Arbor Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Chico, California.
- Location
- 1200 Springfield Drive, Chico, California 95928
- CMS Provider Number
- 555304
- Inspections on file
- 62
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Arbor Post Acute during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, essential tremor, and muscle weakness was assessed on admission as needing bed canes to assist with bed mobility and maintain independence in ADLs. The MDS and care plan documented limited leg function and a need for assistance with rolling and sitting up in bed, and a bed rail/entrapment assessment recommended bed canes. However, repeated observations showed the bed had no bed canes or rails, and the resident reported being quite dependent on staff for bed mobility and unable to roll without something to hold. Staff confirmed the recommendation for bed canes, but a work order was not submitted until many days after admission, and the bed still lacked bed canes because it was not compatible and no alternative bed was available at full facility capacity.
A resident admitted with essential tremor, dysphagia, and a cognitive communication deficit had a physician order and care plan for speech therapy (ST) three times weekly for four weeks following an initial ST evaluation. Despite facility policies requiring that physician orders be carried out, the resident received only the initial evaluation and no subsequent ST treatments, and was not placed on the ordered treatment schedule. The resident later reported expecting ongoing ST for speech but confirmed no further visits occurred, while therapy leadership acknowledged that the ordered visit frequency was not followed.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in an unsafe environment for residents.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
A resident who was totally dependent on staff for ADLs and at risk for skin breakdown was not turned or repositioned every two hours as ordered. Despite care plans and physician orders, staff interviews and observations confirmed the resident remained on her back for extended periods, leading to red areas and indentations on her skin from prolonged pressure and wrinkled linens.
The facility failed to ensure the safety of residents at high risk for wandering and elopement due to non-functional TEC and Wanderguard systems. A resident eloped undetected and was found across the street. The facility's monitoring logs were incomplete, and staff did not follow policy for checking Wanderguard functionality. Interviews revealed maintenance issues with the TEC system, contributing to its failure to alarm.
A resident in an LTC facility was subjected to G-tube feeding for 24 days despite having signed a POLST refusing artificial nutrition. The resident, who was capable of making his own healthcare decisions, expressed a desire to eat regular food and was distressed by the continued G-tube feeding. The facility's Director of Nursing confirmed the failure to honor the resident's documented wishes.
A resident with a surgical wound experienced a change in condition that was not reported to the physician, as required by facility policy. Weekly skin wound evaluations were not conducted, and an antibiotic prescribed by the resident's vascular surgeon was not administered. The Director of Nursing and Administrator confirmed these oversights, which could have delayed necessary interventions.
The facility failed to provide adequate care plans and supervision for two residents, leading to repeated falls and potential hazards. One resident, at high risk for falls, experienced multiple falls and a severe head injury due to ineffective interventions and lack of supervision. Another resident, a smoker, was not properly evaluated for smoking safety, and the path used for smoking had a large pothole, posing a hazard. The facility's policies were not effectively implemented, resulting in increased risks for the residents.
A resident with contractured legs experienced severe pain during brief changes due to the facility's failure to follow its pain management policy. Staff forced the resident's legs apart, causing distress and pain, without evaluating alternative methods for managing incontinence. The care plan lacked specific interventions, and there was inadequate communication with the hospice team, leading to ongoing pain and distress for the resident.
The facility failed to provide a safe and comfortable environment for residents, with issues such as an uncomfortable mattress and inadequate room temperatures. A resident reported a mattress with a hole, which had not been replaced despite new mattresses being available. Additionally, shower rooms and the dining room had temperatures below the recommended range, with heating systems requiring manual operation, leading to inconsistent temperatures. Maintenance staff acknowledged unfinished projects, contributing to the discomfort.
The facility failed to maintain an effective infection prevention and control program, with unclean wheelchairs, improper storage of oxygen tubing, and inadequate hand hygiene practices observed. Wheelchairs were visibly soiled, oxygen tubing was not stored in anti-microbial bags, and personal hygiene products were improperly placed. A CNA was seen touching her face and assisting residents without washing hands, breaching infection control protocols.
A resident found a pain pill at her bedside, causing anxiety due to improper medication administration by an LN who failed to verify ingestion. The facility also had expired medications in carts and incomplete narcotic disposal logs, risking drug diversion.
Two residents experienced a lack of dignity and privacy in an LTC facility. One resident was left exposed in her room, while another did not receive necessary assistance with toileting and meal preferences. Staff failed to provide adequate care, leading to discomfort and disrespectful interactions. Interviews with facility leaders confirmed these actions were inappropriate and against policy.
Two residents in a facility were found with call lights out of reach, despite their care plans indicating the need for accessible call lights due to severe cognitive impairments and fall risks. Observations showed call lights on the floor, and staff confirmed the oversight, highlighting a failure to accommodate resident needs.
A resident with severe cognitive impairment was subjected to sexual abuse by another resident during an activity. The incident was not reported immediately, delaying family notification. The offending resident had a history of inappropriate behavior, and despite interventions, the incident occurred, highlighting a deficiency in protecting residents from abuse.
A facility failed to report a sexual abuse incident involving two residents within the mandated timeframes, delaying the investigation. Resident 22, with severe cognitive impairment, was involved in the incident with Resident 120, who has a history of inappropriate behavior. The delay was due to a staff member not reporting the incident immediately, despite having attended abuse report training.
Two residents were inaccurately assessed in a facility, leading to potential care planning issues. One resident was documented as continent despite evidence of occasional incontinence, while another was incorrectly marked as a non-smoker despite being observed smoking outside the facility. Staff interviews and documentation confirmed these inaccuracies.
The facility failed to provide necessary services for two residents. One resident, with multiple health issues, did not receive a wheelchair despite being measured for it, leading to discomfort and immobility. Another resident, suffering from osteoarthritis and other conditions, did not receive needed medical referrals for knee pain and an IUD removal, despite repeated physician recommendations. These deficiencies were due to a lack of follow-up by the therapy department and the failure of licensed nurses to arrange appointments.
Two residents in an LTC facility did not receive necessary assistance with ADLs. One resident was unable to get out of bed due to a missing wheelchair and missed scheduled showers, while another was not assisted with toileting needs, leading to discomfort. Staff misjudged the residents' abilities, resulting in inadequate care.
A resident with multiple health conditions, including COPD and chronic kidney disease, did not receive adequate foot care, resulting in dry, cracked, and peeling feet. The facility's policy required daily skin checks and lotion application, but these were not consistently performed. Staff interviews revealed a lack of consistent care and communication regarding the resident's condition.
A resident with severe cognitive deficits and multiple diagnoses was not repositioned every two hours as required, leading to redness and indentations on her skin. Despite facility policies and physician's orders, staff interviews and observations confirmed the resident was left on her back for extended periods, increasing the risk of skin breakdown.
The facility failed to conduct annual performance evaluations for a CNA, with the last evaluations recorded in 2021 and 2022. The Director of Staff Development confirmed the absence of evaluations for 2023 and 2024, indicating the facility was behind on these evaluations. This deficiency could prevent CNAs from receiving necessary ongoing education and inservices.
A facility was found to have a medication error rate of 19.2%, with errors in nebulizer and eye drop administration, and improper documentation. A Respiratory Therapist failed to follow nebulizer procedures, leading to medication escape. Licensed Nurses did not adhere to eye drop policies, and a Registered Nurse left a resident before confirming medication intake. The Director of Nursing acknowledged the need for improved competencies.
The facility failed to properly store medications, leading to disorganization in two medication storage rooms. In one room, expired and non-expired medications were stored together, while another room had enteric food supplies next to probiotics and multivitamins, against policy. The DON acknowledged the issue and stated that reorganization had occurred.
A resident kept perishable food at bedside against facility policy, risking foodborne illness. Staff efforts to store food properly were refused by the resident. Additionally, the facility used incorrect products for ice machine maintenance, not following manufacturer's instructions, risking contamination.
A facility failed to implement smoking safety policies for a resident who smoked off property. The resident was not identified as a smoker, leading to unsecured smoking materials in his room and a delayed smoking evaluation. This resulted in an unsafe environment, as evidenced by cigarette burn holes in the resident's clothing.
A resident with a history of COPD and heart issues experienced a significant change in condition, including low blood pressure and refusal to eat. Despite reports from CNAs, the LPN did not retake the blood pressure or notify the physician, assuming an error. The resident's condition worsened, leading to a hospital transfer. The DON confirmed the LPN's failure to document the change timely and noted a lack of competency evaluation.
A resident who only spoke Spanish was not provided with a certified interpreter during a room change, leading to confusion and distress. The facility relied on Spanish-speaking CNAs instead of using a professional language line service, contrary to their policy requiring competent oral translation of vital information.
A resident was moved to a different room without receiving the required one-day written notice, as per facility policy. The resident was informed verbally about the move due to COVID-19 cases and given only a one-hour notice, leading to confusion and emotional distress. Staff confirmed the resident was upset, and the Social Services Director admitted the facility had stopped issuing written notices.
A resident was denied privacy during a call with the Ombudsman when a Business Marketer entered the room and took over the conversation. This violated the facility's policy on providing private telephone access, as the resident was unable to discuss her concerns about a room change without staff interference.
The facility failed to maintain clean and safe bathrooms for eight residents, as observed in various rooms. Bathrooms were found with dark splatter, gouged doorframes, dirt, and improperly stored personal items. Despite a policy for daily cleaning, observations revealed deficiencies such as stained linoleum, chipped paint, and dirty bedpans, contradicting the facility's cleaning claims.
A resident received ENT treatment without the knowledge or consent of their Responsible Party (RP), despite being unable to make healthcare decisions. The facility's staff failed to notify the RP or obtain consent, resulting in unauthorized procedures. The Social Service Assistant and Director confirmed the lack of documentation and orders for the consultation, which violated the facility's policy on resident rights.
A resident experienced a change in condition, leading to a physician ordering medications, but the facility failed to document the resident's condition in the nurse's notes. Additionally, an ENT visit for the resident and 20 others was not documented until two months later. The ADON and SSD confirmed these documentation lapses.
The facility failed to maintain safe and sanitary shower rooms on Station 1 and Station 2. Observations revealed broken tiles and black substances in the grout and corners, confirmed by CNA A, HSK, DON, and IP. The facility's policies on safety and cleaning were not followed, leading to unsanitary conditions.
A resident with multiple health conditions was verbally abused by a CNA, causing emotional distress. Despite being instructed to avoid the resident, the CNA re-entered the room and continued the abuse. The facility failed to follow its abuse policy, allowing the CNA to continue working until the following Monday when they were suspended and later terminated.
Failure to Provide Recommended Bed Canes to Support Resident Mobility
Penalty
Summary
The facility failed to reasonably accommodate a resident’s assessed need for bed canes, which had been recommended to support mobility and independence. The resident was admitted with Parkinson’s disease, essential tremor, and muscle weakness, and the admission MDS showed limited function of both legs, a need for touching assistance to roll in bed, and moderate assistance to sit up in bed. The care plan identified the resident as at risk for decline in ADLs and mobility and directed staff to encourage participation in ADLs to promote independence. On admission, a Bed Rail and Entrapment Risk Observation/Assessment was completed and recommended bed canes due to mobility limitations. Despite this, observations on multiple dates showed the resident’s bed had no bed canes or bed rails. Staff interviews and record reviews confirmed that the resident remained without the recommended bed canes and was dependent on staff for bed mobility. The resident reported needing bed rails/bed canes to pull themselves around in bed and stated they were quite dependent on staff for bed mobility without them. During care, when a CNA asked the resident to roll in bed, the resident stated they could not because there was nothing to hold on to, and the CNA had to assist the resident to roll. The DON and nursing staff confirmed that the assessment recommending bed canes was completed on admission, but a work order for bed canes was not entered until 18 days later, and the bed still did not have bed canes. The Maintenance Director and DON stated the resident’s bed did not accommodate bed canes and there was no compatible bed available because the facility was at maximum capacity, resulting in the resident not receiving the recommended assistive device.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered specialized rehabilitative services, specifically speech therapy (ST), to a resident. Facility policies on Physician Orders required that treatment orders be carried out in accordance with the physician’s order, and the Speech Therapy policy described the purpose of identifying, assessing, and treating speech, language, and swallowing disorders. The resident was admitted with essential tremor, dysphagia in the oropharyngeal phase, and a cognitive communication deficit, and was their own responsible party. The admission MDS showed a BIMS score of 12/15, indicating intact memory, and documented difficulty or pain with swallowing. A physician’s order dated shortly after admission, based on an ST evaluation and plan of treatment, specified that the resident required ST services three times a week for four weeks. During interviews and record reviews with the Director of Rehab and the Regional Director of Therapy Services, it was confirmed that the ST evaluation was completed and that the ordered frequency of three ST visits per week for four weeks was established, but the resident was only seen once for the initial evaluation and was not placed on the ordered treatment schedule. The resident’s care plan for cognitive communication deficit documented that ST would provide skilled treatments three times a week for four weeks, including voice and breathing exercises, group treatment, and speech and hearing interventions, with a goal of improving functional skills to return home safely. On observation, the resident was seen lying in bed with shaking hands, speaking slowly, pausing between words, and reporting that they expected the ST to work with them on speech but had only received the evaluation and no further visits. The Regional Director of Therapy Services confirmed that no ST visits were provided in accordance with the physician-ordered frequency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Reposition Dependent Resident as Ordered, Resulting in Skin Redness and Indentations
Penalty
Summary
The facility failed to ensure that a resident who was totally dependent on staff for all activities of daily living, including turning and repositioning, was provided care as ordered to prevent skin breakdown. The resident, who had severe cognitive impairment, dementia, diabetes, and other significant medical conditions, had a care plan and physician's order requiring turning and repositioning every two hours. Despite these orders and facility policies emphasizing the importance of repositioning to prevent pressure ulcers, staff did not consistently turn or reposition the resident as required. Multiple interviews and observations revealed that the resident remained on her back for extended periods, with staff and family members confirming that turning and repositioning were not performed as ordered. Observations showed the resident lying on wrinkled bed linens, and staff interviews confirmed that the resident had not been turned or repositioned during the day shift. Documentation and direct statements from CNAs and the DON further confirmed the lack of adherence to the turning schedule. As a result of this failure, the resident was observed with multiple red areas, indentations, and red lines on her upper thighs, buttocks, and lower back, attributed to prolonged pressure and wrinkled sheets. The lack of timely repositioning and failure to follow the care plan and physician's orders directly contributed to the resident's skin changes and increased risk for pressure ulcer development.
Plan Of Correction
F 686 Treatment/Svcs to Prevent/Heal Pressure Ulcer How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified was turned upon identification and transferred to her wheelchair. Additionally, a task was added to the POC charting to turn and reposition every 2 hours. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any dependent resident has the potential to be affected by the practice. On 3/19/25, Director of Staff Development educated on repositioning and turning of this resident to the CNA on duty. On 3/20/25, this resident was picked up by therapy to assist with increased range of motion and activity. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/19/25, Director of Staff Development initiated education on repositioning and turning policy. Director of Staff Development will conduct daily visual audits, Monday through Friday, of three residents turning and repositioning. How the facility plans to monitor its performance to make sure that the solutions are sustained: Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. If 95% compliance is achieved after 90 days, the issue will be resolved within QAPI. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 20th, 2025.
Failure to Ensure Safety of Residents at Risk for Elopement
Penalty
Summary
The facility failed to ensure the safety and security of seven residents identified as high risk for wandering and/or elopement. The Touchpad Exit Controller (TEC) system, which is supposed to alarm when a resident wearing a Wanderguard passes through an exit, did not function properly, allowing a resident to elope undetected. This resident was later found across the street with his wheelchair stuck in a sidewalk crack. The facility's monitoring check-off log for the TEC system and exit door alarms was incomplete, missing documentation for certain days and not including all exit doors. The TEC system on one of the exit doors was found to be non-functional during a surveyor's test, and the facility's policy for checking Wanderguard functionality was not followed. The policy required checks every shift, but the orders for residents only required daily checks. Additionally, staff members were not using the available tool to test the functionality of the Wanderguards, relying instead on less effective methods such as placing residents near exit doors to see if alarms would sound. The facility's lack of oversight and failure to ensure that their TEC and Wanderguard systems were fully operational resulted in a resident eloping and endangered the safety of other residents known to wander. Interviews with staff revealed that the TEC system was not properly maintained, with issues such as missing screws and unplugged components, contributing to the failure of the system to alarm as intended.
Plan Of Correction
Accidents and Hazards How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified experienced no adverse effects and does not recall the incident. The resident was moved to a new room on 2/26/25, further from an exit door with no new incident noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any resident who has been identified as an elopement risk had the potential to be affected. No other residents were affected. 1. On 2/25/25, the nurse on duty addressed the loose wire on the identified door. Maintenance conducted an assessment on 2/26/25 and secured the wiring further. Additionally, on 2/26/25, Maintenance installed a Velcro stop sign on the identified door as a deterrent. A fire alarm box was added to this door on 3/13/25 as an additional safety measure. 2. Maintenance log/audit was updated on 3/13/25 to include all doors and the device that is being checked on each door. 3. The TEC system on station 3 door is working but showing a slight delay when alarming. TEC systems have been contacted to address the need for increased sensitivity. Additionally, this door includes a locked alarm box that alarms, and the Wanderguard sensor was an additional backup alarm. 4. Wanderguard Process Guide was edited to match the physician orders. 5. On 3/12/25, nurses identified as not knowing how to check the Wanderguard functionality were in serviced by the nurse manager. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/17/25, the Administrator provided in-service training to the Director of Maintenance during the routine inspection of doors equipped with Wanderguard sensors. The inspection will now also include checks for loose wiring and whether the sensor is secure. On 3/17/25, the Nurse Manager initiated in-service training for licensed nurses on the proper method to check the functionality of the Wanderguard system for their residents. Maintenance will complete a daily audit (Monday through Friday) of the exit doors alarm systems including Wanderguard system and/or Red Fire Box. This audit will include a review for potential loose wires, Wanderguard sensor and functionality, and Red Fire Box sensor and functionality. Medical Records will check weekly that the Wanderguard orders match the policy. The Director of Nursing (or designee) will audit two nurses weekly to ensure they can correctly verbalize the process for checking a resident's Wanderguard functionality. How the facility plans to monitor its performance to make sure that the solutions are sustained: Results of the audit will be brought to the Quality Assurance Performance Improvement (QAPI) monthly. If 95% compliance is met after 90 days, QAPI will be resolved. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 18th, 2025.
Facility Failed to Honor Resident's Refusal of G-Tube Feeding
Penalty
Summary
The facility violated a resident's right to refuse treatment when they continued to provide artificial nutrition through a G-tube for 24 days after the resident had signed a Physician Order for Life Sustaining Treatment (POLST) indicating his wish to refuse such treatment. The resident, who was capable of making his own healthcare decisions, had a BIMS score of 15, indicating intact cognitive function. Despite the resident's clear wishes documented on the POLST form, the facility continued to administer enteral feeding, causing the resident distress, frustration, and pain. The resident had been readmitted to the facility with a G-tube due to dysphagia and aspiration risks. However, he expressed a desire to eat regular food and drink liquids, and he was non-compliant with the NPO diet by consuming oral snacks and beverages. The nursing progress notes documented the resident's distress and his explicit statements about wanting the G-tube removed. The Director of Nursing confirmed that the facility failed to honor the resident's wishes as documented in the POLST, continuing the G-tube feedings against his will for nearly a month.
Plan Of Correction
F 578 Request/Refuse/Dscntnue Trmnt; Formite Adv Dir How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident's rights were followed on 2/10/25 when the diet order was updated by the physician to align with the resident's wishes. The Gastrointestinal Tube was removed on 3/11/25 during an outpatient appointment. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any resident who updates their POLST (Physician Orders for Life-Sustaining Treatment) to include no artificial means of nutrition following the surgical implementation of a Gastrointestinal Tube may be affected by this practice. No other residents were affected by this practice. On 3/13/25, Medical Records completed a facility-wide audit of resident POLSTs, identifying and correcting any issues. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/17/25, the Medical Records Director initiated in-service training for nursing staff on the proper POLST process, including order updates. Medical Records will conduct daily audits, Monday through Friday, of the POLST Binder at each station to ensure the timely completion of any updated POLST orders. How the facility plans to monitor its performance to make sure that the solutions are sustained: Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. If 95% compliance is achieved after 90 days, the issue will be resolved within QAPI. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 18th, 2025.
Failure to Report Change in Condition and Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to recognize and report a change in condition for a resident with a surgical wound on her upper left leg. On 3/29/24, the resident's left lower extremity was noted to be swollen, hard to touch, and red, indicating a potential infection. However, the physician was not notified of this change, which was a requirement according to the facility's policy. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the physician should have been informed. Additionally, the facility did not conduct weekly skin wound evaluations as required by their policy. The resident's weekly skin and wound evaluations were incomplete, with no documentation for the week of 4/1/24. This lapse in monitoring meant that changes in the resident's wound condition were not consistently tracked, potentially delaying necessary interventions. The Director of Nursing confirmed that the evaluations were not performed as required. Furthermore, the facility failed to carry out a physician's order for an antibiotic prescribed by the resident's vascular surgeon. On 4/10/24, the surgeon ordered Augmentin for the resident, but this order was never implemented. There was also no documentation of the resident's departure for or return from the appointment with the vascular surgeon, nor any follow-up on the new orders. The Administrator confirmed that the antibiotic order was not started, and there was a lack of documentation regarding the resident's appointment and subsequent orders.
Inadequate Care Plans and Supervision Lead to Resident Hazards
Penalty
Summary
The facility failed to ensure that the care plans for two residents, Resident 250 and Resident 303, were adequately developed and implemented to prevent accidents and hazards. Resident 250, who was known to have restless and aggressive behaviors, was at a high risk for falls due to dementia and an active urinary tract infection. Despite multiple falls and a severe head injury requiring hospitalization, the facility did not re-evaluate past interventions or develop individualized strategies to address the root causes of the falls. The use of Ativan for restlessness was not effective, and the facility did not consider 1:1 supervision until after multiple falls had occurred. Resident 303, who was not identified as a smoker upon admission, was observed smoking on the sidewalk and off-campus without the facility's knowledge. The facility failed to conduct a smoking safety evaluation upon admission, and Resident 303 was not provided with a smoking apron despite being identified as needing one. Additionally, the path used by Resident 303 to smoke off the property had a large pothole, posing a potential hazard. The facility's lack of safety interventions for Resident 303 increased the risk of injury related to smoking. The facility's policies and procedures were not effectively implemented, as evidenced by the lack of timely assessments and interventions for both residents. The Director of Nursing and Assistant Director of Nursing confirmed that the interventions in place were not effective and that the interdisciplinary team meetings did not adequately address the residents' needs. The facility's failure to provide adequate supervision and safety measures resulted in repeated falls and potential hazards for the residents involved.
Failure in Pain Management for Resident with Contractures
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with contractured legs, leading to severe pain during brief changes. The resident, who had poor cognition and was dependent on staff for toileting hygiene, experienced significant pain and anxiety when her brief was changed. Staff were observed forcing the resident's contractured legs apart, causing her to scream in pain, breathe heavily, and exhibit signs of distress such as grimacing and crying. Despite the resident's clear expressions of pain, staff continued to handle her in a manner that exacerbated her discomfort. The facility's pain management policy required staff to identify causes of pain, implement strategies to manage it, and monitor or modify approaches to ensure adequate control. However, the staff did not evaluate alternative methods for managing the resident's incontinence that would minimize pain. Interviews with various staff members, including CNAs and nurses, confirmed that the resident's pain during brief changes was a known issue, yet no effective measures were taken to address it. The care plan for the resident did not include specific interventions to manage her pain during brief changes, and there was no evidence of staff training on handling residents with contractures. The facility's lack of communication and coordination with the hospice team further contributed to the deficiency. The hospice nurse was unaware of the resident's pain level during brief changes, indicating a breakdown in communication between the facility and hospice care providers. The Medical Director acknowledged the ineffective communication and expressed the need for better problem-solving strategies. Overall, the facility's failure to adhere to its pain management policy and lack of appropriate interventions resulted in ongoing pain and distress for the resident.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents. One resident reported an uncomfortable mattress with a hole in the middle, which had been an issue since their admission. Despite the resident's complaints, the facility had not replaced the mattress, even though new mattresses had been ordered and received. This indicates a lack of timely response to the resident's needs, contributing to their discomfort. Additionally, the facility did not maintain appropriate room temperatures in resident areas, such as shower rooms and the dining room, which were below the recommended range of 71-81 degrees Fahrenheit. The heating systems in these areas were not connected to thermostats, requiring manual operation by staff, which led to inconsistent temperatures. The maintenance team acknowledged the issue and the presence of unfinished projects, such as exposed walls and insulation, and broken tiles in shower rooms, further contributing to an uncomfortable environment for residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. Wheelchairs for multiple residents were found visibly unclean, with dried food substances, crumbs, and dust, indicating a lack of regular cleaning and maintenance. The facility's policy required that resident-care equipment be cleaned according to CDC recommendations, but records showed that wheelchairs had not been cleaned for several months. Interviews with staff confirmed the unclean state of the wheelchairs and the need for regular cleaning to prevent infection. Additionally, the facility did not appropriately store oxygen tubing for a resident with chronic respiratory conditions. The tubing was observed lying on the floor instead of being stored in an anti-microbial bag as per the facility's policy. This improper storage was confirmed by staff, who acknowledged the need for proper storage to prevent contamination. Furthermore, personal hygiene products for residents were not stored correctly, with items left uncovered and in inappropriate locations, such as beside food and water, contrary to the facility's infection control policy. The facility also failed to ensure proper hand hygiene practices among staff. A CNA was observed touching her face and then assisting residents with their meals without washing her hands, which was against the expected hand hygiene protocol. This lapse in hand hygiene was acknowledged by the CNA and the Infection Preventionist, highlighting a breach in infection control practices. These deficiencies collectively posed a risk for the spread of infection within the facility.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications, resulting in several deficiencies. One incident involved a resident who found a pain pill at her bedside upon waking. The resident, who had a history of dysphagia, aphasia, and anxiety disorder, was on a pureed diet and required assistance with medication administration. A Licensed Nurse (LN) had left a Norco pill at the resident's bedside without verifying its ingestion, causing the resident anxiety and concern over the lack of supervision during medication administration. The Director of Nursing (DON) confirmed that the nurse should have stayed with the resident until the pill was swallowed. Additionally, the facility did not implement its medication storage policy for two out of five sampled medication carts, leading to expired medications being available for use. Observations revealed expired insulin pens and ophthalmic ointments in the carts. Furthermore, the facility's narcotic disposal logs were inaccurately maintained, with missing signatures of licensed nurses in several instances, which could potentially allow for drug diversion. The DON acknowledged the missing signatures and the presence of expired medications in the carts.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident 44, who was observed lying in bed with her back and chest exposed due to an open room door and privacy curtains. Despite the resident's intact cognition and preference for privacy, staff did not adequately cover her after wound treatment, leaving her exposed to passersby and her roommate. This lack of privacy was acknowledged by a CNA who later covered the resident with a blanket, admitting that the exposure was inappropriate. Resident 68 experienced a lack of assistance with toileting and meal preferences, which compromised her dignity and comfort. Despite requiring staff assistance for toileting due to her medical conditions, including osteoarthritis and muscle weakness, staff failed to provide necessary help, resulting in the resident waking up wet and cold. Additionally, during breakfast, a CNA refused to accommodate the resident's request for a biscuit instead of an English muffin, leading to a loud argument that was not intervened by the observing LN. Interviews with staff, including the DON and DSD, confirmed that the actions and inactions of the staff were inappropriate and did not align with the facility's policies on resident dignity and respect. The DON acknowledged that arguing with the resident and failing to assist her with ADLs was disrespectful, while the DSD confirmed the resident's dependency on staff for daily activities, highlighting the lack of accommodation provided by the staff.
Call Light Accessibility Deficiency for Residents
Penalty
Summary
The facility's direct care staff failed to ensure that the call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident 39, who has severe cognitive deficits and requires maximum assistance with activities of daily living due to conditions such as Parkinson's disease and dementia, was observed on multiple occasions with the call light out of reach, lying on the floor. Despite the care plan intervention to encourage the use of the call light for assistance, the resident was unable to access it when needed. Similarly, Resident 87, who has a severe cognitive impairment and is at risk for falls, was also found with the call light on the floor, out of reach. The resident's care plan included interventions to keep the call light within reach and to use a reminder sign to encourage its use. However, during observations, the call light was not accessible, and the resident was unable to call for assistance if needed. Staff interviews confirmed the oversight, acknowledging the importance of having the call light within reach, especially for residents at risk of falls.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse when another resident was observed holding the resident's hand inside his unzipped pants. This incident occurred during an ice cream social, where an Activities Assistant witnessed the inappropriate behavior. The assistant separated the residents and moved the offending resident away from other female residents. However, the incident was not reported to a superior until the following day, delaying the notification to the affected resident's family. The affected resident, who was unable to consent to sexual contact due to severe cognitive impairment, was admitted with diagnoses including dementia, anxiety disorder, and major depressive disorder. The resident's Brief Interview for Mental Status (BIMS) score indicated severe cognitive impairment, confirming the lack of mental capacity to consent. The resident's family was upset about the delay in notification, expressing that they would have come to the facility immediately if informed sooner. The resident responsible for the inappropriate behavior had a history of similar incidents, with a care plan addressing behaviors of touching female residents inappropriately. Despite interventions in place, such as separating the resident from female residents during activities, the incident still occurred. The facility's policy required immediate reporting of abuse, which was not followed, contributing to the deficiency in protecting residents from abuse.
Delayed Reporting of Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of sexual abuse involving Resident 22 and Resident 120 to the State Agency and the family within the mandated timeframes. The incident occurred when Resident 22 was seen with her hand in Resident 120's pants during an ice cream social. The abuse was not reported to the State Agency until more than 24 hours later, delaying the investigation and potentially allowing for ongoing abuse. Resident 22, who has severe cognitive impairment and lacks the mental capacity to consent to sexual contact, was involved in the incident. Her medical records indicate diagnoses of dementia, anxiety disorder, transient cerebral ischemic attack, and major depressive disorder. Resident 120, who has moderate cognitive impairment, has a history of inappropriate sexual behavior towards female residents and staff, as documented in his care plan. The delay in reporting was due to AA B, who witnessed the incident, not informing a supervisor immediately. The facility's policy requires immediate reporting of abuse, but AA B only reported the incident the following day. The family of Resident 22 was also not notified until a day and a half after the incident, causing distress to the family. Despite attending an abuse report training, AA B failed to adhere to the facility's internal reporting policies and procedures.
Inaccurate Resident Assessments for Continence and Smoking Status
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents, leading to potential inaccuracies in care planning and adverse health outcomes. Resident 68 was inaccurately assessed as continent in the Minimum Data Sets (MDS) despite documentation and interviews indicating she was occasionally incontinent, particularly at night. Certified Nursing Assistants (CNAs) documented instances of incontinence, and both the resident and staff confirmed her night-time incontinence. The Director of Nursing (DON) acknowledged the inaccuracy in the MDS assessments, confirming that Resident 68 was not continent of urine. Resident 303 was incorrectly assessed as a non-smoker in the Nursing-Admission/Readmission Evaluation/Assessment (NAREA), despite being a smoker who went off property to smoke. Interviews and observations confirmed that Resident 303 smoked outside the facility, and the Licensed Nurse (LN) responsible for the assessment admitted to documenting incorrectly due to the facility's non-smoking policy. The Administrator confirmed that the NAREA should accurately reflect a resident's smoking status to ensure appropriate treatment and care.
Failure to Provide Necessary Equipment and Medical Referrals
Penalty
Summary
The facility failed to meet professional standards of quality for two residents. Resident 69, who was admitted with right side hemiplegia following a stroke, dysphagia, an acquired absence of the left leg, heart disease, and major depressive disorder, did not receive the necessary Durable Medical Equipment (DME). Despite being measured for a wheelchair in September, the equipment was never delivered, and there was no follow-up by the therapy or nursing staff. This oversight resulted in Resident 69 remaining in bed due to discomfort and the inability to move independently, as confirmed by interviews with the resident, a CNA, the Rehabilitation Therapy Director, and the Administrator. Resident 68, admitted with bilateral osteoarthritis of the knee, morbid obesity, chronic respiratory failure, and muscle weakness, did not receive needed medical referrals. Despite expressing concerns about knee pain and the need for an IUD removal, the facility failed to arrange the necessary appointments. The Director of Nursing confirmed that the resident's physician had provided gynecology referrals on three occasions, but the appointments were never made, and no referrals were obtained for the resident's knee pain. This lack of action was attributed to the licensed nurses' responsibility to arrange the appointments, which they did not fulfill.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide necessary assistance for Activities of Daily Living (ADLs) for two residents, leading to deficiencies in care. Resident 69 was unable to get out of bed due to not having an appropriate wheelchair that met his specific needs. Despite being measured for a new wheelchair in September, it was not delivered, and there was no follow-up by therapy or nursing staff. As a result, Resident 69 remained in bed except for showers, which were also not provided as scheduled. The resident's medical record indicated he required substantial assistance with transfers, and his cognitive status was intact, allowing him to express his needs and frustrations. Additionally, Resident 69 did not receive the scheduled showers for January 2025, with only one shower documented and one refusal noted. The Director of Nursing confirmed the resident did not receive all scheduled showers, which were supposed to occur twice a week. The facility's policy indicated that residents should receive care to enable them to carry out ADLs, including hygiene and mobility, but this was not adhered to in Resident 69's case. Resident 68 also experienced a lack of assistance with toileting needs. Despite being dependent on staff for mobility and requiring assistance with a bed pan, staff members, including a CNA and a Licensed Nurse, believed she could manage independently. This led to instances where Resident 68 was left in discomfort due to incontinence at night. Interviews with staff revealed a misunderstanding of Resident 68's needs, with some staff members incorrectly assuming she could manage her toileting needs without assistance. The Director of Staff Development confirmed that telling Resident 68 to manage on her own was inappropriate and not in line with the facility's standards for resident care.
Inadequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for Resident 44, resulting in discomfort and dry, cracked, and peeling feet. The resident, who has a history of chronic obstructive pulmonary disease, morbid obesity, muscle weakness, reduced mobility, chronic pain, atrial flutter, and chronic kidney disease, was observed with dry, cracked, and peeling feet. The resident expressed a preference for Aquaphor cream to be applied to her feet and legs, but this was not done regularly by the staff. The facility's policy on Activities of Daily Living (ADLs) requires that residents receive appropriate care and services to support their ADLs, including skin care. However, the care plan for Resident 44, which included daily skin checks and lotion application, was not consistently followed. Nursing summaries indicated no new skin issues, but observations and interviews revealed that the resident's feet were in poor condition, and the resident reported that family members sometimes applied the cream instead of the staff. Interviews with staff members, including a Licensed Nurse, a Certified Nurse Assistant, and the Director of Staff Development, highlighted a lack of consistent foot care and communication regarding the resident's condition. The staff acknowledged the resident's dry and scaly feet but did not consistently follow through with the necessary care or documentation. The Director of Staff Development stated that chronic conditions should be care-planned and documented, but this was not adequately done for Resident 44.
Failure to Reposition Resident Leads to Skin Breakdown Risk
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 123, was turned and repositioned as ordered to prevent skin breakdown and promote circulation. The facility's policy on repositioning, revised in 2013, outlines the importance of repositioning for residents who are immobile or dependent on staff for repositioning. Despite this, observations and interviews revealed that Resident 123 was not repositioned every two hours as required by her care plan and physician's orders. Resident 123 was admitted with multiple diagnoses, including dementia, diabetes, and severe cognitive deficits, making her totally dependent on staff for all activities of daily living. Her care plan specifically indicated the need for regular turning and repositioning to prevent skin breakdown. However, during observations, Resident 123 was found lying on her back for extended periods, with visible signs of redness and indentations on her skin from lying on wrinkled bed linens. Interviews with family members and staff, including CNAs and the Director of Nursing, confirmed that Resident 123 was not repositioned as required. Family members expressed concerns about the lack of repositioning, and staff admitted to not following the prescribed schedule. The Director of Nursing acknowledged the importance of repositioning to prevent pressure wounds and confirmed that the resident had not been turned as ordered.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to conduct annual performance evaluations for one of the two sampled Certified Nursing Assistants (CNAs), specifically CNA M. A review of CNA M's performance evaluations revealed that she had evaluations on November 10, 2021, and July 15, 2022. However, there were no evaluations found for the years 2023 and 2024 in her employee file. During an interview and record review on January 24, 2025, the Director of Staff Development confirmed that CNA M had not received an annual performance review since 2022, indicating that the facility was behind on conducting annual performance evaluations for CNAs. This deficiency had the potential to prevent CNAs from receiving ongoing education and inservices based on the outcomes of their annual reviews.
Medication Administration Errors in Facility
Penalty
Summary
The facility was found to have a medication error rate of 19.2%, significantly exceeding the acceptable threshold of 5%. This was observed during a survey where five medication errors were identified out of 26 opportunities. One notable incident involved a Respiratory Therapist (RT) who failed to follow the facility's policy for administering medications through a nebulizer. The RT did not wash hands before or after the procedure, did not explain the procedure to the resident, and failed to ensure the nebulizer mask was properly fitted, resulting in medication escaping for three minutes. The resident reported that the medication was ineffective, indicating a potential impact on their treatment. Another incident involved the administration of eye drops, where Licensed Nurses (LNs) failed to adhere to the facility's policy and manufacturer guidelines. The LNs did not instruct residents to look up or close their eyes, did not hold the inner canthus after administration, and did not wash their hands post-procedure. One LN admitted to forgetting the policy, while another did not follow it due to the resident's preference, despite the resident expressing a desire for the procedure to be done according to policy. Additional errors included a Registered Nurse (RN) leaving a resident's room before ensuring the resident had swallowed their medication, and a Licensed Nurse (LN) documenting the administration of a medication that was not given. These actions were confirmed as medication errors by the staff involved. The Director of Nursing (DON) acknowledged the need for staff to improve their medication administration competencies, highlighting a systemic issue in adherence to medication administration protocols.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in two sampled medication storage rooms, leading to disorganization and potential medication errors. During an observation, it was found that medication room number three contained both expired and non-expired medications stored together in the medication discard cabinet, along with medications intended for an incoming resident admission. A Licensed Nurse indicated that facility supervisors are responsible for checking and maintaining medication storage rooms but was uncertain about the frequency of these checks. In another observation, medication room number one was found to have enteric food supplies stored next to probiotics, multivitamins, and alcohol swabs, which is against the facility's policy. Additionally, wooden sticks and gauze were stored next to over-the-counter medications, and a current resident's mail package was found unlabeled in the same cabinet. The Director of Nursing acknowledged the disorganization and stated that the facility had reorganized the medication room cabinets following the survey team's findings.
Improper Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure proper storage and labeling of perishable food items for a resident, identified as Resident 98, who was medically vulnerable due to conditions such as stroke, poor nutrition status, and chronic obstructive pulmonary disease. During observations, it was noted that Resident 98 kept various perishable food items, such as sweet pickles, salsa, and mayonnaise, at his bedside instead of in the refrigerator, contrary to the facility's policy. These items were not labeled with opened or use-by dates, and some had expired. Despite staff efforts to encourage Resident 98 to store his food properly, he refused, citing his rights. Additionally, the facility failed to follow the manufacturer's instructions for descaling and sanitizing the ice machine. The maintenance staff used products not approved by the ice machine's manufacturer, Manitowoc, which could lead to contamination. The maintenance team acknowledged using the wrong solutions, which was confirmed during an interview with the Registered Dietitian, who stated that the descaling and sanitizing should adhere to the manufacturer's guidelines. These deficiencies posed a risk of foodborne illness to Resident 98 and other residents using the ice machine. The facility's policies and procedures were not adequately enforced, leading to potential health hazards due to improper food storage and maintenance practices.
Failure to Implement Smoking Safety Policies
Penalty
Summary
The facility failed to establish and implement policies regarding smoking safety for Resident 303, who was not identified as a smoker despite smoking off the facility property. The facility's policy did not account for residents who smoked off property, leading to a lack of identification and management of smoking materials such as cigarettes and lighters. Resident 303 was observed smoking on the sidewalk in front of the facility, and his admission assessment incorrectly documented him as a non-smoker. This misidentification was due to a misunderstanding by the licensed nurse, who believed that all residents should be identified as non-smokers in a non-smoking facility. Additionally, the facility did not monitor or manage Resident 303's smoking materials, which he kept unsecured in his room. The facility also failed to conduct a timely smoking evaluation to assess Resident 303's ability to smoke safely, despite evidence of cigarette burn holes in his clothing. The medical director acknowledged that a smoking evaluation should have been conducted upon admission to ensure safety, but this was not done until 14 days later. These oversights resulted in an unsafe environment for Resident 303.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to ensure competent nursing care for a resident who experienced a significant change in condition. The resident, who had a history of chronic obstructive pulmonary disease, heart failure, and hypertension, exhibited a dangerously low blood pressure reading of 70/46, which was not addressed appropriately by the nursing staff. Despite the abnormal vital signs and the resident's refusal to eat lunch, the attending licensed nurse did not retake the blood pressure or notify the physician, assuming the initial reading was an error. The resident's condition continued to deteriorate throughout the day, leading to an emergency transfer to the hospital. Interviews with staff revealed that the certified nursing assistants had reported the resident's poor condition and abnormal vital signs to the licensed nurse, who failed to act on this information. The Director of Nursing confirmed that the licensed nurse did not document the change in condition until twelve days later and had not been evaluated for competency upon hiring. This lack of timely intervention and documentation potentially compromised the resident's safety and well-being.
Failure to Provide Certified Interpreter for Spanish-Speaking Resident
Penalty
Summary
The facility failed to ensure effective communication with a resident who only spoke Spanish, as they did not provide a certified interpreter during a room change. The resident, who had difficulty walking and multiple fractures, was moved from one station to another due to COVID-19 cases. However, she did not understand the reason for the move and was confused because there were also COVID-19 cases in the new location. The facility's policy required competent oral translation of vital information, but the staff used Spanish-speaking CNAs who were not certified interpreters. Interviews revealed that the facility relied on staff members who spoke Spanish rather than using a professional language line service. The administrator admitted that while many staff members could speak Spanish, there was no certification to prove their competence or training in medical terminology. The administrator also acknowledged uncertainty about the availability of Spanish-speaking staff on every shift and whether adequate training had been provided for using the language line service.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide a written notice to a resident regarding a room change, as required by their policy. The policy mandates that residents receive at least a one-day advance written notice, including the reason for the change. However, the resident was only informed verbally about the move due to COVID-19 cases on her previous station and was given approximately a one-hour notice instead of the required one-day written notice. This lack of proper notification led to the resident being confused and upset about the move. Interviews with staff members, including a Certified Nursing Assistant and the Business Marketer, confirmed that the resident was visibly upset and crying after the room change. The Social Services Director acknowledged that the facility had stopped providing written notices for room changes because residents were reluctant to sign them, despite the policy requirement. This deviation from the policy negatively impacted the resident's emotional and psychosocial well-being.
Resident Privacy Violation During Ombudsman Call
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to a telephone for private communication, specifically when speaking with the Ombudsman. The facility's policy on resident telephone use, revised in February 2021, states that telephones should be available in areas that offer privacy. However, during an incident, a Business Marketer (BM) overheard a resident's conversation with the Ombudsman from the hallway and entered the resident's room, taking over the call. This action was witnessed by a Certified Nursing Assistant (CNA), who noted that the resident was unable to speak privately about her concerns regarding a room change. The resident, who had been admitted with diagnoses including difficulty in walking and multiple fractures, expressed her upset over the room change to the Social Services Director (SD). The SD confirmed that the resident's right to privacy was violated when BM entered the room and took the phone. The Administrator also acknowledged that the resident was on speakerphone with the Ombudsman when BM intervened. This series of actions and inactions led to the deficiency, as the resident was not afforded the privacy to communicate her concerns without staff interference.
Facility Fails to Maintain Clean and Safe Bathrooms for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and comfortable environment for eight residents, as observed in their bathrooms, which appeared dirty and in disrepair. The facility's policy, revised on 2/1/20, stated that bathrooms should be cleaned and disinfected daily, ensuring a sanitary environment for residents. However, during observations and interviews conducted on 8/1/24, several deficiencies were noted. Housekeeper C mentioned that rooms and bathrooms were cleaned daily, with inspections every other day, but the findings contradicted this claim. Specific observations included dark-colored splatter, gouged doorframes, and dirt on the floor in Resident 9's bathroom. In the shared bathroom of Residents 6 and 3, reddish-brown material was found on the light switch, and there were stained linoleum edges and chipped paint. The bathroom shared by Residents 4 and 2 had chipped paint, black scuff marks, and red-colored splatter. Resident 5's bathroom contained dirty bedpans, a toilet plunger, and cracked linoleum. Lastly, the bathroom shared by Residents 8 and 1 had dirty bedpans, a commode bucket, and various personal items improperly stored, along with dirt and cobwebs.
Failure to Obtain Consent for ENT Treatment
Penalty
Summary
The facility failed to involve a resident and their Responsible Party (RP) in a treatment decision, resulting in the resident receiving treatment from an Ear, Nose, and Throat (ENT) specialist without the RP's knowledge or consent. The resident, who was diagnosed with dementia, muscle weakness, dysphagia, anxiety, and depression, was deemed unable to make healthcare decisions, necessitating the involvement of an RP. Despite this, the RP was not informed of an ENT consultation, nor was consent obtained prior to the treatment, which included cerumen removal, nasal endoscopy, and laryngoscopy. Interviews and record reviews revealed that the Social Service Assistant (SSA) and Social Service Director (SSD) were unaware of the ENT visit and confirmed that there were no orders or documentation for the consultation in the resident's chart. The SSA admitted that the resident should not have been on the list for the ENT visit, as the RP had previously expressed a desire for the resident not to be seen by consulting physicians. The SSD confirmed that the treatment occurred without an order, RP notification, or consent, which was against the facility's policy on resident rights.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident, which is not in accordance with accepted professional standards. The deficiency involved a resident who experienced a change in condition, leading to a physician ordering medications. However, there were no nurse's notes documenting the resident's condition at the time of the medication order. The Assistant Director of Nursing confirmed that there was a lack of documentation regarding the resident's condition and the reason for the medication order. Additionally, a Licensed Nurse admitted to not documenting the resident's condition in the nurse's notes, despite recognizing the need for such documentation. Furthermore, the facility did not document a visit by an Ear Nose and Throat Practitioner for the resident, as well as for 20 other residents seen on the same day. The Social Service Director confirmed the absence of documentation for the ENT consult, which was only realized two months after the appointment. This lack of documentation could potentially prevent accurate information regarding the resident's medical care and condition from being available to the resident, their representatives, and other care providers.
Unsanitary and Unsafe Shower Rooms
Penalty
Summary
The facility failed to ensure that resident shower rooms on Station 1 and Station 2 were safe, sanitary, and comfortable. Observations revealed that the floor tiles had black and brown areas in the grout, and the wall tiles in the shower corners were cracked and covered with a black substance. Certified Nursing Assistant (CNA) A confirmed the presence of broken tiles and a black substance in the cracks and corners of the wall tiles and the shower floor. Housekeeper (HSK) also confirmed the presence of a black substance in the corners and cracks in the tiles, noting that the caulking had worn away. The Director of Nurses (DON) and Infection Preventionist (IP) confirmed the unsanitary conditions during their observation. The facility's policies on safety and cleaning were reviewed, indicating that environmental surfaces should be disinfected regularly and that the facility should comply with governmental health and safety requirements. However, the observations and interviews revealed that the shower rooms were not maintained according to these policies. The Assistant Director of Nursing (ADON) and DON confirmed that the shower rooms on both stations were in poor condition due to broken tiles and mold, which had not been addressed for some time.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to provide a safe environment free from abuse for Resident 10 when Certified Nursing Assistant 2 (CNA 2) verbally abused the resident. Resident 10, who had diagnoses including hemiplegia and hemiparesis following a stroke, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, reported that CNA 2 made hurtful comments about their weight, health status, and personal hygiene, causing emotional distress. This incident was witnessed by CNA 1, who provided therapeutic listening to the upset resident and reported the abuse to Registered Nurse 1 (RN 1). Despite being instructed by RN 1 to avoid Resident 10, CNA 2 re-entered the resident's room and continued to speak harshly, further distressing the resident. RN 1, who was the Charge RN on the day of the incident, heard raised voices from Resident 10's room and intervened by consoling the resident and instructing CNA 2 to stay away from the resident. However, RN 1 did not immediately suspend CNA 2 or notify other administrators, allowing CNA 2 to continue working the rest of the shift and the following day. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were not informed of the incident until the following Monday, at which point CNA 2 was suspended and later terminated. The facility's policy on abuse investigation and reporting was not followed, as it requires immediate suspension of any employee accused of resident abuse pending investigation. CNA 2 had a history of complaints and disciplinary actions, including a recent write-up for failure to perform walking rounds. Despite having received training on elder abuse, CNA 2's actions led to significant emotional distress for Resident 10, highlighting a failure in the facility's abuse prevention and response protocols.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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