West Shore Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Alameda, California.
- Location
- 508 Westline Drive, Alameda, California 94501
- CMS Provider Number
- 056103
- Inspections on file
- 30
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at West Shore Post Acute during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain required records of smoke detector sensitivity testing, as no documentation was available to show that testing had been performed within the required timeframe. This deficiency affected all residents and all smoke compartments, with the Maintenance Director unable to provide the necessary records when requested.
Surveyors found that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room, with items placed about one foot from the panel. The Maintenance Director confirmed the desk was recently added for new staff. This obstruction affected 36 residents in one smoke compartment and did not meet NFPA requirements for clear workspace around electrical equipment.
Surveyors found that the emergency preparedness plan did not include strategies for addressing the needs of at-risk or vulnerable residents. During review, the Administrator could not provide the required policy, and the facility did not submit the missing records when given the opportunity. This deficiency affected all residents.
Surveyors found that the facility did not have a policy or procedure in its Emergency Preparedness plan explaining the use of volunteers or other emergency staffing strategies, as required. During document review and interviews, the Administrator was unaware of the missing policy, and the facility did not provide the required documentation when given the opportunity. This deficiency affected all residents.
Surveyors found that the facility did not have required policies and procedures for providing care at an alternate care site under an 1135 waiver. During review and interviews, the Administrator was unaware of the missing policy, and the facility could not provide the necessary documentation for all residents when requested.
Surveyors found that the facility did not have a documented emergency preparedness training and testing program for staff, and the Administrator was unaware of the missing policy. This deficiency affected all residents, as the required records were not provided when requested.
The facility did not participate in a full-scale community-based emergency preparedness exercise within the required timeframe, as confirmed by record review and staff interviews, resulting in noncompliance with federal emergency preparedness regulations for all residents.
Surveyors found that the facility did not provide documentation of the required annual battery charger test and 30-minute discharge test for the Fire Alarm Control Panel, as required by NFPA standards. The Maintenance Director was unable to explain the absence of these records, and no additional documentation was submitted when requested. This deficiency affected all residents in the facility.
The facility failed to provide documentation for a required night shift fire drill during one quarter, as discovered during a review of fire drill records. The Maintenance Director was unable to produce the missing record, and no documentation was submitted by the deadline, affecting all residents in the facility.
The facility did not document discussions about advance directives with three residents, including one who was cognitively intact and two with severe cognitive impairment and complex medical conditions. Medical records and POLST forms lacked evidence that advance directives were addressed or available, and staff interviews confirmed the absence of required documentation.
Two residents with intact cognition reported discomfort and reluctance to use their bathrooms due to old, worn linoleum flooring with black stains and a toilet seat with visible scratch marks. Observations confirmed the unclean and unhomelike conditions, and staff acknowledged the issues but had not fully addressed or reported them.
A resident with dementia and poor cognition repeatedly wandered into other residents' rooms, turned off lights, and took personal items, despite care plan interventions of monitoring and redirection. Staff and other residents reported ongoing incidents, including falls and emotional distress, as the resident continued these behaviors and became agitated when redirected. The facility's interventions were not effective in preventing these occurrences.
A resident's MDS assessment was inaccurately coded to indicate no wandering behavior, despite observations and staff interviews confirming frequent wandering, room entry, and agitation when redirected. The Social Services Director acknowledged the error in coding.
A resident with a history of aggressive behavior and impaired cognition entered another resident's room, ignored requests to leave, and slapped the resident in the face, causing emotional distress and repeated altercations. The incident was witnessed by a roommate and confirmed through interviews and record review, highlighting a failure to protect residents from physical abuse as required by facility policy.
A resident with Alzheimer's and dementia was not adequately protected from physical abuse, resulting in injury after being struck by another resident and experiencing unwanted physical contact in the activity room. Staff interviews, surveillance footage, and medical records confirmed the incidents, and facility policies requiring monitoring and redirection were not effectively followed.
A resident with dementia, morbid obesity, and complete dependence for ADLs was provided incontinence care by a CNA without the required second staff member. Despite being aware of the need for two-person assistance, the CNA proceeded alone, resulting in the resident falling from bed and sustaining fractures to the left arm and leg. The resident was not a candidate for surgery and was discharged to hospice care. Facility records and staff confirmed the resident was at high risk for falls and required two-person assistance, which was not provided.
The facility failed to provide admission agreements to three residents, including one with dementia and another receiving palliative care. The agreements, which outline residents' rights and services, were either delayed or not provided at all, contrary to facility policy.
A facility failed to provide a resident or their representative with written information about the bed-hold policy during a transfer. The resident, with multiple health issues, had a Bed Hold Notification Form that was incomplete, lacking necessary signatures and information. The facility's policy requires written notification prior to transfers, which was not fulfilled in this case.
The facility's patio area was found to be unsafe due to clutter from refrigerator parts, a broken concrete pad, and leaking water hoses creating puddles near resident doors. These conditions posed trip hazards for residents. Interviews with staff confirmed the presence of these hazards and acknowledged the need for removal and proper maintenance.
A resident was discharged without the correct medication instructions, leading to the potential misuse of heparin, a blood thinner. The discharge summary did not include heparin, despite it being part of the active orders. The Nurse Supervisor discharged the resident with heparin without verifying the discharge summary, and the facility policy on medication reconciliation was not followed.
A resident in an LTC facility lost their hearing aids, valued at $2000, and the facility failed to investigate or assist in their replacement. Despite the resident and their family reporting the loss, the facility did not complete the necessary Theft and Loss Report or notify law enforcement as required by policy. The Social Services Director did not take responsibility for the investigation, and the resident's family stated the facility did not respond to requests for assistance.
A resident with severe cognitive impairment did not receive scabies treatment as ordered, as Permethrin cream was washed off two hours after application instead of the prescribed 12 hours. The error was not reported to the physician, and there was no documentation of the incident. Interviews revealed communication lapses among staff, with the CNA unaware of the treatment, leading to the premature washing off of the cream. Facility policies on medication administration and scabies treatment were not adhered to.
A CNA in a LTC facility failed to follow infection control protocols by not performing hand hygiene before feeding a resident with severe cognitive impairment. The CNA did not wash her hands or use sanitizer after handling items in the resident's room and before feeding, despite being aware of the requirement. Facility staff confirmed the expectation for hand hygiene, as outlined in the facility's infection control policy.
A facility failed to follow infection control procedures when a CNA did not wear PPE while providing care to a resident on contact isolation for scabies. Despite clear signage and policy requirements, the CNA assisted the resident without wearing gloves and a gown, as confirmed by staff interviews and a review of the resident's care plan and physician orders.
Failure to Maintain Smoke Detector Sensitivity Testing Records
Penalty
Summary
The facility failed to maintain required records of smoke detector sensitivity testing as mandated by NFPA 101 and NFPA 72 standards. During a record review and interview with the Maintenance Director, surveyors requested documentation showing that smoke detector sensitivity testing had been performed within the last two years. The facility was unable to provide any records of such testing, and the Maintenance Director stated that he believed the vendor had performed the test but would need to contact them for the records. No documentation was provided to the surveyors by the deadline given. This deficiency affected all 120 residents in all four smoke compartments of the facility. The lack of records means there was no evidence that the smoke detectors had been tested for sensitivity as required, which is necessary to ensure their proper functioning in the event of a fire. The surveyors noted that no previous records were available, and the required documentation was not submitted even after an opportunity was given to provide it.
Plan Of Correction
K347-Smoke Detection 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility contracted with a certified vendor who performed smoke detector sensitivity testing on all applicable smoke detectors. The vendor's report confirmed all devices were within operational parameters. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Maintenance Director educated by the Administrator on the requirements and documentation for smoke detector sensitivity testing requirements per NFPA 72: 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review testing schedules monthly to ensure smoke detector sensitivity testing is completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. K 347
Obstructed Electrical Panel in Staff Development Room
Penalty
Summary
A deficiency was identified when surveyors observed that an electrical panel labeled 'Fire Alarm Panel Inside' was obstructed by a desk, boxes, and a backpack in the Director of Staff Development Room. The items were positioned approximately one foot away from the panel, impeding clear access. This situation was noted during a facility tour and confirmed in an interview with the Maintenance Director, who stated that the desk was recently placed due to new staff and had not been there for long. The obstruction of the electrical panel affected 36 out of 120 residents in one of four smoke compartments. The report cites specific requirements from NFPA 101, NFPA 99, and NFPA 70, which mandate that sufficient workspace must be maintained around electrical equipment to allow for safe operation and maintenance. The observed obstruction did not comply with these standards, as it limited the required clear workspace around the panel.
Plan Of Correction
K919- Electrical Equipment - Other 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, the desk and boxes obstructing electrical panel "D" in the DSD office were removed, restoring the required 36 inches of clearance. 2. Identification of other residents having the potential to be affected was accomplished by: On (date), the Maintenance Director conducted a facility-wide audit of all electrical panels and determined that no other panels were obstructed. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025 the Maintenance Director was educated by the Administrator on the requirements and documentation for maintaining a 36-inch clearance around all electrical panels in accordance with NFPA 70. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly inspection of all electrical panels to ensure required clearance is maintained. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Emergency Preparedness Plan Lacked Strategies for At-Risk Residents
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that addressed the resident population, specifically the needs of at-risk or vulnerable residents. During a record review and interview with the Maintenance Director and Administrator, it was found that the emergency preparedness plan did not include strategies for addressing the needs of these populations. The Administrator was unable to explain why the relevant policy was missing from the emergency preparedness binder. The deficiency affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the regulatory agency. The lack of documentation and planning for at-risk or vulnerable residents was directly observed during the survey process.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the Emergency Preparedness Plan was revised to include specific strategies addressing the needs of at-risk and vulnerable populations such as residents with cognitive impairments, limited mobility, and complex medical needs. 2. Identification of other residents having the potential to be affected was accomplished by: On 5/12/2025, the Interdisciplinary Team reviewed all resident records to determine which individuals were considered at-risk during an emergency. All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/25, the Emergency Plan was updated to include a section for identifying vulnerable residents, and care protocols were developed for each type of identified risk (e.g., evacuation assistance, medication needs). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Missing Emergency Staffing and Volunteer Policy in EP Plan
Penalty
Summary
The facility failed to maintain its Emergency Preparedness (EP) plan by not providing a policy and procedure that explains the use of volunteers or other emergency staffing strategies. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the EP policies and procedures and found that there was no documentation addressing the facility's use of volunteers or integration of state and federally designated health care professionals to address surge needs during an emergency. The Administrator, who had recently started working at the facility, was unaware of the missing policy. This deficiency affected all 120 residents in the facility, as the lack of a documented policy could result in an ineffective emergency preparedness plan. The facility was given an opportunity to submit the missing records, but no records were received by the specified deadline.
Plan Of Correction
E024 - Policies/Procedures: Volunteers and Staffing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/25, the facility developed a written policy outlining procedures for the use of volunteers and alternative staffing during emergencies. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected during emergency staffing shortages or volunteer involvement. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/12/2025, the policy was incorporated into the facility's Emergency Preparedness Plan. All department heads were trained on how to implement the policy during an emergency. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Emergency Preparedness Plan. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. E 024
Missing Emergency Preparedness Policy for 1135 Waiver Alternate Care Site
Penalty
Summary
The facility failed to develop and implement policies and procedures outlining its role in providing care and treatment at an alternate care site under an 1135 waiver, as required by federal regulations. During a document review and interview with the Maintenance Director and Administrator, surveyors requested the Emergency Preparedness policies and procedures. The facility was unable to provide documentation indicating a plan for the provision of care at an alternate location in the event of an emergency requiring activation of an 1135 waiver. The Administrator, who was new to the facility, stated she was not aware that the required policy was missing. The absence of this policy affected all 120 residents in the facility. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E 026 E026 - Roles Under a Waiver Declared by the Secretary 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/12/2025, the Emergency Preparedness Plan was updated to include a policy addressing alternate care sites and adjusted staffing/licensure protocols. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected in the event of a federally declared emergency requiring relocation or altered care settings. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility incorporated all guidelines into the Emergency Plan and added procedures for continuity of care in alternate locations on (date). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly inspection of the Emergency Plan to ensure waiver protocols are included and current. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Maintain Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness training and testing program for staff, as required by federal regulations. During a record review and interview with the Maintenance Director and Administrator, surveyors found that the facility could not provide the policy and procedure related to emergency preparedness training and testing. The Administrator was unaware that the policy was missing and indicated she would need to investigate the reason for its absence. This deficiency affected all 120 residents in the facility, as the lack of a documented and maintained emergency preparedness training and testing program meant that staff were not adequately prepared according to regulatory requirements. The facility was given an opportunity to submit the missing records by a specified deadline, but no records were received by the survey agency.
Plan Of Correction
E036 - Emergency Preparedness Training and Testing 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/2025, the facility conducted an Emergency Preparedness training for all staff and completed a tabletop exercise to simulate emergency response procedures. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/2025, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of training logs and exercise documentation to ensure all staff are trained and drills are conducted annually. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. 05/15/25 E 036
Failure to Conduct Required Emergency Preparedness Drill
Penalty
Summary
The facility failed to develop and maintain an Emergency Preparedness Training and Testing plan as required by federal regulations. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise within the last 12 months. This was confirmed during a record review and interview with the Maintenance Director and Administrator, where no documentation could be provided to show compliance with this requirement. During the review, it was found that the Emergency Preparedness Training program lacked evidence of participation in the mandated exercise. The Administrator confirmed that the facility had not taken part in a full-scale community-based drill, as required by 42 CFR §483.73(d)(2) for long-term care facilities. This deficiency was identified during a survey and affected all 120 residents in the facility at the time. The absence of participation in the required emergency preparedness exercise means that the facility did not meet the federal standard for testing its emergency plan. The surveyors noted that this failure could result in the facility not having adequate planning and preparation in place to protect the health and safety of residents and staff, as directly stated in the report.
Plan Of Correction
E 039 E039 - Emergency Preparedness Testing Requirements 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/09/25, the facility implemented an emergency preparedness training program for staff. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/09/25, the facility implemented an annual Emergency Preparedness training and testing calendar and established a system for tracking staff participation. On 05/09/25, the Maintenance Director educated by the Administrator on the requirements and documentation for Emergency Preparedness Training. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will review the emergency preparedness training program schedule monthly to ensure required drills are completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved. --- K345 - Fire Alarm System: Testing and Maintenance 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/08/2025, the facility's licensed fire safety vendor completed the missing annual battery charger test and the 30-minute battery discharge test for the fire alarm control panel. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On 05/08/2025, the Maintenance Director educated by the Administrator on the requirements and documentation for Fire Alarm System: Testing and Maintenance. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of the Fire Alarm testing log to ensure required testing; including battery charger and discharge tests are scheduled and completed. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Maintain and Document Required Fire Alarm System Battery Testing
Penalty
Summary
The facility failed to maintain the Fire Alarm System (FAS) in accordance with NFPA 101, NFPA 70, and NFPA 72 requirements. During a tour, record review, and interview with the Maintenance Director, surveyors requested documentation of the annual Fire Alarm Control Panel (FACP) battery charger test and the 30-minute battery discharge test for the sealed lead-acid batteries. The facility provided annual and semiannual FAS testing records, but these did not include evidence that the required battery charger test or the 30-minute discharge test had been performed within the last 12 months. The Maintenance Director stated that he believed the vendor had performed the services but could not explain why the tests were not documented in the reports. The facility was given an opportunity to provide the missing records by email, but no additional documentation was received by the deadline. This deficiency affected all 120 residents in all four smoke compartments, as the required testing and documentation for the FACP batteries were not available for review as required by the applicable codes and standards.
Missing Fire Drill Documentation for Night Shift
Penalty
Summary
The facility failed to maintain complete fire drill records as required by NFPA 101, Life Safety Code, 2012 Edition. During a record review and interview with the Maintenance Director, it was found that one of twelve required fire drills was not conducted. Specifically, the facility did not provide documentation for the night shift (NOC) fire drill during the fourth quarter of 2024. The Maintenance Director was unable to produce the missing record at the time of the survey and indicated that he would need to consult with the Administrator to determine if the records had been sent. The surveyors gave the facility an opportunity to submit the missing fire drill documentation by email, but no records were received by the specified deadline. This deficiency affected all 120 residents across four smoke compartments, as the absence of the required fire drill could impact staff familiarity with emergency procedures. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K712-Fire Drills 1. Immediate action(s) taken for the resident(s) found to have been affected include: On 05/07/2025, a fire drill was conducted on the NOC shift, which had previously been missed during Q4 of 2024. Documentation was completed and added to the fire drill log. 2. Identification of other residents having the potential to be affected was accomplished by: All residents had the potential to be affected by inadequate staff response during an emergency if drills are not routinely conducted on all shifts. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: A fire drill schedule was implemented with quarterly drills planned for all three shifts (day, evening, night). On (date) the Maintenance Director was educated by the Administrator on the requirements and documentation for Fire Drills. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Maintenance Director or designee will complete a monthly review of fire drill documentation to ensure each shift completes a fire drill every quarter. Any issues identified will be immediately corrected. This plan of correction has been integrated into the facility Quality Assurance Committee, and the results of these audits will be reviewed quarterly until substantial compliance has been achieved.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with the residents and/or their responsible parties. Specifically, for three out of 25 sampled residents, there was no documentation indicating that advance directives were addressed. One resident, who was cognitively intact and admitted with muscle wasting and atrophy, had no record of an advance directive discussion in their file, as shown by the absence of such documentation on their POLST form. Two other residents, both with severe cognitive impairment and diagnoses including depression, adult failure to thrive, and dementia, also lacked documentation of advance directive discussions or availability in their medical records. During interviews and record reviews, the Social Service Director Assistant confirmed that there was no evidence in the records for these residents that advance directives had been discussed with them or their responsible parties. The Director of Nursing was not aware of the facility's policy regarding advance directives. The facility's policy requires inquiry about advance directives upon admission and annual review, with documentation to be prominently displayed in the medical record, but this was not followed for the affected residents.
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, as evidenced by observations and resident interviews. In one case, a resident reported discomfort due to the dirty appearance of her bathroom floor, which was visible from her bed. Observation confirmed that the linoleum flooring in her bathroom was old, worn, and discolored with black stains resembling dirt. The resident had intact cognition, as indicated by a BIMS score of 15, and expressed that the condition of the bathroom made her feel uncomfortable. In another case, a resident with intact cognition also expressed reluctance to use her bathroom, describing it as dirty and gross. Observation revealed that the linoleum flooring in her bathroom was similarly old, worn, and discolored with black stains, and the toilet seat and cover had multiple gray and black linear scratch marks. The Housekeeping Supervisor acknowledged the inability to remove the stains despite cleaning efforts and was aware of the toilet seat's condition but had not reported it to Maintenance. The Maintenance Supervisor was unaware of the issue, and both supervisors agreed that the bathrooms did not provide a homelike environment. The facility's policy requires a clean, sanitary, and homelike environment, which was not met in these instances.
Failure to Implement Effective Interventions for Resident with Dementia-Related Wandering
Penalty
Summary
The facility failed to develop and implement adequate person-centered interventions for a resident diagnosed with dementia who exhibited wandering behaviors, including entering other residents' rooms. The resident, who had a BIMS score of 5 indicating poor cognition and a diagnosis of non-Alzheimer's dementia, was observed and reported by staff and other residents to frequently wander the hallways, enter other residents' rooms, turn off lights, and take items belonging to others. The care plan for this resident included monitoring and redirection, but these interventions were not effective in preventing the resident from continuing these behaviors. Multiple incidents were documented where the resident was found in other residents' rooms, sometimes becoming verbally aggressive when asked to leave. Staff interviews confirmed that the resident became agitated when redirected and continued to wander despite interventions. Other residents reported discomfort and distress due to the resident's actions, including invasion of privacy and taking personal items. The resident's behaviors were also noted to have led to falls, including one incident where the resident sustained a bump on the forehead and was diagnosed with a closed fracture of the temporal bone after being found on the floor in the hallway. The facility's records and staff interviews indicated ongoing challenges in managing the resident's wandering and associated behaviors. Despite recognition of the need for more intensive interventions, such as one-on-one monitoring or memory care placement, the existing care plan and implemented strategies were insufficient to prevent the resident from wandering into other residents' rooms and causing distress or injury.
Inaccurate MDS Coding of Resident Wandering Behavior
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, specifically in section E, which addresses wandering behavior. Observation showed the resident wandering the hallways with a walker and entering other residents' rooms. During interviews, a CNA confirmed that the resident frequently wandered, entered other rooms, turned off lights, and became agitated when redirected. However, a review of the resident's annual MDS assessment indicated that wandering behavior was coded as not exhibited. The Social Services Director, responsible for completing this section of the MDS, acknowledged that the wandering behavior was not coded accurately.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with impaired cognition, schizophrenia, and a history of unpredictable and aggressive behavior entered another resident's room late at night and pulled open the curtain around the bed. The resident whose space was invaded, who had mild cognitive impairment and was able to communicate clearly, screamed and asked the intruding resident to leave. When the resident stood up to ask the other to leave, the aggressive resident slapped her on the left side of the face. This incident was witnessed by a roommate, who confirmed the slap and reported that the event disturbed their sleep. The aggressive resident's care plan documented a pattern of physical behavioral symptoms directed toward others, including previous altercations. Facility records and interviews indicated that the aggressive resident's behavior had previously put others at significant risk for injury. The facility's abuse prevention policy states that residents have the right to be free from physical abuse, but the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident diagnosed with Alzheimer's disease and dementia from physical abuse by another resident. The resident was found in the hallway with a bleeding and swollen lower lip after being hit by another resident. Multiple staff interviews and a review of surveillance footage confirmed that the resident had entered another resident's room, after which a hand was seen pushing the resident's wheelchair out of the room. The resident reported being hit by a man, and medical documentation confirmed bruising and injury to the mouth and chin. Staff acknowledged that the resident was confused, wandered, and required close monitoring, which was not adequately provided at the time of the incident. Additionally, the same resident was subjected to unwanted physical contact in the activity room when another resident touched her face. Staff present during the incident confirmed the contact, and the resident questioned why she was being touched. Facility policies reviewed indicated a requirement to protect residents from all forms of abuse and to monitor and redirect residents to ensure safety, which was not effectively implemented in these instances.
Failure to Provide Required Two-Person Assistance During Care Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) provided incontinence care to a resident with significant physical and cognitive impairments without the required assistance of a second staff member. The resident, who had dementia, morbid obesity, osteoarthritis, osteoporosis, and was completely dependent on staff for toileting and bed mobility, required two or more staff for all activities of daily living (ADL) care due to her weight and inability to assist in her own care. Despite being aware of the need for two-person assistance, the CNA attempted to perform care alone after being unable to find help, and did not receive a report from the previous shift or the charge nurse regarding the resident's care needs. During the care, the CNA rolled the resident onto her side and instructed her to hold onto the bed rail. The resident appeared to comply, but when the CNA looked away to retrieve a cleaning wipe, the resident slid off the bed and fell to the floor. The CNA was unable to prevent the fall. Both roommates witnessed the incident and confirmed that the resident always required two or more staff for care and was unable to safely hold onto the bed rail. Following the fall, the resident was assessed by nursing staff and transported to the hospital, where she was found to have sustained fractures to her left arm and left leg. Due to her medical condition, she was not a candidate for surgical repair and was subsequently discharged to hospice care. Facility records and staff interviews confirmed that the resident was at high risk for falls and required two-person assistance for all care, but this protocol was not followed at the time of the incident.
Failure to Provide Admission Agreements
Penalty
Summary
The facility failed to provide a written notice of rights and services prior to or upon admission for three sampled residents. For Resident 1, the admission agreement was provided more than nine months after admission. Resident 1 had multiple diagnoses, including dementia and major depressive disorder, and lacked the capacity to understand healthcare decisions. The Assistant Director of Nursing confirmed that the admission agreement was not provided until much later. For Residents 2 and 3, no admission agreements were provided during their stay. Resident 2, who was receiving palliative care for pancreatic cancer and had Alzheimer's disease, was oriented to the facility but did not receive an admission agreement before passing away shortly after admission. Resident 3, who was self-responsible, was admitted and discharged without receiving an admission agreement. The Medical Records Director confirmed the absence of signed agreements for these residents. The facility's policy required that admission agreements be signed at the time of admission, but this was not adhered to, potentially leaving residents unaware of their rights.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information to a resident or their representative regarding the duration of the state bed-hold policy, reserve bed payments, and conditions for returning to the facility during a transfer to a hospital or therapeutic leave. This deficiency was identified for one of the three sampled residents. The resident, who was admitted in January 2024, had multiple diagnoses including a rib fracture, unspecified dementia with behavioral disturbance, major depressive disorder, hypertension, and chronic pain syndrome. The resident's representative was listed as the responsible party. During a review of the resident's records, it was found that the Bed Hold Notification Form, dated January 31, 2023, was signed by the resident's representative but lacked completion in the section meant to be filled out upon transfer. The facility's policy, last revised in 2017, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to transfers. However, this requirement was not met, as the necessary section of the form was not completed or signed, indicating a failure to ensure the resident or their representative was adequately informed.
Patio Safety Hazards Due to Clutter and Leaking Hoses
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents, staff, and the public in the patio area. Observations revealed that the patio was cluttered with refrigerator parts, a circular concrete pad with broken edges, and two leaking water hoses creating puddles near resident patio doors. These conditions posed potential trip and fall hazards for ambulatory residents using the patio. During an observation, a maintenance worker confirmed that one of the hoses was leaking due to a water faucet not being completely turned off. Interviews with the maintenance worker, Director of Nursing (DON), and Environmental Supervisor (ES) confirmed the presence of these hazards. The maintenance worker acknowledged that the refrigerator parts had been on the patio for more than a day, although the exact duration was unknown. The DON and ES both recognized the refrigerator parts and pooling water as trip hazards, and the ES stated that the broken concrete and refrigerator parts should be removed, and water faucets should be fully turned off after use.
Failure to Provide Correct Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident received the correct medications and instructions upon discharge. The resident, who had been admitted with diagnoses of diabetes mellitus and chronic kidney disease, was discharged without the necessary medication, heparin, which was prescribed to prevent blood clot formation. The discharge summary and instructions did not include heparin, although it was part of the resident's active orders. The Assistant Director of Nurses confirmed that the discharge records did not list heparin as a medication to be administered after discharge. The Nurse Supervisor, who was responsible for the discharge, stated that the night shift had completed the Discharge Medication List, but she was unable to find the Discharge Summary to verify it. Despite this, she discharged the resident with heparin for home use. The facility policy required a reconciliation of pre-placement and post-discharge medications, which was not documented in this case. The resident and a family member confirmed that heparin was sent home, and the resident's doctor later advised against its use. The facility's policy on discharge and transfer of residents was not followed, as there was no documentation of a signed discharge medication list by the resident.
Failure to Assist Resident with Lost Hearing Aids
Penalty
Summary
The facility failed to assist a resident in accessing vision and hearing services by not investigating or replacing the resident's lost hearing aids. The resident, who was admitted in July 2024 with a diagnosis of hypertension, reported the loss of hearing aids valued at $2000. Despite the report, the facility did not complete the Theft and Loss Report, as it lacked essential details such as the name of the person who made the report, the person taking action, and follow-up actions. The Social Services Director (SSD) was informed of the missing hearing aids but did not provide documentation of notifying the police or taking further action. The facility's policy required missing items to be referred to Social Services if not found within 24 to 48 hours, and for law enforcement to be notified if the item's value exceeded $100. However, the SSD stated she was not responsible for investigating the loss, and the Assistant Director of Nursing confirmed the hearing aids were lost while the resident was in the facility. The resident's family reported the facility did not respond to requests for assistance, and the Concern and Grievance Log did not list the missing hearing aids. The facility's failure to adhere to its policy resulted in the resident not having access to necessary hearing aids, impacting their medical and social interactions.
Failure to Administer Scabies Treatment as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of treatment for scabies for a resident, as per the physician's order and instructions. The resident, who had severe cognitive impairment and required substantial assistance for personal care, was prescribed Permethrin 5% cream to be applied from scalp to toe and left on for 12 hours before washing off. However, the cream was washed off only two hours after application, contrary to the physician's order. This error was not reported to the physician, and there was no documentation of the incident in the resident's records. Interviews with facility staff revealed a lack of communication and documentation regarding the treatment. The Corporate Clinical Services Resource acknowledged the error and the need for immediate physician notification, which did not occur. The Licensed Vocational Nurse who applied the cream endorsed the instructions to the next shift, but the Certified Nursing Assistant, unaware of the treatment, gave the resident a shower, washing off the cream prematurely. The facility's policies on medication administration and scabies treatment were not followed, contributing to the deficiency.
Infection Control Protocol Breach During Resident Feeding
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) followed proper infection control protocols while feeding a resident. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including dementia. During an observation, the CNA was seen wheeling the resident into their room and setting up a meal tray without performing hand hygiene. The CNA retrieved a paper towel from the bathroom and placed it on the resident without washing her hands or using hand sanitizer. She then proceeded to feed the resident without cleaning her hands or the resident's hands, acknowledging that she was aware of the requirement to do so to prevent the spread of germs. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD), confirmed that the staff are expected to perform hand hygiene before and after assisting residents with meals and to clean the residents' hands before feeding. The facility's policy on infection control and hand hygiene, revised in August 2014, also mandates the use of alcohol-based hand rub or soap and water before handling food and assisting residents with meals. The failure to adhere to these protocols had the potential to contaminate the resident's food with pathogens.
Failure to Follow Infection Control Procedures for Resident on Contact Isolation
Penalty
Summary
The facility failed to follow infection prevention and control procedures when a Certified Nursing Assistant (CNA) did not wear Personal Protective Equipment (PPE) while providing care to a resident who was on contact isolation due to a confirmed case of scabies. The resident was admitted to the facility with a diagnosis that included scabies and was placed in a single room under contact isolation. Despite clear signage indicating the need for contact precautions, including the use of gloves and gowns, the CNA assisted the resident with meals without wearing the required PPE. This was observed during an interview and concurrent observation, where the CNA admitted to not wearing a gown and gloves without providing a reason for the omission. The facility's policy and procedure for transmission-based precautions clearly stated the need for gloves and gowns when entering the room of a resident on contact isolation. The Director of Nursing (DON) confirmed that staff should wear gowns and gloves when providing Activities of Daily Living (ADLs) care to residents on contact precautions. The failure to adhere to these infection control measures was corroborated by multiple staff interviews and a review of the resident's care plan and physician orders, which all indicated the necessity of contact precautions to prevent the spread of infection.
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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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