Courtyard Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Davis, California.
- Location
- 1850 E. 8th Street, Davis, California 95616
- CMS Provider Number
- 055922
- Inspections on file
- 51
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Courtyard Health Care Center during CMS and state inspections, most recent first.
The facility failed to report the results of an abuse allegation investigation within the required five working days. An SBAR note documented that two residents in the lobby began cussing at each other while one was preparing to leave for dialysis, and that one resident punched the other on the body as she was on the gurney leaving. The Administrator confirmed that while the initial SOC 341 was sent on the date of the incident, the 5-day summary of the investigation was not sent to the state agency until several days later, exceeding the timeframe required by the facility’s abuse reporting policy.
Two residents with multiple medical diagnoses, including surgical aftercare and respiratory failure, reported physical abuse by a CNA. The facility submitted initial incident reports to CDPH but did not provide the required 5‑day investigation results within the mandated timeframe. In addition, after one resident’s abuse allegation, nursing staff did not complete or document the immediate assessment required by facility policy, as confirmed by the DON.
A resident with CKD, schizophrenia, and bipolar disorder, who was cognitively intact, was found with bruising on the face and reported that a CNA had hit her and pulled her hair during care. Another CNA had been told of this allegation the prior day when the resident pointed out the facial bruise and described being hit and having her hair pulled at night, but the CNA did not report the allegation immediately, stating she did not know what to do and did not believe the resident. The facility’s abuse policy required staff to immediately report any actual or potential abuse to a supervisor or the administrator, and leadership confirmed this incident was reportable and should have been reported without delay.
Surveyors observed that clean utensils had food particles and water residuals, and utensil holders contained black particles. A dietary aide handled clean kitchenware without washing hands after working with dirty dishes. The dietary manager and registered dietician confirmed these practices did not meet sanitation standards, and facility policy requiring proper dishwashing and hand hygiene was not followed.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
A resident with severe cognitive impairment and recent brain surgery was discharged to a hotel without home health services in place, contrary to physician orders. The required 30-day discharge notice was not provided in advance, and necessary post-discharge follow-up and documentation, including a physician discharge summary and MDS assessment, were missing. The resident was later found confused and hospitalized, and facility staff confirmed these failures.
A resident with severe cognitive impairment and a history of wandering exited the facility without staff authorization and was found offsite. Facility staff did not complete an elopement risk assessment, care plan, or document the incident as required by policy.
Three residents with specific dietary preferences and medical conditions did not receive their requested meal items, including double protein portions, green salad, and fresh fruit, as documented on their meal tickets. These omissions were confirmed by both the residents and dietary staff, indicating a failure to honor resident food preferences during meal service.
Surveyors found that refrigerated food items, including yogurt, were left at room temperature for several hours after delivery and not promptly stored as required. Additionally, staff failed to document freezer temperatures during one shift, contrary to facility policy. These actions did not meet professional standards for food safety.
A resident with hemiplegia and no memory impairment was physically struck multiple times by another resident with severe memory impairment and bipolar disorder, as witnessed by staff. The incident caused physical pain, facial redness, and emotional distress, with the affected resident becoming tearful and upset. Staff acknowledged the event as physical abuse, and facility records confirmed the altercation and its impact.
Sixteen meal tickets containing residents' names, allergies, and therapeutic diets were left unattended in the memory unit dining area. Both the RD and DON confirmed this was a HIPAA violation, as facility policy requires safeguarding and proper disposal of PHI.
Licensed nurses did not administer medications on time, failed to verify resident identity or explain medications before administration, and did not follow physician orders for continuous gastrostomy feeding. These deficiencies were observed in multiple residents with complex medical needs, and staff acknowledged not following required procedures.
During an EHR system outage, nursing staff were not provided with timely instructions and were unaware of the contingency procedures, resulting in delays in medication administration. The DON and ADM confirmed that no mock drills for EHR outages had been conducted, and staff had not been trained on the emergency plan, despite facility policies requiring such preparation.
The facility did not maintain documentation or evidence of QAPI meetings for three consecutive quarters, and multiple staff members were unaware of the required QAPI activities. The Administrator confirmed the absence of records and meetings, and the facility's policy requiring ongoing documentation was not followed.
Surveyors found that infection control practices were not followed, including improper storage of a CPAP mask, lack of Enhanced Barrier Precautions for multiple residents with invasive devices or wounds, and failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags. Staff were also observed not performing hand hygiene between resident contacts and during medication administration, with both a CNA and an LPN confirming they forgot to do so.
Several residents with complex medical needs reported and were observed experiencing late meal service, with some waiting up to 1 to 2 hours for meals. Staff confirmed the delays, and the posted dining schedule lacked specific meal times. The facility's policy required timely meal delivery in line with resident preferences and community norms, but this was not followed, resulting in resident dissatisfaction and potential impacts on care.
Surveyors found that food service staff failed to label, date, and monitor refrigerated and frozen foods, with expired and improperly stored items present. Temperature logs for all cold storage units were incomplete. In the dry storage area, fruit flies and improperly sealed food items were observed. Additionally, a dietary aide was seen assembling trays without a beard net, exposing facial hair near uncovered food. These failures were confirmed by the Dietary Manager and Registered Dietician.
Surveyors observed a brownish frozen residue in a freezer, ovens and stove burners with food and burnt residue, and a boilerless steamer leaking liquid onto the floor. The Dietary Manager and Registered Dietician confirmed these unsanitary conditions, and the Maintenance Assistant stated the steamer was broken and not repaired. Facility policies required regular cleaning and maintenance, which was not followed.
Three non-English speaking residents with documented language barriers and care plans requiring communication boards did not have these aids available at their bedside. Staff confirmed that communication boards in the residents' primary languages should have been present, but observations showed they were missing, with only English-language materials available in one case. This was not in accordance with facility policy or the residents' care plans.
A resident reported and staff confirmed unsanitary conditions in a shower room, including a dark brown substance on the floor, and four rooms in the memory care unit had dirty, worn curtains with brown discolorations. Facility policy required clean, intact linens and prompt reporting of areas needing cleaning, but these standards were not met.
A resident who was bedbound and dependent on staff for mobility did not receive regular turning and repositioning as required for pressure ulcer prevention. Despite being at risk for skin breakdown and unable to reposition independently, the care plan lacked specific interventions for two-hourly turning, and staff interviews confirmed the resident was not consistently turned. This failure to follow professional standards and facility policy placed the resident at risk for pressure injuries.
A resident with multiple complex medical conditions, including dementia and dysphagia, experienced significant unaddressed weight loss after admission. Despite care plans and facility policies requiring weekly weight monitoring and prompt intervention for significant changes, a weight entry was missed, and the resident was not included in weight review meetings. This failure to monitor and address the resident's weight loss resulted in further decline.
Two residents with significant pain-related diagnoses did not receive timely pain assessments or administration of prescribed pain medications. One resident was left in severe pain and unable to participate in therapy, while another experienced prolonged discomfort due to delayed medication administration. Staff did not follow care plans or facility policies regarding pain management and medication timing.
The facility did not maintain proper destruction logs for discontinued controlled medications and failed to reconcile controlled drug records when original narcotic sheets went missing for 11 residents. The DON confirmed that medications were not properly documented or scanned into the pharmacy system, and no reconciliation was performed when the original records were recovered, contrary to facility policy.
Surveyors found expired tube feeding formulas, unlabeled medical supplies, and improper storage of medications in medication rooms and carts. Non-narcotic medications were kept in narcotic cabinets, expired and unsealed medications were not discarded, and medications for discharged residents remained in carts. Opened over-the-counter medications lacked open dates, and narcotic count sheets were missing required nurse signatures, all contrary to facility policy as confirmed by the DON and pharmacy consultant.
A resident with diabetes and a recent amputation did not receive prescribed Novolin insulin on several occasions, with medication administration records left blank or marked as held without a physician's order. The DON confirmed there was no documentation or order to justify withholding the insulin, in violation of facility policy requiring proper medication administration and documentation.
The facility failed to maintain sanitary practices in the kitchen, with freezer temperatures out of range and incomplete cleaning schedules. Mold was found near the kitchen exit, and infection control practices were inadequate, as confirmed by the RD and Environmental Services staff.
A resident with anemia, depression, and diabetes did not receive their prescribed Vitamin D3 1000 IU due to the facility's failure to stock the medication. A nurse resorted to cutting unscored 2000 IU tablets, contrary to policy. The DON expected OTC medications to be stocked, but a refill request was pending.
The facility failed to follow food safety standards by improperly thawing frozen fish filets on a countertop and not labeling opened food items, including spices and beef base. The Dietary Supervisor confirmed these practices, which contradict the facility's policies on safe food handling and labeling.
A kitchen freezer in the facility was found with a broken seal gasket and ice buildup, potentially compromising food safety. The Dietary Supervisor confirmed the issue, noting that some food items were not properly frozen and had freezer burn. The facility's guidelines and FDA Food Code require equipment seals to be intact and free of ice buildup, which was not maintained.
A resident with dementia and other mental health conditions was punched by another resident while attempting to enter their room, as witnessed by staff. The incident occurred due to inadequate supervision, allowing the resident to access the courtyard. Both residents had care plans indicating the need for monitoring, which were not effectively implemented, leading to the altercation.
A resident with a history of disruptive behavior and cognitive impairments was unsupervised in the courtyard, leading to an altercation with another resident. Despite protocols requiring supervision and locked doors, the resident accessed the courtyard and was punched by another resident, resulting in a fall.
A resident with Type 2 diabetes was struck multiple times by another resident with moderate memory impairment and hemiplegia after a minor collision in the hallway. The incident, witnessed by staff and other residents, resulted in no physical injury but impacted the victim's self-esteem. Facility staff acknowledged the incident as abuse, as it affected the resident's mental well-being.
The facility failed to provide a resident with recommended Restorative Nursing Aide (RNA) services after discharge from Physical Therapy (PT), leading to a decline in the resident's ability to use a walker. Despite a care plan and PT discharge summary recommending RNA services, these were not implemented, resulting in decreased mobility and frustration for the resident.
The facility failed to protect resident information when meal tickets containing personal and medical details were discarded into the garbage and subsequently into an outside dumpster. This practice was confirmed by the dietary manager and the assistant director of nursing, who stated that tray cards should be shredded. The facility's policy indicated that PHI must be safeguarded and disposed of using methods that render it unusable.
The facility failed to ensure adequate indications for the use of psychotropic medications for two residents. One resident was administered olanzapine despite no documented indicators of psychosis, and another was given aripiprazole without proper documentation. Non-pharmacological interventions were not adequately considered, and the documentation did not support the use of these medications.
A facility failed to ensure a medication error rate below 5% when a nurse administered a resident's medications through a gastrotomy tube in a manner not consistent with standard practices or facility policy, resulting in a 30.3% error rate. The nurse mixed multiple medications together and did not flush between administrations, contrary to the resident's medication orders and facility policy.
The facility failed to ensure medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates. Loose pills and improperly labeled medications were found in medication carts, and a medication blister pack was displaced. The ADON acknowledged these issues and stated that the night shift should be responsible for checking and cleaning the carts.
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. Issues included non-functional thermometers, incomplete temperature logs, improperly labeled and expired food items, unsanitary kitchen equipment, and inadequate hand hygiene practices by kitchen staff. These failures decreased the facility's potential to prevent foodborne illness for the residents who ate facility-prepared food.
The facility failed to obtain informed consent for the use of psychotropic medication from the responsible party (RP) for a resident. The resident, who had multiple diagnoses including dementia and major depressive disorder, was prescribed quetiapine. The physician increased the dosage, but there was no documented informed consent from the RP for this change. The absence of documented informed consent was confirmed by the ADON and SSD during the survey.
The facility failed to develop and implement person-centered comprehensive care plans for three residents requiring oxygen therapy. One resident was receiving oxygen at a higher rate than prescribed, while two others had no care plans reflecting their need for oxygen therapy, despite having physician orders.
The facility failed to revise care plans for two residents in a timely manner, impacting their potential to receive appropriate interventions. One resident with a gastrostomy tube had a discrepancy in tube feeding orders, while another resident with a urinary tract infection had no active antibiotic orders despite the care plan indicating otherwise. Additionally, a resident with absence epileptic syndrome had issues with oxygen therapy compliance, with the nasal cannula tubing found on the floor and not connected to the resident.
The facility failed to ensure professional standards of quality in nursing care for a resident by not obtaining informed consent for psychotropic medication, not having a physician's order to flush a midline catheter, and not following the prescribed oxygen administration order.
The facility failed to ensure proper pharmacy services when a medication was improperly disposed of in an open trash can on the side of the medication cart. A Licensed Nurse acknowledged the safety hazard, and the Assistant Director of Nursing confirmed that the practice did not align with the facility's policy for medication disposal.
The facility failed to ensure pureed foods were prepared according to standardized recipes, affecting their nutritional value and flavor. Cook 1 used unmeasured amounts of tap water and canned liquid instead of the specified low sodium broth, gravy, or milk. The Dietary Manager confirmed that staff are expected to follow recipes to maintain nutritional value and flavor.
The facility failed to maintain two reach-in freezers and two reach-in refrigerators in safe operating condition, compromising food safety and quality for 103 residents. The seals on the equipment were found to be torn or covered with tape, and the Maintenance Director could not provide proof of progress in obtaining replacements.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to ensure the results of an abuse allegation investigation were reported to the state agency within the required five working days. Resident 1, who had diagnoses including a right shoulder fracture and end-stage renal failure, was involved in an altercation documented in an SBAR note dated 4/13/26, which stated that the resident and her roommate were in the lobby, began cussing at each other while the roommate was preparing to leave for dialysis, and that when Resident 1 was on the gurney leaving, the roommate punched Resident 1 on the body. The Administrator confirmed that the initial SOC 341 report was sent on 4/13/26, but the 5-day summary of the abuse allegation investigation was not sent to CDPH until 4/21/26. This reporting timeframe did not comply with the facility’s policy titled “Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment,” which requires that results of all investigations of alleged violations be reported within five working days of the incident. The deficiency centers on the delay between the incident date and the submission of the 5-day investigation summary, as verified through interview with the Administrator and review of the email to CDPH, demonstrating that the facility did not adhere to its own policy and the expected reporting timeframe for abuse investigation results.
Failure to Timely Report Abuse Investigation Results and Assess Resident After Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of abuse investigation results to the California Department of Public Health (CDPH) and failed to complete a required nursing assessment following an abuse allegation. One resident, admitted in September 2025 with multiple diagnoses including surgical aftercare, and another resident, admitted in December 2024 with multiple diagnoses including respiratory failure, each reported physical abuse by a CNA. Incident reports for these allegations were submitted to CDPH on 1/26/26 and 1/28/26. However, the facility’s 5‑day investigation results for both incidents were not submitted to CDPH until 2/10/26, which exceeded the required five working days. The Administrator confirmed that the results of the investigations were not provided within the regulatory timeframe, despite facility policy stating that allegations of abuse will be reported to state or federal agencies within applicable regulatory timeframes. The facility also failed to perform and document a nursing assessment for the resident with respiratory failure after the abuse allegation on 1/28/26. Review of this resident’s medical record showed no documentation that a nurse assessed the resident following the reported abuse. In an interview, the DON confirmed that an assessment was not completed after the allegation and stated that the expectation was for an assessment to be done. The facility’s abuse prevention policy specified that a licensed nurse will immediately examine a resident upon receiving reports of alleged physical abuse and that the findings of the examination shall be recorded in the resident’s medical record, which did not occur in this case.
Failure to Timely Report Resident’s Allegation of Physical Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported within the required timeframe after a cognitively intact resident reported being injured by staff during care. The resident, admitted with chronic kidney disease, schizophrenia, and bipolar disorder, was observed by a charge nurse late in the evening with purple and yellow discoloration on the right cheek. When questioned, the resident stated that a CNA assigned to her had hit her in the face and pulled her hair after she touched the CNA without notice, though she could not recall the exact date, time, or identity of the staff member involved. The resident later described that the CNA thought she was acting out in aggression, grabbed her hands, hit her in the face, and pulled her hair, which made her feel scared and hurt. Investigation documents showed that another CNA (CNA 2) became aware of the resident’s allegation the day before the charge nurse noted the bruising, when the resident asked if she saw the bruise and reported that a CNA had hit her and pulled her hair in the middle of the night. CNA 2 did not report this allegation at that time, stating she did not know what to do with the information and did not believe the resident because of things the resident says, and instead waited until the next day to ask the resident again, who repeated the same story. The facility’s abuse policy required staff with knowledge of an actual or potential violation to report it to a supervisor or the administrator immediately, and stated that all allegations of abuse, neglect, misappropriation, or exploitation should be reported immediately to the administrator. The Executive Director confirmed this was a reportable incident and that his expectation was that staff report such allegations to the charge nurse within the required timeframe.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in food service, as evidenced by observations of unclean utensils and improper hand hygiene practices among dietary staff. During an inspection, multiple small black particles were found on utensil holders, and several forks and spoons had visible food particles and water residuals. Both the Dietary Manager and Registered Dietician confirmed that these utensils were not properly cleaned and acknowledged that utensils used for residents should be free of food particles. The facility's policy requires all dishes to be properly sanitized and gross food particles to be removed before washing, which was not followed in this instance. Additionally, a Dietary Aide was observed manually washing kitchenware and then handling clean kitchen containers without performing hand hygiene in between tasks. The aide confirmed that he did not wash his hands before touching the clean side of the dishwashing area, despite being the only person assigned to dishwashing at the time. The Registered Dietician stated that two people should be involved in dishwashing to prevent cross-contamination and that handwashing is required before handling clean items. The facility's policy also specifies the need to wash hands and change gloves to prevent cross-contamination, which was not adhered to during the observed events.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Ensure Safe and Appropriate Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident with severe cognitive impairment and a history of brain tumor and craniotomy. The facility did not follow physician discharge orders, as the resident was discharged to a hotel without home health services being established, despite orders for home health RN, PT, and OT. The required 30-day discharge notice was not provided in advance but was instead given at the time of discharge, depriving the resident of the opportunity to appeal. Additionally, the facility did not develop or document post-discharge follow-up for a neurology referral, and there was no physician discharge summary in the resident's medical record. Further review revealed that the MDS discharge assessment was incomplete and not submitted, and cognition and mood assessments were not performed. The resident, who had documented severe cognitive deficits and required maximum cues for memory and following directions, was found confused and non-verbal after discharge, leading to hospitalization. Facility staff, including the Social Services Director, MDS Coordinator, DON, and Administrator, confirmed these deficiencies and acknowledged that the discharge was not conducted safely or in accordance with facility policy and federal requirements.
Failure to Assess and Intervene After Resident Elopement
Penalty
Summary
A resident with a history of severe cognitive impairment, including a brain tumor, cognitive communication deficit, and memory impairment, was admitted to the facility. The resident's records indicated difficulty following directions and a need for maximum cues. Despite these documented cognitive deficits and a known tendency to wander, the resident was able to exit the building without staff authorization and was later found at a liquor store by facility staff. Review of the resident's medical records revealed there was no documented evidence of an elopement care plan, elopement risk assessment, or change of condition assessment following the incident. Interviews with facility staff, including a licensed nurse, the Social Services Director, and the Administrator, confirmed that the facility did not assess or implement interventions for the resident's elopement risk as required by facility policy. Additionally, there was no documentation of the incident or follow-up actions in the resident's record, contrary to the facility's elopement and missing resident policy.
Failure to Accommodate Resident Food Preferences During Meal Service
Penalty
Summary
The facility failed to accommodate the documented food preferences of three residents during a lunch meal service. One resident, with a history of anemia and vitamin D deficiency, did not receive the double portion of protein as specified on her meal ticket and confirmed this during an interview. The Dietary Manager also verified that the lunch tray did not include the required double protein portion. Another resident, also diagnosed with anemia, had a preference for a green vegetable with every meal, specifically requesting a green salad, but did not receive any salad with her lunch. This was confirmed by both the resident and the Dietary Manager upon review of the meal tray. A third resident, with a diagnosis of vitamin D deficiency, had a preference for fresh fruit for dessert, as indicated on her meal ticket. During observation and interview, it was noted that no fresh fruit was provided on her lunch tray, and the resident expressed concern about its absence. The Registered Dietician confirmed that the fresh fruit was not included and acknowledged that residents' food preferences should have been honored according to their choices. The facility's policy requires staff to determine and provide for residents' food preferences at meals, but this was not followed for these three residents.
Plan Of Correction
This plan of correction constitutes the facility's written credible allegation of compliance. Preparation and/or execution of this Plan of Correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusion set forth on the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because required by the provisions of the health and safety code section 1280 and 42 CFR 483. Immediate corrective action(s) for those Residents affected by the deficient practice: Dietary Manager (DM) and Resident 1 communicated to clarify this resident's preference as it was stated small portions and double protein. Residents requested to maintain small portions and remove double protein. Dietary Manager updated resident's preferences. Registered Dietitian (RD) clarified with Resident 2 that she wants green vegetables with lunch and a spinach salad during dinner, no green vegetable with breakfast. Resident's meal ticket updated with these preferences. In addition to a preference on her meal ticket, RD added Resident's request to the standing daily meal request list to ensure our staff prepare and serve this each meal. RD clarified with Resident 3 who confirmed she wants fresh fruit with all meals, and this Resident's meal ticket updated reflecting this. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be negatively affected if Resident's preferences aren't followed. Facility measures and systemic changes to ensure the deficient practice does not recur; Systemic changes to address the deficient practice include, but are not limited to auditing all current residents' preferences regarding double protein, green vegetables with every meal, and fresh fruit for dessert. RD to clarify that double protein requests are nutritionally appropriate. Dietary Manager will create a list of residents who request green vegetables with every meal and fresh fruit for dessert and assign a Dietary Aide to prepare an adequate number of items prior to meal service. Each of the following team members will audit 2 meal services per week by pulling 4 random trays prior to each meal cart exiting the kitchen. The attached audit form will be utilized for this audit.
Failure to Store and Monitor Food Safely
Penalty
Summary
The facility failed to store food in a sanitary manner for its residents. On the day of the survey, two boxes containing 48 cups each of yogurt were observed left on the kitchen floor at room temperature for over three hours after delivery. The Dietary Manager confirmed that the yogurt, along with other refrigerated items such as milk and eggs, should have been placed in the refrigerator immediately upon arrival but were not. Both the Dietary Manager and the Registered Dietician acknowledged that the yogurt should have been discarded due to the risk of foodborne illness. Facility policy requires that potentially hazardous foods be put away quickly to minimize contamination and bacterial growth. Additionally, the facility did not monitor and document the temperature of a freezer during an evening shift, as required by their policy. The Dietary Manager confirmed that the freezer temperature log was missing an entry for the specified shift, and stated that accurate documentation is necessary to ensure food is held at safe temperatures. The facility's policy mandates that cooler and freezer temperatures be checked and recorded daily using internal thermometers.
Plan Of Correction
Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; RD will compile data from these audits and present to monthly QAPI meetings for 3 months to ensure substantial compliance. F0812 - Immediate corrective action(s) for those residents affected by the deficient practice; Dietary staff threw the yogurt out that wasn't properly stored within two hours of delivery. Plan / Process to identify other residents potentially affected by the same deficient practice and corrective action(s) to be taken; All residents have the potential to be affected if time sensitive foods aren't properly stored after delivery within 2 hours. Facility measures and systemic changes to ensure the deficient practice does not recur; Dietary Manager (DM) completed an in-service focusing on the urgency of prioritizing time sensitive foods on 7/29/25 for dietary staff that manage food delivery. In-service conducted on 8/7/25 covering proper procedure for logging fridge and freezer temperatures. The DM or designee will audit to ensure that all time sensitive items have been properly stored one hour after food delivery (Tuesdays and Fridays). If any item is found to still be out, DM or designee will assist Dietary Aide to ensure time sensitive items are stored properly within 2 hours of delivery. Freezer temperature logs will be audited daily by the DM and Assistant Dietary Manager daily. Facility plan to monitor corrective actions & sustain compliance; Integrate QA Process; Audit results will be presented at monthly meetings for a minimum of three months to the QAPI committee to ensure compliance.
Resident-to-Resident Physical Abuse Resulting in Pain and Emotional Distress
Penalty
Summary
A deficiency occurred when a resident with hemiplegia and no memory impairment was physically abused by another resident with severe memory impairment and a diagnosis of bipolar disorder. Staff, including a CNA, witnessed the second resident striking the first resident multiple times on the hand and face. The incident resulted in the first resident experiencing physical pain, redness on the face, and emotional distress, as documented in progress notes and interviews. The affected resident was observed to be tearful, upset, and uncomfortable following the altercation. The facility's own policy states that each resident has the right to be free from abuse, including physical abuse such as hitting. Multiple staff members, including the CNA, Social Services Director, and DON, acknowledged that the first resident was a victim of physical abuse by another resident. The incident was documented in the SBAR form and progress notes, and the emotional impact on the resident was significant enough to warrant a referral to psychiatry.
Resident Meal Tickets with PHI Left Unattended in Memory Unit
Penalty
Summary
Sixteen resident meal tickets containing sensitive information, including residents' names, allergies, and therapeutic diets, were left unattended on a table in the facility's memory unit dining area. This was observed during a visit with the Registered Dietician, who acknowledged that the meal tickets should not have been left out and should have been taken to the shredder, identifying the situation as a HIPAA violation. The Director of Nursing also confirmed that leaving meal tickets unattended constitutes a HIPAA violation and that such documents need to be shredded. Review of the facility's policy indicated that employees are required to safeguard protected health information (PHI) and ensure proper disposal to prevent unauthorized access.
Failure to Adhere to Medication Administration and Feeding Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted professional standards of clinical practice in several key areas. Licensed nurses did not administer medications in a timely manner to multiple residents, with medication administration times significantly delayed beyond the facility's policy of one hour before or after the scheduled time. For example, medications scheduled for early morning were not given until late morning or early afternoon for several residents with complex medical conditions, including Parkinson's disease, diabetes, heart failure, stroke, and hypertension. These delays were confirmed through review of medication administration records and direct interviews with staff, who acknowledged the late administration. Additionally, licensed nurses did not follow proper procedures for verifying resident identity or explaining medications prior to administration. Observations showed that nurses prepared and administered medications to several residents without checking identification or informing them about the medications being given. When questioned, the nurses admitted to omitting these steps. Facility policy requires verification of resident identity and explanation of medications, but these procedures were not followed during the observed medication passes. The facility also failed to follow physician orders for continuous gastrostomy feeding for a resident dependent on tube feeding. Observations revealed that the resident's feeding pump was repeatedly beeping with a hold error, and the feeding formula volume remained unchanged over several hours, indicating that the prescribed nutrition was not being delivered. The nurse responsible confirmed that the pump should have been running continuously, and the DON stated that staff are expected to monitor and respond to feeding pump alarms. The facility's policy requires medications and treatments to be administered in accordance with prescriber orders, but this was not done in this case.
Failure to Implement EHR Downtime Contingency Plan and Staff Training
Penalty
Summary
The facility failed to implement its facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime. When the EHR became inaccessible due to an internet outage, nursing staff were not provided with timely direction and were unaware of the procedures to follow. The Director of Nursing (DON) stated that nurses were expected to print medication administration records (MARs) from a backup computer, but the backup computer was also not functioning, requiring staff to use a different computer. Multiple licensed nurses reported that upon arrival, they were informed of the system outage by the night nurse, but had not received any guidance from management and were not aware of the contingency plan for EHR outages. There was no prior notification from management regarding the outage, and staff were left waiting for instructions. Interviews with the DON and Administrator (ADM) confirmed that no mock drills had been conducted for an EHR outage, despite facility policies indicating that such drills should be performed. Review of the facility's assessment and policies showed that procedures and drills for EHR outages were outlined, but these were not followed or communicated to staff during the incident. As a result, there were delays in medication administration, with the potential to affect the health and safety of the facility's 104 residents.
Failure to Maintain and Document QAPI Program Activities
Penalty
Summary
The facility failed to ensure an effective and comprehensive Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) program was performed for a census of 104 residents. During interviews, multiple staff members, including the Director of Staff Development, Social Services Director, Infection Preventionist, and Minimum Data Set Manager, were either unaware of or unable to provide documentation for the previous three quarterly QAPI meetings. The Administrator confirmed that there were no records of QAPI meetings for the last three quarters and acknowledged that QAPI meetings had not been conducted prior to their arrival. The facility's policy requires maintaining documentation and evidence of ongoing QAPI activities, but this was not followed. Record review and staff interviews revealed that the facility did not maintain documentation or present evidence of QAPI meetings as required. The lack of documentation and awareness among staff indicated that QAPI activities were not being consistently performed or tracked. The Minimum Data Set Manager noted ongoing issues with resident rehospitalization rates, suggesting that performance improvement activities were not being effectively evaluated or revised. The absence of QAPI meeting records and lack of staff knowledge about the process contributed directly to the deficiency.
Infection Control Lapses in Device Management, EBP Implementation, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. One deficiency involved a resident's CPAP mask, which was not stored in a microbial bag as required by facility policy. Instead, the mask was left on top of the CPAP machine, exposing it to potential contamination. The Director of Nursing and Infection Preventionist confirmed that the mask should have been stored in a microbial bag to prevent infection, as per standard practice. Another deficiency was observed regarding the lack of Enhanced Barrier Precautions (EBP) for several residents with invasive medical devices or wounds. Residents with urinary catheters, gastrostomy tubes, suprapubic catheters, and pressure ulcers did not have EBP signage posted, nor was personal protective equipment (PPE) available inside or outside their rooms. Medical records for these residents did not document EBP implementation, despite facility policy requiring EBP for residents with such conditions. The Infection Preventionist confirmed that EBP, including gown and glove use during high-contact care, should have been in place for these residents. Additional deficiencies included the failure to label and date medical equipment such as oxygen tubing, feeding tubes, and IV bags and tubing for several residents. Staff were observed not performing hand hygiene between resident contacts in the dining room and during medication administration. Both a CNA and a licensed nurse admitted to forgetting to perform hand hygiene, which was confirmed as a requirement by the facility's policies. These lapses in infection control practices were directly observed and verified by staff interviews.
Failure to Serve Meals Timely According to Resident Needs and Preferences
Penalty
Summary
The facility failed to serve meals and snacks at times consistent with resident needs, preferences, and requests, as well as with community norms, for five sampled residents. Multiple residents reported that meals were consistently late, with some waiting up to 1 to 2 hours for their food. Observations confirmed that meal trays were not served at the scheduled times, and staff interviews acknowledged the delays. The posted dining schedule did not indicate specific meal times, and on several occasions, meal trays had not arrived or been served at the expected times. Residents expressed dissatisfaction, noting that meals were sometimes cold and that the lack of a consistent schedule made it difficult to plan their day. The affected residents had various medical conditions, including type 2 diabetes with hypoglycemia, hypomagnesia, hypokalemia, acute kidney failure, myopathy, paraplegia, anemia, and hyperlipidemia. Some residents had impaired cognition, while others were cognitively intact. Staff, including a registered dietician, CNA, dietary consultant, and the DON, confirmed awareness of the late meal service and acknowledged that it could impact medication administration and resident satisfaction. Review of facility policy indicated that meals should be served according to routine schedules and resident preferences, but these procedures were not followed.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure food service staff adhered to current standards of practice for food safety in several key areas. Surveyors observed that staff did not consistently label, date, or monitor refrigerated and frozen foods, with expired items and items lacking expiration dates found in multiple refrigerators and freezers. Additionally, temperature logs for all refrigerators and freezers were incomplete, with missing entries for several days. The Dietary Manager confirmed these findings and acknowledged that expired food should be discarded and that failure to do so could result in residents becoming ill. In the dry storage area, surveyors observed the presence of fruit flies and flies, as well as improperly stored food items such as an uncovered container of sugar, unsealed boxes of instant hot cereal mix, and bags of oats and cereal with ripped openings. The Registered Dietician confirmed that these conditions could lead to food contamination and stated that expired food should be thrown out and food should be stored in sealed containers. Both the DM and RD confirmed the missing temperature log entries and agreed that temperatures should be checked and logged regularly. Additionally, staff failed to adhere to standards of practice regarding personal hygiene, as a dietary aide was observed assembling resident trays without wearing a beard net, with facial hair protruding from a face mask and later exposed while calling out tray orders over uncovered food. The RD confirmed that beard nets are required and that the facility had run out of them. Review of facility policy and the FDA Food Code indicated that all perishable food items must be properly stored, labeled, and dated, and that staff must wear appropriate hair restraints to prevent contamination.
Failure to Maintain Kitchen Equipment in Safe and Sanitary Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe and sanitary operating condition. Observations revealed a brownish frozen residue on the bottom shelf of a freezer, which was confirmed by the Dietary Manager, who stated that there should not be any residue or crumbs present. Additionally, two ovens were found with brownish-black residue, and all four stove burners had food and black burnt residue. Three of the burners were in use at the time, with a pot containing a clear golden liquid with sediment. The Registered Dietician confirmed these findings and noted that the boilerless steamer was leaking clear liquid onto the floor, pooling at the base of a metal panel, and described the equipment as unstable and in disrepair, an issue that had been ongoing for weeks. The Maintenance Assistant confirmed the drainage and leaking from the boilerless steamer, stating that it was broken and not fixed. The Dietary Manager reiterated that the expectation is for equipment to be in clean working order and not leaking. Review of facility policies indicated that equipment should be cleaned and sanitized regularly to prevent foodborne illness, with specific cleaning schedules for freezers and stoves, and that maintenance tasks should ensure all equipment is safe and functional. These observations and staff interviews demonstrate a failure to adhere to the facility's own sanitation and maintenance policies.
Failure to Provide Communication Boards for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide communication boards at the bedside for three residents who did not speak English, despite care plans indicating the need for such aids due to language barriers. Resident 19, whose primary language was Russian and who had chronic kidney disease and hemiplegia, was observed without a communication board in the room. Resident 24, with congestive heart failure and a primary language of Cantonese, also did not have a communication board available. Resident 58, diagnosed with Alzheimer's disease and dementia and whose primary language was Mandarin, had only an English-language poster in the room, with no communication board in Mandarin present. Interviews with staff confirmed that communication boards in the residents' primary languages should have been available in their rooms. The facility's policies emphasized the importance of dignity, respect, and non-discrimination, including the provision of free language services and information in other languages. However, during observations and interviews, it was evident that these communication supports were not in place for the identified residents, contrary to both care plan interventions and facility policy.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a homelike environment as evidenced by unclean and worn conditions in resident areas. In one instance, a resident with myopathy and paraplegia, who was cognitively intact, reported that the shower rooms were dirty and unsanitary, specifically noting the presence of mold and dirt in the grout. Direct observation confirmed a dark brown substance on the floor of a shower room, which was acknowledged by a licensed nurse, who stated that staff should have notified housekeeping. The Infection Preventionist confirmed that shower rooms should always be clean to prevent infection and support residents' psychosocial wellbeing. Additionally, four rooms in the memory care unit were found to have curtains by the sliding doors that were worn and had visible brown discolorations. The Director of Staff Development described the curtains as dirty, old, and stained, and the Director of Nursing stated that curtains should be clean and intact to maintain a homelike environment. Review of facility policy indicated that stained or worn linens should be removed upon discovery and that areas needing cleaning should be reported to housekeeping, but these practices were not followed.
Failure to Provide Timely Turning and Repositioning for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to implement regular and timely turning and repositioning for a resident who was dependent on assistance for bed mobility and at risk for pressure ulcers. The resident, admitted with multiple diagnoses including hematoma of the skin, chronic kidney disease, muscle weakness, and limited mobility, was assessed as being at risk for skin breakdown and unable to turn or reposition independently. The care plan identified the need for assistance with activities of daily living and bed mobility, but did not include specific interventions for turning and repositioning every two hours. Multiple observations and interviews revealed that the resident remained in the same position for extended periods and was not aware of the need for regular repositioning. Staff interviews confirmed that the resident had not been turned as required, despite facility policy and professional standards indicating the necessity of such care for immobile residents. The lack of consistent implementation of pressure injury prevention measures placed the resident at risk for skin breakdown.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to address and monitor significant weight loss for one resident. The resident, who had multiple diagnoses including metabolic encephalopathy, Alzheimer's disease, dementia, hypothyroidism, hyperosmolality, hypernatremia, and dysphagia, was dependent on staff for feeding. Upon admission, the resident's usual body weight was around 125 lbs, and care plans were in place to monitor for malnutrition and significant weight changes, including weekly weight checks for the first month and notification of the physician if significant changes occurred. However, a weight entry was missing for the week following admission, and the resident experienced a 13.5% weight loss over a week and a half, dropping from 124 lbs to 107.2 lbs, which was not promptly identified or addressed. Further review revealed that the resident continued to lose weight, reaching 102.6 lbs, and was not included in the most recent weekly weight meeting. The facility's policies required weekly weight monitoring for new admissions and for residents with significant unplanned weight loss, but these procedures were not followed. The registered dietician confirmed the lack of timely monitoring and intervention, which resulted in continued weight loss for the resident.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents, resulting in deficiencies related to pain assessment and timely administration of pain medication. One resident, admitted with multiple fractures and osteoarthritis, had a care plan indicating the need for pain medication before therapy and as needed for pain. Despite this, the resident reported severe pain in the morning, rated as 10 out of 10, and stated that they had been requesting pain medication since waking. The resident was observed in discomfort and unable to participate in therapy exercises due to pain. The nurse confirmed that the resident had not been assessed or given pain medication, and the occupational therapist had not communicated the resident's pain to nursing staff. Another resident with chronic pain conditions, including intervertebral disc degeneration, rheumatoid arthritis, and osteoarthritis, was observed in visible distress, moaning and expressing pain. The resident's scheduled pain medications, including opioids and other analgesics, were not administered at the prescribed times. Staff interviews revealed that the nurse had not been able to administer any scheduled morning medications, and the resident continued to experience pain for an extended period. The delay in medication administration was confirmed by both the resident's family and staff, and the facility's medication administration audit showed that medications were given significantly later than scheduled. Both cases demonstrated a lack of timely pain assessment and intervention consistent with the residents' care plans and professional standards of practice. The facility's own policies required pain management and medication administration within specific timeframes, but these were not followed, resulting in unmanaged pain and discomfort for the affected residents.
Failure to Maintain Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain proper pharmacy services for 11 residents by not documenting destruction logs for discontinued controlled medications and not reconciling controlled drug records when original narcotic sheets went missing. During an observation and record review, it was found that 11 controlled medications stored in the DON's office lacked destruction logs, and the medications were not scanned or recorded into the pharmacy website upon receipt from the nurses. The DON confirmed these omissions and acknowledged that the controlled drugs in the locked cabinet were not properly accounted for at the time of transfer from nursing staff. Additionally, the original controlled drug sheets for medication cart A2 went missing and were replaced with photocopied handwritten narcotic sheets. When the original sheets were later found, no reconciliation was performed to check for discrepancies. The DON verified that the reconciliation process was not completed, and the facility's consultant pharmacist confirmed that both a destruction log and reconciliation between two nurses were required by facility policy. The facility's policy also stated that all controlled substances must be fully accounted for and any discrepancies resolved by the end of the shift.
Deficient Medication Storage, Labeling, and Accountability Practices
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management and storage practices. In the medication room, expired tube feeding formulas and unlabeled medical supplies, such as anti-embolic stockings, suction catheter trays, and tracheostomy care kits, were found. These items lacked use-by dates or were past their expiration, and the DON confirmed that such items should have been disposed of according to facility policy. The facility's policy requires routine checks and removal of expired or opened items, which was not followed. Further observations in medication carts revealed additional deficiencies. In medication cart A1, non-narcotic medications were stored in the narcotic cabinet, expired and unsealed medications were present, and medications belonging to discharged residents were not removed. Some medications, such as Doxycycline and Famotidine, were found in cups without resident labels or original packaging. Treatment supplies were also stored in the medication cart instead of the designated treatment cart. The pharmacy consultant and DON confirmed these practices were not in line with facility policy and could lead to medication errors. In medication cart A2, opened over-the-counter medications lacked open and discard dates, and the narcotic count sheet was missing required signatures from both incoming and outgoing licensed nurses. Facility policy mandates that all opened medications be labeled with the date opened and that narcotic count sheets be signed by both shifts to ensure accountability. These lapses in documentation and storage practices were confirmed by interviews with nursing staff and the DON.
Failure to Administer Insulin as Prescribed and Inadequate Documentation
Penalty
Summary
The facility failed to administer insulin as prescribed for one resident with diabetes and a recent surgical amputation. The resident had a physician's order for Novolin Insulin 90 units subcutaneously twice daily. Review of the Medication Administration Record (MAR) for March showed that on two occasions, the initial boxes for insulin administration were left blank with no documentation explaining the omission. Additionally, on two other occasions, the licensed nurse documented codes indicating the insulin was not given due to blood sugar being outside parameters or being held, but there was no physician's order allowing the insulin to be withheld for any parameters. The Director of Nursing (DON) confirmed these findings during interviews and record reviews, acknowledging the lack of documentation and absence of physician orders to hold the insulin. The facility's policy required staff to follow the MAR and document medication administration according to regulations, which was not done in these instances. The failure to administer insulin as ordered and to properly document or obtain appropriate physician orders for withholding medication constituted a deficiency in pharmaceutical services.
Sanitary Practices Lapse in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, which could potentially lead to foodborne illness. During an observation, the freezer temperatures were found to be out of the acceptable range, with one freezer at the entrance of the kitchen observed at 10 degrees Fahrenheit and another next to the dishwashing area at 38 degrees Fahrenheit. The Registered Dietician (RD) confirmed these temperatures were out of range and should have been reported to environmental services immediately. The facility's policy indicated that freezer temperatures should be maintained at 0 degrees Fahrenheit or below. Additionally, the Registered Dietician Consultant (RDC) noted that the freezer door was left open, contributing to the temperature issue, and reported that two freezers and two refrigerators needed replacement. Unsafe infection control practices were also observed in the kitchen. The cleaning schedule was incomplete, with only three signatures and blank sheets, and the RD could not provide documentation of staff sanitizing kitchen areas. A sanitizer bucket and log were observed, but it was unclear if the sanitizer was replaced throughout the day as required. Mold was found near the kitchen exit door, confirmed by the Environmental Services Director and Manager, who stated it was not sanitary for a food preparation area. The Infection Preventionist noted issues with freezer temperature checks and other infection control practices during audits. The Executive Director stated that the dietary supervisor manages kitchen cleaning and staffing, but no documentation was provided to confirm daily cleaning activities.
Deficiency in Medication Availability for Resident
Penalty
Summary
The facility failed to ensure the availability of routine medications for a resident, leading to a deficiency in pharmaceutical services. The resident, admitted in November 2024 with conditions including anemia, depression, and diabetes, had a prescribed order for Vitamin D3 1000 IU to be administered daily. However, the facility did not have the Vitamin D3 tablets in the required dosage in stock. This lack of availability was confirmed during an interview with a licensed nurse, who indicated that due to the absence of the correct dosage, she resorted to cutting unscored 2000 IU tablets to meet the resident's medication order. Further investigation revealed that a refill request for the Vitamin D3 1000 IU was placed, but the medication was still not available at the time of the survey. The Director of Nursing expressed an expectation that over-the-counter medications should be stocked adequately. A review of the facility's policy indicated that unscored tablets should not be split, highlighting a deviation from the established medication administration procedures. This deficiency had the potential to impact the resident's therapeutic needs or exacerbate their medical conditions.
Improper Food Thawing and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food safety, as observed during a survey. Two packages of frozen salmon filets and two packages of frozen cod filets were found thawing on a kitchen table countertop, which is not in accordance with the facility's policy and procedure for safe food handling. The policy specifies that frozen foods should be thawed during the cooking process, under refrigeration, or by immersion under running potable water at a temperature of 70 degrees Fahrenheit or lower. This improper thawing method was confirmed by the Dietary Supervisor during an observation and interview. Additionally, the facility did not comply with its policy on labeling and dating food items. Nine opened bottles of dry spices, one opened bottle of beef base, and one bag of opened pink lemonade powder were found unlabeled. The Registered Dietitian indicated that proper labeling is crucial for kitchen staff to know when food was prepared and when it expires. The facility's policy requires that all opened food products be labeled with the date they were opened, which was not followed in this instance.
Freezer Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a kitchen freezer, which was found to have a broken seal gasket and ice buildup on its ceiling. This issue was observed during a survey with the Dietary Supervisor, who confirmed the freezer's poor condition. The broken gasket seal and ice buildup were noted to potentially affect the quality of food stored within, as evidenced by five bags of hash browns that were not frozen solid and one bag of vegetables that had freezer burn. The facility's document on kitchen sanitation and food storage required that freezer seals be tight and free of ice buildup, which was not adhered to in this instance. The Registered Dietitian confirmed that a poor seal could lead to ice buildup and affect the freezer's ability to maintain consistent temperatures, potentially compromising food safety. The 2022 Federal Food and Drug Administration Food Code also mandates that equipment components such as seals be kept intact and tight to ensure proper operation, which was not the case here.
Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when Resident 4 punched Resident 5. This incident was witnessed by two staff members as Resident 5 attempted to enter Resident 4's room from the courtyard. Resident 5, who has multiple diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, fell to the ground and began yelling at the nurse during an assessment. Resident 4, who also has dementia, bipolar disorder, and Alzheimer's disease, confirmed the altercation, stating that he knocked Resident 5 down. The facility's policy and procedure on abuse prevention and reporting were not effectively implemented, as evidenced by the lack of supervision in the Activity Room, which allowed Resident 5 to access the courtyard. Resident 5's care plan included monitoring for behaviors such as intrusiveness and wandering, as well as regular checks for safety, but these measures were not adequately followed. Resident 4's care plan, initiated after the incident, noted a risk for psychosocial decline related to resident-to-resident altercations. The facility's failure to monitor and intervene in situations likely to lead to conflict contributed to the occurrence of this incident.
Failure to Supervise Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate monitoring and supervision for Resident 5, who has a history of disruptive behavior and cognitive impairments, resulting in an altercation with Resident 4. Resident 5, admitted in 2016 with diagnoses including dementia, major depressive disorder, bipolar disorder, and undifferentiated schizophrenia, was found unsupervised in the courtyard, an area where residents from the locked memory care unit are not allowed without supervision. Resident 5 attempted to enter Resident 4's room from the courtyard, leading to Resident 4, who also has severe cognitive impairments and a history of aggressive behavior, punching Resident 5, causing him to fall to the ground. Interviews with facility staff, including the Administrator, CNA, Activity Assistant, and Sr Regional Director Clinical, confirmed that residents from the locked memory care unit should not be in the courtyard unsupervised and that the sliding glass doors should always be locked. Despite these protocols, Resident 5 accessed the courtyard through the sliding glass doors in the Activity Room, which were supposed to be locked. The facility's policy on abuse prevention emphasizes the need for a safe environment and monitoring residents with behaviors that may lead to conflict, which was not adhered to in this instance.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck him multiple times in the chest and face. Resident 1, who has Type 2 diabetes and no memory impairment, was involved in an incident where he accidentally bumped into Resident 2's wheelchair in the hallway. In response, Resident 2, who has moderate memory impairment and hemiplegia following a stroke, struck Resident 1 in the face and chest three times. Although Resident 1 was not physically injured, the incident negatively impacted his self-esteem. Interviews conducted with staff and residents revealed that the incident was witnessed by others, including a licensed nurse who heard the altercation and a resident who saw the physical confrontation. The Social Services Director and the Assistant Director of Nursing acknowledged that the incident constituted abuse, as it affected Resident 1's mental well-being. The facility's policy on abuse emphasizes the right of each resident to be free from abuse, including resident-to-resident abuse that results in physical injury, pain, or mental anguish.
Failure to Provide Recommended Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Resident 43 received services to maintain her mobility as recommended by a Physical Therapist (PT). Resident 43, who was readmitted with multiple diagnoses including spinal stenosis, osteoarthritis, and muscle weakness, had a care plan that included goals for improving her ability to walk. Despite these goals, the facility did not provide the necessary Restorative Nursing Aide (RNA) services after her discharge from PT, which led to a decline in her ability to use a walker. This was confirmed through interviews and record reviews, which showed that the recommendation for RNA services was not followed through in the electronic health record (EHR) and care plan assessments. During interviews, Resident 43 expressed frustration and anger over her declining mobility, stating that she was doing well with the walker while receiving PT but had not received any assistance with the walker since PT services stopped. The Area Director of Rehabilitation (ADOR) and the Minimum Data Set Licensed Nurse (MDS LN) both confirmed that Resident 43's PT discharge summary included a recommendation for RNA services, which was not implemented. The MDS LN acknowledged that the lack of RNA services could lead to a decline in the resident's functioning, and the Assistant Director of Nursing (ADON) stated that residents recommended for RNA should be initiated into the program within a month. Further interviews with Certified Nursing Assistants (CNAs) revealed that they had not assisted Resident 43 with her walker for over a month, corroborating the resident's account. The facility's policy on Restorative Nursing Programs indicated that residents should receive RNA services upon discharge from therapy to maintain or improve their abilities. However, this policy was not followed, resulting in a decline in Resident 43's physical functioning and psychosocial well-being.
Failure to Protect Resident Information
Penalty
Summary
The facility failed to protect resident information when meal tickets containing personal and medical details were discarded into the garbage and subsequently into an outside dumpster. During a visit to the kitchen, a dietary aide was observed throwing meal tickets, which included resident names, room numbers, diet orders, food allergies, food preferences, and special dietary needs, into the trash as part of the usual process for setting up for dishwashing. This practice was confirmed by the dietary manager, who acknowledged that the trash is brought to an outside dumpster accessible to the public, thus constituting a HIPAA violation. Further interviews revealed that the assistant director of nursing stated that tray cards should be shredded and not disposed of in regular trash. The facility's policy on safeguarding protected health information (PHI) indicated that PHI must be reasonably safeguarded to limit incidental uses or disclosures and that the disposal of records should comply with federal and state laws, using methods that render the PHI unusable. This failure had the potential to compromise the information of 103 residents receiving facility-provided meals out of a census of 109.
Inadequate Indications for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents had adequate indications for the use of psychotropic medications. Resident 80 was administered olanzapine, a psychotropic medication indicated for psychosis, despite having no documented indicators of psychosis. The resident exhibited behaviors such as yelling and agitation, but these were deemed manageable through redirection by staff. The resident's responsible party initially consented to the medication but later requested its discontinuation due to increased distress. Interviews with staff and medical professionals revealed that non-pharmacological interventions were not adequately considered before prescribing the medication, and the documentation did not support the use of olanzapine for this resident's symptoms. Resident 93 was administered aripiprazole, another psychotropic medication indicated for psychosis, despite having no documented indicators of psychosis. The resident had a history of depression and anxiety and was noted to have mood improvements when engaged in social activities. The resident experienced an episode of suicidal ideation and was subsequently prescribed aripiprazole upon return from the hospital. Interviews with staff indicated that the resident's mood could be managed through social interaction and non-pharmacological means. The documentation did not support the use of aripiprazole, and the resident was not on the maximum dose of the previously prescribed anti-anxiety medication, buspirone. The facility's policy on psychotropic medication use requires a comprehensive assessment and documentation of clinical indications for such medications. However, in both cases, the documentation did not support the use of antipsychotic medications, and non-pharmacological interventions were not adequately explored. This failure decreased the facility's potential to prevent residents from experiencing adverse effects such as sedation, falls, and abnormal involuntary movements from the use of antipsychotic medications.
Medication Administration Error
Penalty
Summary
The facility failed to ensure the medication error rate did not exceed 5% for one resident when a licensed nurse administered medications not in accordance with standard nursing principles and practices or the facility policy. During an observation, the nurse was seen crushing six pills together and mixing them with two liquid medications and two powdered medications, then administering the mixture in a bolus through a gastrotomy tube without flushing between administrations. This resulted in a medication error rate of 30.3% for the resident. The resident's medication orders required each medication to be administered separately with flushing between each administration. The nurse admitted to always mixing all the resident's medications together and was unaware of the facility's policy and procedure for gastrotomy tube medication administration. The Assistant Director of Nursing confirmed that the expectation was to administer each medication separately and flush between administrations, as outlined in the facility's policy dated January 2022.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in a clean and sanitary environment and labeled correctly with open and discard dates. During an inspection of medication cart two, a loose pill was found, and a medication cup containing 11 loose pills was stored in the top drawer without any resident's name or drug identifiers. The Assistant Director of Nursing (ADON) acknowledged these issues, stating that the night shift should be responsible for checking and cleaning the carts. Additionally, the ADON confirmed that nurses should not pre-pour pills and should administer medications directly in front of the resident after proper identification. Further inspection revealed that three bottles of eye drops and one inhaler in medication cart two were not labeled with open or discard dates. The ADON acknowledged this issue, stating that the expectation was to label pharmaceutical products with an open date and dispose of them after 28 days. The facility's policy and procedure indicated that medications with shortened expiration dates should be labeled with the date opened and the date to expire. However, the facility was unable to provide a policy addressing the 28-day discard date requirement. Additionally, a medication blister pack was found displaced in the back of medication cart one. The ADON acknowledged that the blister pack should not be there and stated it was a safety concern. The ADON reiterated that the night shift should be responsible for checking the carts for loose pills and blister packs. These failures decreased the facility's potential to prevent drug diversion and medication administration errors.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen observation, it was found that there were no functional thermometers for dry storage room monitoring and for internal temperature monitoring for freezer #1. Additionally, the temperature logs for refrigerators, freezers, and the dry storage area were incomplete, with several missing entries. This lack of proper temperature monitoring could lead to food being stored at unsafe temperatures, increasing the risk of foodborne illness among residents. The Dietary Manager (DM) confirmed these observations and acknowledged the need for functional thermometers and complete temperature logs to ensure food quality and safety. Food items in the kitchen were not properly labeled or sealed, and expired foods were not discarded. During an initial kitchen tour, it was observed that multiple food items lacked proper labels for received, use by, or expiration dates. Additionally, some food items were mislabeled, and expired food, such as a gallon of milk, was found in the refrigerator. The DM confirmed these observations and stated that food items should be labeled correctly to prevent the risk of having expired food items in the kitchen. The facility's policy and procedure indicated that food should be inspected for contamination and labeled with the date it was transferred to a new container. The facility also failed to maintain cleanliness and proper sanitation in the kitchen. The racks in two refrigerators had rust on the surface and were unable to be readily sanitized. The facility did not install or maintain a drain air gap in the sink used to prepare fruits and vegetables. The can opener had dark residue buildup around the blade, and the exterior surface of the dishwasher and drawers containing kitchen utensils were not clean. Additionally, kitchen surfaces were stained, had chipped paint, and missing floor tiles. Kitchen staff did not perform hand hygiene when moving from dirty to clean surfaces, and they did not properly fill the red sanitizer bucket with the correct concentrations of sanitizer. The logs for the red sanitizer bucket and dishwasher disinfectant were incomplete, and kitchen staff were unable to verbalize the manual dishwashing procedure with the correct sanitizer solution used. These failures decreased the facility's potential to prevent foodborne illness for the residents who ate facility-prepared food.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of psychotropic medication from the responsible party (RP) for one resident. Resident 73, who was admitted in April 2022 with multiple diagnoses including hemiplegia, hemiparesis, dementia with psychotic disturbance, anxiety disorder, personality disorder, and major depressive disorder, was prescribed quetiapine. The physician increased the dosage of quetiapine from 50 mg to 75 mg daily on 12/28/23, but there was no documented informed consent from the RP for this change in medication dosage. The resident's medical chart and nursing progress notes did not indicate that the RP was informed or that an informed consent was completed before administering the increased dosage of quetiapine. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) confirmed the absence of documented informed consent in the resident's records. During an initial tour of the facility, Resident 73 was observed to be in bed, receiving oxygen, and exhibiting confusion and a flat affect. The facility's policy on psychotropic medication management and an All Facilities Letter (AFL) both require that informed consent be obtained and documented before administering psychotropic medications. Despite these requirements, the facility did not have the necessary documentation to show that the physician had informed the RP of the risks and benefits of the increased dosage of quetiapine. This failure was confirmed by the ADON and SSD during the survey, and no additional physician's notes or documentation were provided by the conclusion of the survey.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for three residents, which decreased the facility's potential to provide appropriate interventions for residents to maintain their highest medical and physical practicable level of function. Resident 30 was admitted with diagnoses including adult failure to thrive and generalized weakness, and had an order for oxygen at 2 liters per minute through a nasal cannula. However, a review of Resident 30's care plans indicated that there was no comprehensive or person-centered care plan that included the use of oxygen. Similarly, Resident 53, who was admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, had an order for oxygen at 3 liters per minute through a nasal cannula, but did not have a comprehensive or person-centered care plan that included the use of oxygen. Both residents were observed receiving oxygen as per their physician's orders, but their care plans did not reflect this need for oxygen therapy. Resident 73, admitted with COPD, had a physician's order for oxygen at 2 liters per minute via nasal cannula, but was observed receiving oxygen at 6 liters per minute. The Licensed Nurse confirmed the discrepancy and adjusted the oxygen flow rate to the prescribed 2 liters per minute. The Associate Director of Nursing confirmed that residents should have an established care plan for the use of oxygen and that staff should be aware of the oxygen conditions. The facility's policies on oxygen administration and comprehensive care plans were not followed, leading to the deficiencies observed.
Failure to Revise Care Plans in a Timely Manner
Penalty
Summary
The facility failed to revise care plans for two residents in a timely manner, which decreased the potential to provide appropriate interventions for maintaining their highest medical and physical practicable level of function. Resident 38, admitted in August 2017 with diagnoses including dysphagia and the presence of a gastrostomy tube, had a tube feeding order that started on December 24, 2019. However, during an observation in May 2024, the resident was found receiving Jevity 1.2 at 55 ml per hour, contrary to the care plan revised in February 2024, which indicated 75 ml per hour. This discrepancy was confirmed by the Assistant Director of Nursing (ADON), who stated that care plans should be revised within 72 hours if there is a change in condition or update to the resident's physician orders, including nutritional status. Resident 82, admitted in April 2024 with diagnoses including a urinary tract infection and muscle weakness, had a care plan initiated on May 6, 2024, indicating antibiotic therapy for the infection. However, a review of the resident's Order Summary Report (OSR) on May 23, 2024, did not show any active orders for antibiotics. The ADON confirmed that care plans should be updated within 72 hours of any change in condition or physician orders. The facility's policy and procedure on comprehensive care plans, dated December 2017, also indicated that resident progress should be regularly evaluated and approaches revised or updated as appropriate. Additionally, Resident 77, admitted in late 2023 with diagnoses of absence epileptic syndrome, had a new order for oxygen via nasal cannula at 2 liters per minute starting on May 15, 2024. However, during observations on May 21, 2024, the resident's nasal cannula tubing was found on the floor, and the resident was not using the oxygen. The Certified Nursing Assistant (CNA) and Licensed Nurse (LN) confirmed that the tubing should be clean and connected to the resident, and that care plans should indicate the need for continuous oxygen. The care plan for Resident 77 was revised on May 21, 2024, to indicate non-compliance with the plan of care and refusal of oxygen via nasal cannula. The ADON reiterated that care plans should be updated quarterly, with any change of condition, and within three days or right away to ensure proper care direction.
Failure to Ensure Professional Standards of Quality in Nursing Care
Penalty
Summary
The facility failed to ensure nursing care was provided per professional standards of quality for one resident when Licensed Nurses did not obtain informed consent from the resident's Responsible Party (RP) before administering psychotropic medication. The resident, who had multiple diagnoses including dementia and major depressive disorder, had their quetiapine dosage increased without documented informed consent from the RP. The Assistant Director of Nursing (ADON) and the Social Services Director (SSD) confirmed that there was no documentation of informed consent in the resident's medical records, which is a requirement according to the facility's policy and state regulations. Additionally, the facility did not obtain a physician's order to flush the resident's midline catheter, which is necessary for administering intravenous medication. The resident had a midline catheter inserted for the administration of IV rocephin, but there was no documentation indicating that the midline catheter had been flushed as required. The Licensed Nurse (LN) confirmed that only Registered Nurses (RNs) are authorized to flush midline catheters and that there was no record of this procedure being performed. Furthermore, the facility did not follow the prescribed physician's order for oxygen administration. The resident, who had a diagnosis of COPD, was observed receiving oxygen at a rate of 6 liters per minute (l/min) instead of the prescribed 2 l/min. The LN confirmed the discrepancy and adjusted the oxygen flow rate accordingly. The facility's policy on oxygen administration requires adherence to the physician's order, which was not followed in this case.
Improper Disposal of Medication
Penalty
Summary
The facility failed to ensure proper pharmacy services for a census of 109 residents when a medication was improperly disposed of in an opened, regular trash can on the side of the medication cart. During an inspection of medication cart two, a Licensed Nurse (LN) was observed disposing of a loose pill in an open trash can. The LN acknowledged that this practice could pose a potential safety hazard, as unauthorized individuals could retrieve the pill. The Assistant Director of Nursing (ADON) confirmed that pills should not be disposed of in a regular trash can and stated that the proper procedure was to use a pill buster for non-narcotic medications. The facility's policy and procedure for the disposal of expired or discontinued medications indicated that medications should be placed in a designated, secured location and disposed of in a manner that limits access by unauthorized personnel and residents. The ADON acknowledged that the observed practice was a safety concern and did not align with the facility's policy. This failure decreased the facility's potential to prevent unauthorized access to prescription drugs, drug diversion, and medical adverse consequences.
Failure to Follow Standardized Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure pureed foods were prepared in a manner that conserved nutritive value and palatability. During an observation, Cook 1 was seen preparing pureed roast beef by adding an unmeasured amount of hot tap water instead of the recommended low sodium broth or gravy. Additionally, Cook 1 prepared mashed sweet potatoes using liquid from the can instead of milk as specified in the recipe. These actions were not in accordance with the facility's standardized recipes, which specify measured amounts of appropriate liquids to maintain nutritional value and flavor. The Dietary Manager confirmed that the expectation was for dietary staff to follow the recipes in the book. The DM stated that for pureed diets, staff should count out portions, grind down the meat, add measured amounts of gravy or broth, blend, and add small amounts of liquid as needed. The failure to follow these recipes can affect the nutritional value and flavor of the food provided to residents, thereby not meeting their nutritional needs.
Failure to Maintain Refrigerator and Freezer Seals
Penalty
Summary
The facility failed to maintain two reach-in freezers and two reach-in refrigerators in safe operating condition. During an initial kitchen tour, it was observed that the seals on freezer #1 and freezer #3 had gaps in various corners, and the seals on refrigerator #2 and refrigerator #3 were either torn or covered with black tape. The Dietary Manager confirmed that the seals were broken and needed replacement, and the Maintenance Director acknowledged the issue but could not provide any quotes or written proof of progress in obtaining new seals. The FDA Food Code 2022 requires that equipment be maintained in a state of repair and condition that meets specific requirements, including keeping components such as doors and seals intact and tight. The failure to maintain these seals compromised the facility's ability to ensure food safety and quality for 103 residents who consumed facility-prepared meals. The Maintenance Director stated that efforts were being made to find suitable replacement parts, but no concrete progress had been documented.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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