bruising, there was no evidence that the care plan interventions were implemented, as required. The DON confirmed that the resident's bruising should have been monitored according to the care plan, but this was not documented or carried out.
Failure to Provide Proper Nail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with functional quadriplegia, who was dependent on staff for personal hygiene, was observed with untrimmed and dirty fingernails on the right hand. The resident's Admission Record indicated a diagnosis of functional quadriplegia, and the Minimum Data Set confirmed functional limitations in both upper and lower extremities, requiring staff assistance for personal hygiene. During an observation, the resident's fingernails were found to be untrimmed and dirty, and a Certified Nurse Assistant acknowledged that the nails should have been trimmed and clean, in accordance with facility expectations. A review of the facility's policy and procedure for nail care revealed that daily cleaning and regular trimming of nails during activities of daily living (ADL) care were required to prevent infections and skin problems. The Director of Nursing confirmed that the facility's policy was not followed in this instance and that the expectation for grooming services for the resident was not met.
Failure to Consistently Assess and Document Wound Care
Penalty
Summary
The facility failed to provide consistent wound assessments for a resident with moisture-associated skin damage (MASD) on the buttocks, as required by the facility's policy and procedure. The resident, who had a history of peripheral vascular disease and chronic obstructive pulmonary disease, was admitted with a physician's order for daily wound care and a reevaluation after 21 days. However, a review of the medical record revealed that there were no documented assessments of the wound for two consecutive weeks, despite the ongoing treatment. During interviews and record reviews, a licensed vocational nurse confirmed the absence of wound assessment documentation for the specified weeks and acknowledged the importance of such documentation in guiding care and monitoring the wound's progress. Observations confirmed the presence of scattered areas of skin redness and shallow open areas on the resident's buttocks. The facility's policy required weekly head-to-toe assessments by licensed nursing staff, which were not completed as documented for the resident during the identified period.
Failure to Replace CPAP Filter According to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide appropriate respiratory care services for one resident with obstructive sleep apnea who required nightly use of a CPAP machine. The resident's care plan and physician's order specified the use of the CPAP machine at bedtime. During multiple observations and interviews, it was found that the filter in the resident's CPAP machine was discolored, appearing light grey and dark grey, rather than the white color of a new filter. Staff, including a licensed vocational nurse, the assistant director of nursing, and the respiratory therapy supervisor, acknowledged the filter's condition and were unsure who was responsible for checking or replacing it. A review of the manufacturer's user guide indicated that the CPAP filter should be checked and replaced at least every six months, or more frequently if dirty or blocked. However, there was no documentation that the filter had been inspected or changed for this resident. The director of nursing confirmed that nursing staff were responsible for ensuring the CPAP machine was functioning and that the respiratory department was responsible for settings, but acknowledged the facility did not follow the manufacturer's guidelines for filter replacement.
Failure to Timely Remove Dialysis Site Bandage
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, who required regular dialysis treatments, was found to have a bandage left on their dialysis access site for more than four hours after returning from dialysis. The resident was admitted with a diagnosis of irreversible kidney failure and had physician orders for dialysis three times a week. On the morning following a dialysis session, a bandage was observed on the resident's left arm by both an LVN and the DON. Upon review, it was confirmed that the bandage had been in place since the previous day's dialysis treatment. Facility records, including the Facility/Dialysis Center Nursing Communication Record and the facility's inservice lesson plan, indicated that post-dialysis care required bandages to be removed within three to four hours after treatment. The DON acknowledged that the bandage should have been removed within this timeframe, but it remained on the resident's arm for longer, contrary to facility policy and best practices for post-dialysis care.
Inaccurate Bed Rail Assessment and Use for Dependent Resident
Penalty
Summary
The facility failed to ensure that the bed rail assessment for a resident with significant functional limitations was accurate and that the use of side rails was appropriately indicated. The resident in question had contractures and impaired range of motion in both upper extremities, as documented in multiple assessments, including the Minimum Data Set and Occupational Therapy evaluation. Despite these limitations, a physician's order and a Bed Rail Safety Evaluation indicated that side rails were to be used to aid in bed mobility, and the evaluation inaccurately stated that the resident could move freely in bed without signs of impaired mobility. Observations and staff interviews confirmed that the resident was dependent on staff for all mobility and activities of daily living, and was unable to use the side rails due to contractures. During care, the resident did not reach for or hold onto the side rail when prompted, and staff acknowledged the resident's inability to use the rails. The Director of Rehabilitation Services also confirmed that the side rails could not aid the resident's mobility due to the functional limitations. The facility's policy required ongoing assessment to ensure bed rails met the resident's needs, but this was not accurately reflected in the resident's documentation or practice.
Failure to Clarify Medication Orders Leads to Missed Dose
Penalty
Summary
The facility failed to ensure safe and effective pharmaceutical services for a resident with a history of chronic congestive heart failure, hypertension, and dependence on renal dialysis. The resident had a physician's order for furosemide, a diuretic, to be administered twice daily for congestive heart failure. A subsequent order instructed staff to hold all blood pressure medications on the morning of dialysis days. However, the furosemide, which was prescribed for heart failure and not specifically for blood pressure, was withheld by the nurse on a dialysis day without clarifying the order with the physician. During interviews and record reviews, the nurse acknowledged that the furosemide was categorized as a diuretic and not a blood pressure medication, and that the two orders should have been clarified to avoid confusion. The Director of Nursing confirmed that facility policy requires verification of any order that appears inappropriate considering the resident's condition or diagnosis. The failure to clarify the medication orders resulted in the resident not receiving the prescribed furosemide dose as intended.
Medications Stored Above Manufacturer-Recommended Temperature
Penalty
Summary
Surveyors found that the facility failed to store medications at the appropriate temperature in one of three medication rooms, specifically the Station 2 Medication Room. The daily temperature log showed that the room temperature reached 78°F on two consecutive days, exceeding the maximum storage temperature of 77°F indicated on the product labeling for several medications. During an inspection, multiple medications, including acetaminophen, senna syrup, loperamide, and docusate sodium, were observed stored in this room. The Assistant Director of Nursing confirmed that the product labels required storage at or below 77°F. A review of the facility's policy on medication storage, approved in January 2025, stated that medications and biologicals must be stored safely and according to manufacturer recommendations. The Director of Nursing acknowledged this policy during the interview and record review. The failure to maintain the required storage temperature for these medications constituted a deficiency in following both manufacturer guidelines and facility policy.
Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Restorative Nursing Assistant (RNA) services for one resident. The resident, who had diagnoses including osteoarthritis in both knees and a history of stroke, was admitted with physician orders specifying RNA services for ambulation with a front wheel walker five times a week. Review of the resident's medical record showed only four RNA entries for March and no entries for April, despite the ongoing order for daily services on weekdays. During an interview and record review, the RNA stated that documentation should be completed after providing or attempting RNA services, including noting if the resident refused. The Director of Nursing confirmed the absence of documentation for RNA services from March 9 through the end of April. Facility policies reviewed indicated that appropriate documentation is required to address program goals and resident tolerance, as well as to provide a complete account of care and treatment.
Failure to Discard Single-Dose Acetic Acid and Unauthorized Access to Clean Laundry Area
Penalty
Summary
The facility failed to implement proper infection prevention and control measures in two distinct situations. In the first instance, a single-dose container of acetic acid, used to prevent blockage in tubes connected to residents, was not discarded after being opened. The container was labeled with the date it was opened and was found stored in a treatment cart several days later. Interviews with the LVN, DON, and Infection Preventionist confirmed that the acetic acid was a single-dose, preservative-free solution, and manufacturer instructions required prompt use and immediate disposal of any unused portion. Facility policy also required medications to be stored and handled according to manufacturer recommendations, which was not followed in this case. In the second situation, a non-laundry staff member entered the restricted clean area of the laundry department and removed clean linens from a linen cart. Observations and interviews with the Environmental Services Supervisor, Infection Preventionist, and DON confirmed that only laundry staff were permitted to handle clean linens in the clean area, and non-laundry staff were required to remain outside this area. Facility policies on infection prevention and laundry services emphasized the importance of restricting access and handling of clean linens to prevent the spread of infection. Both deficiencies were identified through direct observation, staff interviews, and review of facility policies and manufacturer instructions. The actions taken by staff in both cases were inconsistent with established infection control protocols and facility procedures, leading to the cited deficiencies.
Failure to Ensure Resident Privacy and Timely Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was admitted with diagnoses including an internal right hip prosthesis, heart failure, and hypertension. The resident's care plan emphasized the need for privacy to promote dignity. However, a Certified Nursing Assistant (CNA 1) left the resident naked and uncovered in bed with the curtain halfway open, failing to ensure privacy as required by the care plan. This action was acknowledged by CNA 1, who admitted to forgetting to cover the resident with a sheet before leaving the room. Additionally, another CNA (CNA 2) took an extended period to attend to the resident for a change. During an interview, CNA 2 mentioned being occupied with other residents, which delayed attending to the resident's needs. The Director of Nursing (DON) indicated that CNA 2 should have requested assistance to ensure timely care. Both instances were noted as failures to adhere to the facility's policy and procedure, which mandates treating residents with respect and dignity.
Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide a resident or their legal representative with a copy of medical records following a written request. This deficiency was identified for one of the three residents reviewed for resident rights. The resident in question was admitted to the facility with multiple diagnoses, including sepsis, urinary tract infection, generalized muscle weakness, type 2 diabetes mellitus, and dementia. The legal representative of the resident claimed to have sent a fax request for the medical records, with a successful transmission confirmation, but the facility's Medical Record Director (MRD) denied receiving such a request. Interviews with the MRD and the Administrator revealed that the facility did not acknowledge receiving the faxed request on the date specified by the legal representative. The facility's policy requires a 48-hour notice for such requests, excluding weekends and holidays. Despite the legal representative's confirmation of the fax transmission, the facility maintained that they did not receive the request until a later date, when a follow-up phone call was made by the legal representative's law office. The facility's failure to provide the requested medical records within the stipulated time frame potentially violated the resident's rights.
Failure to Respect Resident's Dignity and Rights
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a staff member entered the resident's room and removed her oxygen tubing without permission. The incident involved a resident who was cognitively intact and required maximal assistance for daily living activities. The resident had been admitted with diagnoses including heart failure, Type 2 diabetes mellitus, and hypertension. On the day of the incident, a Licensed Vocational Nurse (LVN) entered the room without announcing herself and mistakenly removed the resident's oxygen tubing, assuming it belonged to another resident. This action was taken without verifying the ownership of the oxygen concentrator or explaining the action to the resident. The resident was left confused and upset by the removal of her oxygen tubing, which was reported to the facility administrator the following day. The resident's daughter also reported the incident, and the resident expressed her distress to a Certified Nursing Assistant (CNA) who assisted her afterward. The Director of Nursing (DON) confirmed that the facility's policy on resident rights, which emphasizes respect and dignity, was not followed in this instance. The failure to adhere to these policies compromised the resident's dignity and violated her rights.
Failure to Prevent Pressure Ulcer in High-Risk Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of a pressure ulcer in a resident who was admitted with multiple serious health conditions, including metabolic encephalopathy, acute respiratory failure, and acute kidney failure. Upon admission, the resident had scar tissue on the coccyx and unstageable tissue depth blisters on the heels, but no open wounds. The resident was assessed as high risk for pressure sores, with a Braden Scale score of 7. Despite this, the resident developed an unstageable pressure ulcer on the coccyx and left buttocks while in the facility. The facility's records indicate that the resident was initially observed with moisture-associated skin damage to the buttocks, and interventions such as turning and repositioning every two hours and the use of a low air loss mattress were ordered. However, these measures were implemented after the pressure ulcer had already developed. Interviews with the treatment nurse and the DON revealed that the resident's fragile condition and comorbidities contributed to the development of the ulcer, but the facility's policy required preventive measures to be in place to avoid such occurrences. The facility's failure to prevent the pressure ulcer placed the resident's health and safety at risk.
Failure to Accommodate Resident's Toileting Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident 1, by not providing a bedside commode and not assisting the resident to the bathroom for toileting. This deficiency was identified during a review of Resident 1's admission record and care plan, which indicated a self-care performance deficit related to limited mobility. The care plan aimed for the resident to perform activities of daily living with modified independence, including toilet use, while promoting dignity and ensuring privacy. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) revealed that the facility's usual practice is to assess residents upon admission for their ability to transfer and to assist them to the bathroom upon request. The facility's policy and procedure for admission, transfer, and discharge rights outlined the objectives to admit residents who can be adequately cared for by the facility. However, the failure to provide the necessary toileting assistance and equipment for Resident 1 had the potential to impact the resident's psychological well-being by affecting their respect and dignity.
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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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