Crestwood Wellness And Recovery Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Redding, California.
- Location
- 3062 Churn Creek Rd., Redding, California 96002
- CMS Provider Number
- 05A371
- Inspections on file
- 25
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Crestwood Wellness And Recovery Center during CMS and state inspections, most recent first.
A resident with schizoaffective and bipolar disorders, known for delusions and disruptive verbal behaviors, shared a room with another conserved resident diagnosed with schizophrenia and delirium. On the morning of the incident, a CNA heard the first resident loudly state, “I’m going to kill you,” but did not enter the room to assess safety, did not place eyes on the residents, and did not effectively report this behavioral change to the SC or an LN as required by the facility’s crisis intervention policy and CNA job description. Staff later reported that the first resident had been making daily death threats toward the roommate, yet there was no CNA documentation of such threats in the progress notes, and the DON, ADON, Wellness and Recovery Director, and LNs were unaware of them. Feeling threatened when the first resident put her fists up as if to fight, the roommate struck her in the face multiple times, causing facial and neck redness and bruising that lasted for over two weeks, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident with schizoaffective disorder and bipolar type, but with intact cognition on BIMS, told an LPN that people were coming into her room and "rape her" when she was not fully awake, and a subsequent note by social services documented that a peer was having sex with her without consent. The Wellness and Recovery Director and the Administrator conducted an internal investigation after the allegation was discussed in a team meeting, and an SOC 341 later reflected that the conservator’s office was informed of non-consensual sex by a peer. Despite a facility policy requiring immediate reporting of reality-based abuse allegations to the Administrator and external authorities, and the Administrator’s own description that such allegations should be reported to police, social services, CDPH, and the Ombudsman within two hours, the allegation was not reported to these required agencies.
Surveyors found that the facility did not review or update its emergency preparedness plan within the required annual timeframe, as the last update was in 2023. Staff confirmed the absence of a current plan, affecting planning for all residents.
Surveyors identified that the facility did not update its emergency preparedness plan (EPP) policies and procedures within the required annual timeframe. Staff confirmed the last review was in 2023, resulting in a deficiency for not maintaining current EPP documentation for all residents.
Surveyors identified that the facility did not maintain an annually updated emergency preparedness communication plan, as required by regulation. Staff confirmed the last review was in 2023, resulting in the absence of a current communication plan for all residents.
Surveyors identified that the facility did not provide evidence of an annual update to its emergency preparedness plan (EPP) training and testing program. The last documented review was in 2023, and staff confirmed no subsequent update had occurred, resulting in noncompliance with regulatory requirements for emergency preparedness.
A failed water flow test revealed that the facility's sprinkler system alarm did not activate within the required timeframe, as the water flow was tested for over 90 seconds without initiating the alarm. Staff were unaware of the malfunction, and this deficiency affected all residents and smoke compartments in the facility.
A smoke detector outside a resident room failed to activate the fire alarm system during two separate tests with artificial smoke. Staff could not determine the cause at the time, but noted the proximity of an AC vent, which may have affected the detector's function. This issue impacted 14 residents in one smoke compartment.
Surveyors found a suspended power strip in a resident area, plugged into a television and positioned about one foot off the ground. Staff confirmed the power strip was accidentally suspended, indicating a failure to maintain electrical equipment according to NFPA standards.
A review of facility records and staff interviews revealed that the fire watch policy did not specify that a fire watch would be implemented within four hours of the fire alarm system being out of service, as required. This omission affected all residents in the facility.
A review of facility records and staff interviews revealed that the fire watch policy lacked required language specifying that a fire watch must be implemented if the sprinkler system is out of service for more than ten hours. This omission affected all residents and smoke compartments in the facility.
The facility did not document the results of the DON's annual TB infection screening on the required form, as confirmed by a review of personnel records and acknowledgment from Human Resources.
Two residents with schizoaffective disorder and intact cognition were permitted to self-administer oxygen per physician orders, but the MARs lacked a section for LPNs to document oxygen administration. The facility also did not formally assess the residents' ability to self-administer oxygen or provide required education, contrary to facility policy.
Surveyors observed that opened packages of frozen fried eggs, soy chicken patties, and soy beef patties were stored in the kitchen freezer without required labels or dates. The Food Service Supervisor confirmed these items had been opened and should have been labeled with an open date according to facility policy.
A resident with a history of schizoaffective disorder and anxiety was verbally and physically assaulted by another cognitively intact resident with schizophrenia and substance abuse history. The aggressor yelled derogatory names and struck the resident on the head, then chased him down the hallway before staff intervened. The incident resulted in increased anxiety and emotional distress for the victim.
A client eloped from a facility due to a malfunctioning door lock and staff oversight. The client exited through a door with a faulty magnetic lock, and a TOA, unfamiliar with residents, mistook her for an employee. Program Staff saw the client outside but assumed she was with another staff member, leading to the client being missing for eight hours.
A resident with a history of aggressive behavior physically abused two other residents in separate incidents. The first incident involved the resident striking another resident in the face, causing injuries. The second incident involved the resident choking another resident. Despite being on frequent welfare checks, the aggressive resident's behavior was unpredictable, and the facility failed to manage the situation effectively.
The facility did not label and date food containers and product bags after opening, as observed in the freezer and refrigerator. Items such as frozen breaded fish, frozen french toast, and fresh pepperoni were found open and unlabeled. A staff member acknowledged forgetting to label the items, and the Food Service Supervisor confirmed the requirement for labeling with an open date.
Failure to Intervene on Verbal Threats Resulting in Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to follow its own crisis intervention and reporting policies. The facility’s Crisis Intervention Program required staff to recognize early warning signs of crisis, such as changes in behavior, mood, or thinking, and to provide early intervention when a resident exhibited increased acting-out behaviors. The CNA job description required CNAs to immediately report all changes, including agitation, to the Shift Coordinator (SC). On the day of the incident, a CNA heard one resident yelling, “I’m going to kill you,” but did not enter the room to assess the situation, ensure safety, or investigate what was happening, and did not effectively report this change in behavior to nursing staff or the SC. The resident who was later physically abused (Resident 1) had a history of schizoaffective disorder, bipolar type, and was conserved. An Annual MDS indicated this resident had delusions, verbal behavioral symptoms directed toward others, intruded on others’ privacy and activities, and significantly disrupted the care or living environment of others. Staff interviews confirmed that this resident had delusions involving being married to Elvis and yelling about wanting to kill a woman she believed was after her husband. However, review of progress notes from 5/5/25 through 12/25/25 showed no CNA documentation that any CNA had witnessed or reported verbal death threats during these recurring delusions. The resident who committed the physical abuse (Resident 2) was also conserved and had diagnoses of schizophrenia and delirium, with documented delusions. On the day of the incident, Resident 2 reported feeling threatened when Resident 1 put her fists up as if they were going to fight, and Resident 2 hit Resident 1 in the face approximately three times. Staff interviews indicated that Resident 1 had been making daily verbal death threats toward Resident 2, but the licensed nurses, DON, ADON, and Wellness and Recovery Director all confirmed they had not been notified of these threats or of the specific statement, “I’m going to kill you,” made that morning. A licensed nurse stated that if the CNA had reported the observed threat, she would have assessed the situation, determined whether the statement was related to a delusion or directed at the roommate, and attempted to redirect or separate the residents. As a result of the unreported threat and lack of timely intervention, Resident 1 sustained reddened areas and bruising on the neck and right side of the face, with bruising that persisted for 15 days.
Failure to Report Resident’s Allegation of Sexual Abuse to Required Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving one resident to CDPH, the police, and the local Ombudsman as required. The facility’s abuse prevention policy stated that staff must immediately report any suspicions of client abuse to the Administrator, and that all reality-based accusations must be immediately investigated and reported to officials in accordance with state law, including CDPH. The resident involved had schizoaffective disorder, bipolar type, and was conserved, with a documented history of hallucinations and delusions. However, the resident’s most recent BIMS score was 15/15, indicating intact memory, orientation, and judgment. On one occasion, a licensed nurse reported via internal communication that the resident stated people came into her room and “rape her” when she was not fully awake. This information was relayed to the Wellness and Recovery Director (WRD) and the Director of Nurses. The WRD documented in a Social Services Note that the resident told a nurse she felt a peer was coming into her room and having sex with her without her consent, and noted that the statement was similar to previous unverifiable accusations. The WRD and Administrator subsequently conducted an internal investigation after a team meeting where the allegation was discussed. An SOC 341 form later showed that the WRD had emailed the resident’s conservator’s office stating that a peer was having sex with the resident without her consent and that the facility had investigated the allegation. During interviews, the resident became visibly distressed and denied making the statements attributed to her, while the nurse involved denied that the resident had said she was raped and characterized the communication as related to the resident’s fixation on becoming pregnant. The Administrator acknowledged that, according to facility procedure, allegations of sexual abuse should trigger immediate steps to protect residents and notification of police, social services, CDPH, and the Ombudsman within two hours, and confirmed that this allegation was not reported to those authorities.
Failure to Annually Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain its emergency preparedness plan (EPP) in accordance with federal regulations, which require the plan to be reviewed and updated at least annually. During a record review and interview with staff, surveyors requested the EPP and found that the most recent update was dated 11/15/23. Staff confirmed that the last review of the EPP occurred in 2023, and no updated version was available for the current year. This deficiency was identified during a survey on 6/9/25, where it was determined that the EPP had not been reviewed or updated within the required annual timeframe. The lack of an updated EPP could impact the facility's ability to ensure proper planning and preparation for the health and safety of all 90 residents, as the plan may not reflect current risks or procedures.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan. The facility will continue to maintain the emergency preparedness plan every year by reviewing and updating the plan annually. The facility shall update the EPP on June 26, 2025, during the QA Committee meeting. The facility shall include the EPP review and update as part of the facility's annual review for all facility Policies and Procedures, to be conducted in January 2026 and then each consecutive year in the following January. The update will be communicated to staff during the all-staff meeting scheduled for June 26, 2025, coordinated by the Administrator and facility Environmental Services Supervisor. Further issues regarding the EPP annual update and approval will be received during the QA process and brought to the QAPI Committee for review. The Environmental Services Supervisor, Administrator, and QA Manager will be responsible to ensure ongoing compliance.
Failure to Annually Update Emergency Preparedness Plan Policies and Procedures
Penalty
Summary
The facility failed to maintain and update its emergency preparedness plan (EPP) policies and procedures as required. During a record review and interview with staff, it was found that the EPP had not been updated annually, with the last documented review occurring in November 2023. Staff confirmed that the most recent review date was in 2023, indicating that the required annual update had not been completed. This deficiency was identified during a survey in which the EPP was specifically requested and examined. The lack of an updated EPP could result in the absence of proper planning and preparation to protect the health and safety of all 90 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining the emergency preparedness plan (EPP). The facility shall continue to ensure the emergency preparedness plan has updated policies and procedures. The facility shall update the emergency preparedness plan policies and procedures by June 26, 2025, during the QA Committee meeting. The facility shall include the reviewed and updated emergency preparedness plan policies and procedures as part of the annual review for all facility policies and procedures to be conducted in January 2026, and then each consecutive year in the following January. Further issues regarding the facility's emergency preparedness plan's policies and procedures shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and Director of Nursing shall be responsible to ensure ongoing compliance. This page is purposefully left blank.
Failure to Annually Update Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to maintain compliance with federal regulations requiring an annually reviewed and updated emergency preparedness communication plan. During a record review and interview with staff, surveyors found that the emergency preparedness plan (EPP) had not been updated since 11/15/23, and staff confirmed that the last review occurred in 2023. As a result, the facility did not have an up-to-date communication plan as required, affecting the planning and preparation for the health and safety of all 90 residents. No additional details regarding the medical history or condition of the residents at the time of the deficiency were provided in the report.
Plan Of Correction
The facility recognizes the importance of maintaining an updated communication plan. The facility shall continue to maintain an updated communication plan and review it annually. The facility shall update the emergency preparedness communication plan by June 26, 2025, during the QA Committee meeting. The communication plan shall be included when the facility reviews the emergency preparedness plan annually in January 2026 and each year consecutively in the following January. Further issues regarding the facility's development of a communication plan as part of the emergency preparedness plan shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance.
Failure to Annually Update Emergency Preparedness Training and Testing Program
Penalty
Summary
The facility failed to maintain compliance with emergency preparedness requirements by not updating its emergency preparedness plan (EPP) training and testing program on an annual basis. During a record review and interview with staff, it was found that the last update to the EPP training and testing program occurred in November 2023, and no subsequent annual update was provided as required. Staff confirmed that the most recent review date was in 2023, indicating that the program had not been reviewed or updated within the required timeframe. This deficiency was identified during a survey in which the facility was unable to produce documentation of an updated EPP training and testing program. The lack of an annual update could affect the facility's ability to ensure proper planning and preparation for emergencies for all 90 residents. The findings were based solely on the absence of the required annual review and update of the emergency preparedness training and testing program.
Plan Of Correction
The facility recognizes the importance of developing and maintaining an emergency preparedness training and testing program. The facility shall continue to provide an EPP training and testing program update annually. The Emergency preparedness training and testing program shall be reviewed June 26, 2025 during the QA Committee meeting. The emergency training and testing program shall be included in the annual review of facility policy and procedures in January 2026 and then each year consecutively in the following January. Further issues regarding the training and testing program of the EPP shall be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or more frequent if necessary. The Administrator, Environmental Services Supervisor, QA Manager, and DON shall be responsible for monitoring and ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Sprinkler System Water Flow Alarm Failure
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 and NFPA 101 Life Safety Code requirements. During a tour and inspection, the water flow test was conducted at the inspector test valve located in an exterior electrical closet near the generator. The test revealed that the water flow alarm did not activate within the required 90 seconds, as the water flow was tested for over 90 seconds without initiating the alarm. The last documented water flow test was during the annual inspection on 5/16/25. Staff interviewed during the inspection were unaware that the water flow alarm was not functioning as required. This deficiency affected all 90 residents and all ten smoke compartments in the facility, as the lack of a functioning water flow alarm could delay sprinkler protection in the event of a fire. Records of system design, maintenance, inspection, and testing were maintained, but the failure to ensure the water flow alarm's proper operation led to the cited deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System, including the water flow test. The repair and retest of the Sprinkler System was conducted and completed by Environmental Services Supervisor June 9, 2025. The facility will continue to complete the Sprinkler System flow test monthly in July, August, and September—then will revert back to normal quarterly testing in October. Further issues regarding the facility Sprinkler System will be received during the QA process and brought to the QAPI Committee for review and discussion at least quarterly, or as necessary. The Administrator, Environmental Services Supervisor, QA Manager, and maintenance staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Smoke Detector Failed to Initiate Fire Alarm During Testing
Penalty
Summary
During a facility tour and staff interview, surveyors observed that a smoke detector located outside resident room 209 failed to initiate the fire alarm system when tested with artificial smoke. The test was conducted twice, and on both occasions, the alarm did not activate. Staff present during the testing were unable to provide an explanation for the malfunction at the time of the observation. It was noted that the air conditioning vent was approximately 36 inches from the smoke detector, and staff speculated that airflow from the vent might be interfering with the detector's ability to sense smoke. This deficiency affected 14 out of 90 residents in one of ten smoke compartments, as the non-functioning smoke detector could delay notification to emergency forces in the event of a fire.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the smoke detectors and fire alarm system. The facility contacted Sa-Fire to inspect the current locations of the smoke detectors. Facility plans to move / re-locate the 4 ceiling mount smoke detectors away from the proximity of the air registers that may have affected the smoke detectors, causing the testing issues. Sa-Fire will be placing the system on test to complete the work, and the annual fire alarm inspection is scheduled to be completed July 25, 2025. The detectors will be re-tested at that point. Further issues regarding the fire alarm system and/or the smoke detectors will be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance. This page is purposefully blank.
Improper Use of Suspended Power Strip in Resident Area
Penalty
Summary
During a facility tour, surveyors observed a suspended power strip in the Trinity center, approximately one foot off the ground and plugged into a television. Staff confirmed that the power strip had been accidentally suspended by facility personnel. This observation indicated that the facility failed to maintain electrical equipment in accordance with regulatory requirements, specifically regarding the proper use and placement of power strips as outlined by NFPA standards. No information was provided regarding any residents directly affected or their medical conditions at the time of the deficiency.
Plan Of Correction
The facility recognizes the importance of maintaining electrical equipment. The facility shall continue to properly maintain electrical equipment. Environmental Services Supervisor removed the suspended power strip in the Trinity Center June 9, 2025. In-service was provided to maintenance staff on NFPA code and to look for during room inspections, specific to power strips. Power strip audits will be conducted monthly, using the facility Monthly Maintenance Log. Further issues regarding electrical equipment shall be received during the facility QA process and brought to the QAPI Committee for review and discussion. The Environmental Services Supervisor, Administrator, maintenance staff, nursing staff, and housekeeping staff shall be responsible to monitor for ongoing compliance. This page is purposefully left blank.
Incomplete Fire Watch Policy During Fire Alarm System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than four hours of the fire alarm system being out of service, as required. Staff confirmed that the policy lacked a defined time frame for initiating a fire watch. This deficiency affected all 90 residents across ten smoke compartments.
Plan Of Correction
The facility recognizes the importance of maintaining the fire alarm system. The facility shall continue to maintain the fire alarm system, and shall update the fire watch policy. When the fire alarm system is "out of service," the facility's fire watch policy shall include language stating, "fire watch will be implemented after no more than four hours of the fire alarm system being out of service." The updated Fire Watch Policy will be reviewed, updated, and adopted June 26, 2025, during the QA Committee meeting. Further issues regarding the fire alarm system fire watch policy shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, DON, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Fire Watch Policy for Sprinkler System Outage
Penalty
Summary
The facility failed to maintain compliance with fire safety regulations by not having a complete fire watch policy in place. During a record review and interview, it was found that the facility's fire watch policy did not specify that a fire watch would be implemented after no more than ten hours of the sprinkler system being out of service. Staff confirmed that the required time frame was not included in the policy. This deficiency affected all 90 residents across ten smoke compartments, as the policy omission could impact the facility's response during a sprinkler system impairment.
Plan Of Correction
The facility recognizes the importance of maintaining the Sprinkler System. The facility shall continue to maintain the Sprinkler System. When the Sprinkler System is out of service, the facility shall update the Fire Watch policy to include language indicating "fire watch will be implemented after no more than ten hours of the sprinkler system being out of service." The updated Fire Watch policy will be reviewed, updated, and approved June 26, 2025 during the QA Committee meeting. Further issues regarding the Fire Watch policy or the sprinkler system shall be received during the QA process and brought to the QAPI Committee for review and discussion. The Administrator, Environmental Services Supervisor, QA Manager, maintenance staff, and nursing staff shall be responsible for monitoring and ongoing compliance.
Incomplete Documentation of TB Screening for DON
Penalty
Summary
The facility failed to provide documented evidence of the results of the Director of Nursing Services' (DNS) annual tuberculosis (TB) infection screening on the required examination form. During a review of the DNS's personnel record, it was found that the most recent annual TB exam did not indicate whether the result was positive or negative for TB. This omission was confirmed during an interview and record review with Human Resources, who acknowledged that the TB exam documentation for the DNS was incomplete and lacked the necessary result information.
Plan Of Correction
DNS's personnel record was reviewed by DNS, Clinical Care Manager, Medical Director, and Administrator on 6/5/2025. The document was corrected and updated to reflect a negative TB result on 6/7/2025. The facility's Clinical Care Manager, DNS, Medical Director, and Administrator are responsible for the correction. Results of TB screening, examinations, and completion of forms will be conducted by the Clinical Care Manager. The Facility QA Manager will perform quarterly audits of initial health exams and annual exams to monitor for ongoing compliance. The DNS personnel file was corrected on 6/7/2025. Further issues regarding Employee Health Exams and/or Health Records will be brought to the QA/QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, and Administrator shall be responsible to monitor for ongoing compliance.
Failure to Document and Assess Oxygen Self-Administration
Penalty
Summary
The facility failed to ensure proper documentation and assessment related to oxygen administration for two patients. Specifically, the Medication Administration Records (MARs) for both patients did not include a section for licensed nursing staff to document the administration of oxygen, despite physician orders allowing the patients to use oxygen at specified rates via nasal cannula. The Director of Nursing Services confirmed that there was no place in the MARs for this documentation. Additionally, the facility did not conduct formal assessments to determine the patients' ability to safely self-administer oxygen, nor did it provide formal education to the patients regarding self-administration, as required by facility policy. Both patients involved had a diagnosis of schizoaffective disorder and were assessed as cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The facility's policies required interdisciplinary team assessments of cognitive, physical, and visual abilities for self-administration of medications, as well as patient instruction and demonstration of self-administration skills. These steps were not completed for either patient, resulting in incomplete health records and a lack of formal verification of their ability to self-administer oxygen safely.
Plan Of Correction
The facility recognizes the importance of maintaining complete and accurate health records. June 27, 2025. The facility shall continue to maintain complete and accurate health records. For Resident 3 and Resident 5, the oxygen administration was documented on MAR June 4, 2025. Formal education regarding self-administration of oxygen was completed on June 4, 2025, by the Clinical Nurse, and assessments will be performed by the Clinical Nurse Supervisor by July 15, 2025. The DNS, Clinical Care Manager, Director of Staff Development, LN Shift Supervisors, Medical Records Supervisor, and Nursing staff shall be responsible for the correction. Newly admitted patients with supplemental oxygen orders will have a self-administration evaluation assessment completed upon admission. Education on self-administration of supplemental oxygen will be provided upon admission. Residents with supplemental oxygen orders will have a self-administration evaluation assessment completed at least quarterly by licensed staff. Education on self-administration of supplemental oxygen will be provided at least quarterly, by licensed staff. Further issues regarding the content of health records and documentation of oxygen administration will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or with more frequency if an issue is identified. The Clinical Care Manager, DSD, DNS, Medical Director, Nurse Shift Supervisors, Nursing staff, Medical Records Supervisor, and Administrator shall be responsible to monitor for ongoing compliance. This page is purposefully left blank. This page is purposefully left blank.
Failure to Label and Date Opened Frozen Food Products
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by not labeling and dating food product bags after opening them for use. During an observation in the kitchen's second freezer, open and unlabeled packages of frozen fried eggs, soy chicken patties, and soy beef patties were found. The Food Service Supervisor confirmed that these bags had been previously opened and that there was no apparent label present on any of the packages. A review of the facility's policy titled 'Labeling and Dating of Foods' indicated that newly opened food items are required to be closed and labeled with an open date and a use-by date according to guidelines. The Food Service Supervisor acknowledged that, per facility policy, products are to be labeled with an open date once the packaging is opened for use. The failure to follow this procedure was directly observed and confirmed during the survey.
Plan Of Correction
The facility recognizes the importance of storing, labeling, and dating food products in accordance with professional standards. The facility shall continue to store, label, and date food products in accordance with professional standards. The facility's Food Service Supervisor will begin utilizing a freezer-proof storage bag that works well with our permanent markers with no smearing. The Food Service Supervisor ordered for delivery on Friday, 6/13/2025. The facility will continue to utilize these to prevent labeling and dating issues in the freezer. Food Service Supervisor and the facility's Registered Dietitian have not seen any "smearing" or "smudging." The RD will include labeling, storing, and dating of food products in the freezer in the monthly audit. Further issues regarding storing, labeling, and dating of food products in accordance with professional standards will be received by the Food Service Supervisor or Registered Dietitian during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Food Service Supervisor, Registered Dietician, dietary staff, and Administrator shall be responsible for monitoring ongoing compliance. This page purposefully left blank.
Failure to Protect Resident from Verbal and Physical Abuse by Peer
Penalty
Summary
A deficiency occurred when a resident was not protected from verbal and physical abuse by another resident. Specifically, one resident with a history of schizophrenia, psychoactive substance abuse, and visual hallucinations verbally assaulted another resident by yelling and calling him derogatory names, then physically assaulted him by striking him on the head with a closed fist. The aggressor continued to chase the victim down the hallway until staff intervened and separated the two individuals. Both residents were cognitively intact according to their most recent assessments. The facility's policy required all appropriate preventative measures to ensure residents are not at risk for abuse, but this was not followed in this instance. The assaulted resident, who had a history of schizoaffective disorder, bipolar type, and self-reported anxiety, reported feeling upset and experiencing tenderness in his head following the incident. The event resulted in increased anxiety and the potential for emotional stress for the resident who was attacked.
Plan Of Correction
The facility recognizes the importance of maintaining an environment that is free from abuse and neglect. The facility will continue to maintain an environment that is free of abuse and neglect. The facility intervened immediately when the incident involving Resident 56 occurred. Resident 38, the aggressor in this incident, was transferred to a different level of care immediately after the incident. Resident 38 will not return to the facility. The facility initiated a Care Plan on 5/24/25 to monitor Resident 56 for "feelings of being unsafe through the next review date." Interventions attached to the Care Plan included "Encourage Resident 56 to inform staff if he is feeling unsafe," "Provide Resident 56 with 1:1 contacts as needed for emotional support," and "Support Resident 56 with pro-social outlets to encourage feelings of safety in the milieu." Resident 56 was placed on routine monitoring immediately after the incident, with frequent Progress Notes reflecting his comfort, levels of anxiety, and safety. 5/24/25 0239 - "Resident was counseled on staying safe and letting us know if he is being bothered" 5/24/2025 0557 - Nurse Note "Resident has not shown any s/s of emotional distress" 5/24/2025 0851 - Alert Note "Resident denies any pain or discomfort" 5/24/2025 1302 - Nurses Note "No complaints of pain or discomfort" 5/24/2025 1428 - Welfare Check "No noted issues this shift. No statements of feeling unsafe" 5/24/2025 1514 - Program Note "Resident stated he is feeling fine... The writer encouraged Resident to seek staff if he felt unsafe" 5/24/2025 1538 - Welfare Check "Feeling fine, a little better". Asked if he has concerns about safety, he stated "No I think it was a one off, he even apologized to me" 5/24/2025 - Welfare Check "Had an okay day" and felt safe in the facility 5/24/2025 2209 - Welfare Check "I am doing good and feel safe here" 5/25/2025 1356 - Nurses Note "Compliant with neuro checks... no c/o pain or discomfort and this time" 5/25/2025 1528 - Nurses Note "Stated they felt safe at this time" 5/25/2025 2145 - Asked if he is okay "Yes, I am happy here. I feel good. I am okay" 5/26/2025 0618 - Welfare Check "Client has not made any statements of distress or feeling unsafe" 5/26/2025 1407 - Welfare Check "No noted issues or statements of feeling unsafe" 5/27/2025 0939 - IDT Note "Did not wish to discuss the incident further... Did not report feeling unsafe through the weekend... Did not express any s/s of distress... will be discontinued from welfare checks due to not expressing feeling unsafe" 5/28/2025 1722 - IDT Note "Ombudsman met with Resident 58... Resident denied feeling unsafe and had no concerns at the time of the interview" Facility will continue to provide Elder and Dependent Adult Abuse education as part of the new hire orientation for newly hired staff. Facility will continue to provide Elder and Dependent Adult Abuse in-service education to staff through the year as part of the facility's annual educational calendar. Facility DSD began providing in-services to staff on 6/4/2025, including guidelines and expectations of maintaining a facility free of abuse and neglect. As part of the facility admission process, the Admission Coordinator will screen for residents with a history of abuse or assaultive behavior towards others. Further issues regarding Resident Abuse will be received during the QA process and brought to the QAPI Committee for review at least quarterly, or more frequently if an issue is identified. The Administrator, Director of Nursing, DSD, Medical Director, department heads, leadership team, nursing staff, and all departments shall be responsible to monitor for ongoing compliance.
Client Elopement Due to Malfunctioning Door and Staff Oversight
Penalty
Summary
The facility failed to ensure the safety and security of a client, identified as Client 1, who eloped from the facility due to a malfunctioning security door locking system. The incident occurred when the magnetic lock on the south door intermittently malfunctioned, allowing Client 1 to exit the facility without detection. The facility's Administrator confirmed that the door could only be opened with a key, but the malfunction allowed Client 1 to push open the door and walk into the front lobby, leading to her elopement. The Temporary-Office Assistant (TOA), who was unfamiliar with the residents, did not recognize Client 1 as a client when she passed through the front lobby and exited the facility. The TOA, who had started working in August, mistook Client 1 for an employee due to the time of day when staff were coming and going. This lack of recognition contributed to the failure to prevent Client 1's elopement. Additionally, Program Staff (PS) observed Client 1 outside the facility but did not inquire about her presence or take action to ensure her safety. PS assumed that another staff member was accompanying Client 1 on an outing and did not verify this assumption. As a result, Client 1's whereabouts were unknown for eight hours, during which she was at risk for injury and exposure to cold weather.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, Resident 84, who had a history of impulsive and aggressive behavior. On June 12, 2024, Resident 84 struck Resident 82 in the face multiple times, causing bleeding injuries. This incident occurred after Resident 84 accused Resident 82 of spitting on them, which Resident 82 denied. The facility's investigation confirmed the incident, and it was noted that Resident 84's conservator was seeking a more suitable facility due to Resident 84's behavior. Earlier, on May 22, 2024, Resident 84 was involved in another incident where they placed their hands around Resident 3's throat while Resident 3 was reclined in a chair. This incident was witnessed by staff, who intervened and separated the residents. Resident 84 later claimed not to remember the incident and showed a lack of insight into their behavior during a telepsychiatry session. Despite being on welfare checks every 15 minutes for aggressive behavior, Resident 84's actions were unpredictable and sporadic. Both incidents highlight the facility's failure to adequately assess and manage Resident 84's aggressive tendencies, despite having a policy in place for abuse prevention. The facility's interdisciplinary team was expected to identify residents needing treatment planning to prevent such occurrences, but the incidents with Residents 82 and 3 indicate a lapse in effectively implementing these measures.
Failure to Label and Date Opened Food Products
Penalty
Summary
The facility failed to adhere to professional standards for food storage by not labeling and dating food containers and product bags after opening. During an observation and interview, it was found that multiple packages in the freezer, including frozen breaded fish, frozen french toast, frozen hashbrowns, and frozen fried eggs, were open and unlabeled. A staff member admitted to opening and using some of these items without labeling them. Additionally, in the walk-in refrigerator, a package of fresh pepperoni and a bag of peeled garlic cloves were also found open and unlabeled. The Food Service Supervisor confirmed that these products should have been labeled with an open date once the packaging was opened.
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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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