Eureka Rehabilitation & Wellness Center, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Eureka, California.
- Location
- 2353 Twenty Third St, Eureka, California 95501
- CMS Provider Number
- 055003
- Inspections on file
- 31
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Eureka Rehabilitation & Wellness Center, Lp during CMS and state inspections, most recent first.
The facility failed to timely report an allegation of resident-to-resident sexual abuse to CDPH as required by its abuse policy. Staff observed one resident placing another sleeping resident’s hand on their genital area, and although the charge nurse notified the DON and staff attempted to contact the Administrator, the SOC 341 abuse report was not submitted until approximately nine hours after the incident was identified. Interviews with an LN and a CNA revealed they were unaware that such allegations required prompt reporting to CDPH, despite a written policy requiring notification of law enforcement and submission of the SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours of the initial report.
Surveyors found that one of two licensed nurses did not have CPR certification that included required hands-on skills training. The nurse, employed through an agency, obtained CPR certification from an online provider that offered only written testing without in-person or virtual instructor-led skills validation. The Administrator reported that all licensed nurses, including agency staff, were expected to maintain CPR for Healthcare Providers with hands-on practice on a mannequin. Facility policy required CPR training with a hands-on component in line with AHA guidelines, but this was not met for the nurse, decreasing the facility’s potential to provide effective basic life support and CPR for all residents during respiratory or cardiac emergencies.
A resident with COPD and asthma experienced progressive respiratory distress that was repeatedly reported by CNAs to an LPN, who did not promptly assess the resident, did not document a timely change-of-condition assessment, and did not notify the physician as required by facility policy and the resident’s care plan. The LPN later documented administering a nebulized breathing treatment without an active physician order and without clear documentation of the medication or date of administration, while the MAR showed no albuterol doses given that month. When the resident became unresponsive with severely low O2 saturation and labored breathing, the LPN called a non-emergent ambulance despite being instructed by another LPN to call 911, and the physician reported she was only notified after the resident had already coded and been transferred.
A resident with COPD and asthma experienced progressive respiratory distress during a shift, with CNAs repeatedly reporting abnormal, gurgling respirations and declining O2 saturations to an LPN who, according to CNA interviews and record review, did not promptly assess the resident or document a change in condition. The medical record contained no assessment, COC entry, or physician notification between mid-afternoon and early evening, despite facility policies and care plan directives requiring such documentation and action. Later notes by two LNs described rapid breathing, severely low O2 saturations, and subsequent unresponsiveness requiring CPR and EMS intervention, but a late-entry note by one LPN referenced a breathing treatment without specifying the medication or correct date, and the MAR showed no administration of the ordered albuterol nebulizer. The attending MD confirmed no prior notification of the resident’s shortness of breath or request for a respiratory treatment order that day, and the facility’s DON and policies indicated that nurses were expected to assess, obtain appropriate orders, and document all COCs and interventions.
The facility failed to employ a dedicated onsite RD and relied instead on a remote RD who only participated in virtual meetings to review resident weights and diets, without conducting in-person assessments or kitchen consultations. Surveyors found multiple dietary and kitchen issues, including failure to follow recipes, improper dumpster closure, and problems with sanitation, cleanliness, maintenance, equipment, and food storage. Interviews with the Dietary Supervisor, Regional Consultant, and Regional RD confirmed that the last full-time onsite RD had left months earlier, the Regional RD managed about 30 facilities with infrequent, unscheduled visits, and that an RD was expected to be physically present weekly but was not. Review of RD and Regional RD job descriptions and training records showed that required duties such as regular facility visits, inspection of food service areas, and ensuring regulatory compliance were not being carried out onsite.
Surveyors identified that kitchen staff failed to follow standardized recipes and use measuring tools during meal preparation. A cook prepared garlic bread, pureed bread, and a zesty spinach side dish without recipes at the workstation, adding unmeasured amounts of butter, garlic powder, and milk, and omitting required ingredients such as salt and red pepper flakes. Spinach was also spilled into a sink during draining, with only the remaining portion used. The dietary supervisor and regional RD later confirmed that recipes were required to be visible and followed, and that ingredients, including salt when listed, should be measured to maintain the planned nutrient content.
Surveyors found multiple failures in dietary sanitation and food service operations affecting a large number of residents. Kitchen staff were observed preparing food without required hair or beard nets and while wearing prohibited jewelry, contrary to facility policy and infection control expectations. The kitchen environment included a wall near cooking equipment with chipped and scratched paint and paint chips on the floor, as well as a dirty three-drawer utensil bin with sticky handles and food crumbs inside. Floors under and around handwashing and prep areas were soiled with grime, debris, and dried spills, and a utility cart used for food and beverage service was visibly dirty yet remained in use during meal service, with no cleaning log available despite policy requirements. Food-contact items, including scoops, were stored wet, a can opener had peeling metal and label remnants on the blade, and several discolored cutting boards had deep grooves, all of which were acknowledged by dietary leadership as unclean or unfit for use. Additionally, the facility’s emergency water supply was found to be expired, despite policies requiring regular rotation of disaster food and water stocks.
Surveyors found that staff failed to follow professional standards and facility policies in several areas. A resident with hypothyroidism received levothyroxine and famotidine together despite a pharmacist’s recommendation and documentation that levothyroxine should not be given with other medications. Two residents who experienced changes of condition, including diarrhea and unwitnessed falls, were not monitored every shift for 72 hours as required by the facility’s COC policy, and one of these residents did not have a care plan initiated or updated to address the new condition. For a resident with multiple fractures who sustained an unwitnessed fall and was transferred to the hospital, post-fall neurological checks were not completed at the required frequencies outlined in the facility’s neuro check and fall management protocols.
Surveyors found that the facility did not complete required annual competency/skills assessments for two CNAs and lacked documented abuse and dementia training for two other CNAs. One CNA’s last competency review was several months overdue, and another had an unsigned, undated skills checklist with no confirmation of completion. Training files for two additional CNAs lacked evidence of abuse prevention and dementia management education, despite facility policy and the facility assessment requiring annual competency validation and inclusion of dementia and abuse training. The DSD acknowledged these training gaps and that they could affect staff ability to respond to abuse situations and care for residents with dementia.
The facility failed to implement consultant pharmacist (CP) medication regimen review (MRR) recommendations for multiple residents receiving medications for BPH, constipation, hypothyroidism, HTN, gout, GERD, type 2 diabetes, and other conditions. The CP had recommended adding specific administration instructions (such as timing with meals, not crushing hazardous drugs, and separating famotidine from levothyroxine), adding hold parameters for laxatives, clarifying maximum daily acetaminophen dosing, specifying monitoring parameters for antihypertensives, and updating indications for melatonin. On review, these recommendations were not reflected in the residents’ active orders, and the DON confirmed that the December MRR recommendations had not been implemented or forwarded to the prescriber. The CP and Administrator both stated expectations that such recommendations be reviewed and acted upon in a timely manner, and facility policies required timely communication and documentation of CP recommendations, which did not occur.
Surveyors found that medications were not stored and labeled according to professional standards and facility policy during an inspection of a medication cart with the DON. Ten loose pills were discovered in the cart, six medications lacked required open dates after the manufacturer’s seal was broken, and six used insulin pens for different residents were comingled in the same drawer, allowing the pens to touch. The DON acknowledged that loose pills could be mistakenly given or taken, that open dates were needed to ensure medications were not outdated, and that insulin pens should not touch to prevent cross contamination.
Surveyors found that one of the facility’s dumpsters was overflowing with trash, left open without lids, and surrounded by garbage on the ground. A Dietary Supervisor confirmed the dumpster was too full to close and acknowledged that lids were supposed to be closed to keep pests and critters out, while the Maintenance Director stated that lids were to remain closed at all times for infection control and to prevent birds from accessing the waste. Facility policy required medical waste containers to be covered, closable, and stored so they are protected from animals and do not provide a breeding place or food source for insects and rodents.
A resident with spinal stenosis, strabismus, vascular dementia, and moderate cognitive impairment, who required partial to moderate assistance with mobility and ambulation, did not have a functional or accessible bed light. The pull cord behind the bed was only about three inches long and could not be reached, and the light did not work even when the wall switch was turned on, leaving the resident unable to control the room lighting and dependent on others. A CNA confirmed the cord length and nonfunctioning light. While the Maintenance Director initially claimed the issue had not been reported, the Business Office Manager and a regional consultant stated that the problem had been raised repeatedly over several months and that the Maintenance Director was aware the light needed repair, contrary to facility policies requiring a safe, hazard-free, and home-like environment.
Licensed nurses did not update care plans after an incident of resident-to-resident abuse involving two residents with severe cognitive impairment and behavioral issues, nor did they complete the required 72-hour monitoring after a resident with metabolic encephalopathy experienced a fall and returned from the emergency department. These actions did not meet professional standards or facility policy.
A resident with a recent history of falls and orthopedic injuries was incorrectly assessed as moderate fall risk upon admission, leading to a care plan that did not reflect their actual needs. The resident, who had moderate cognitive impairment and required moderate assistance for transfers, later fell and sustained a distal radial fracture. Facility staff and documentation confirmed that the fall prevention protocol was not properly followed.
The facility failed to label and date food items in the kitchen, as observed during tours with the Dietary Manager. Items such as sliced carrots, vegetable patties, and Salisbury steaks were found without labels or open/use-by dates. Staff interviews confirmed the expectation for all opened food items to be labeled, aligning with the facility's policy.
A facility failed to accurately complete a Level I PASRR for a resident with depression and PTSD, omitting these diagnoses and resulting in a missed Level II Evaluation. Staff interviews revealed that the MDS nurse was responsible for PASRR accuracy, and both the DON and Administrator expected accurate PASRR reviews.
A resident in an LTC facility developed severe pressure injuries due to inadequate care. The resident did not receive scheduled showers, and treatment plans for skin conditions were not consistently followed. The facility failed to turn and reposition the resident every two hours, and documentation of the resident's skin condition was inaccurate. These deficiencies led to the resident developing a Stage 4 pressure injury with infection.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and resident concerns about safety. Four residents, with conditions such as muscle weakness and chronic pain, reported waiting up to an hour for assistance. Staff confirmed the shortage, noting increased risks of falls and injuries. The facility did not meet the required Direct Care Service Hours Per Patient Day for 8 out of 10 days, falling short of the 3.5 nursing hours per patient day policy.
A facility failed to ensure licensed nurses had the necessary competencies, resulting in inaccurate documentation of a resident's skin impairment and failure to recognize UTI and sepsis. This led to a fall causing a severe hip fracture. The facility lacked specific policies for managing UTIs, sepsis, and accurate documentation.
A resident with severe cognitive impairment did not receive scheduled showers, receiving only one shower and one bed bath in April, and no showers with three bed baths in May. This failure, confirmed by staff, led to the resident's transfer to the emergency department for treatment of a sacral wound infected with MRSA. The facility lacked a specific policy for shower and ADL care.
A resident with a history of muscle weakness and severe cognitive impairment fell and sustained serious injuries due to the facility's failure to monitor and recognize signs of UTI and Sepsis. Despite being identified as a fall risk, the resident was not adequately supervised or assessed for infection, leading to a fall that resulted in a skin tear and a femoral fracture requiring surgery. The facility lacked specific policies for managing UTIs and Sepsis, contributing to the oversight.
Failure to Timely Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of resident-to-resident sexual abuse to the California Department of Public Health (CDPH) for two residents. On 3/20/26 at approximately 10:00 p.m., staff observed Resident 1 placing Resident 2’s hand on Resident 1’s genital area while Resident 2 was asleep. The incident was later reported to the Department as a facility reported incident received on 3/26/26 at 8:00 a.m. During interview, the Regional Administrator confirmed the incident time and stated that the SOC 341, the standardized abuse reporting form, was submitted at 7:11 a.m. on 3/21/26, approximately nine hours after the incident was identified. The Regional Administrator explained that the charge nurse notified the Director of Nurses, who instructed staff to notify the Administrator. The Administrator was ill, did not answer the phone that night, and only listened to the message the following morning before coming to the facility and completing the report. Licensed Nurse A and CNA B stated in interviews that they would separate residents and notify supervisors if abuse occurred, but both reported they were unaware that the allegation required timely notification to CDPH. Review of the facility’s Abuse Prevention and Management policy, last revised on 5/30/24, showed that the Administrator or designee was required to notify law enforcement by telephone immediately or as soon as practicably possible, but no longer than two hours after an initial report, and to send a written SOC 341 to the Ombudsman, law enforcement, and CDPH within two hours, which did not occur in this case.
Failure to Ensure Hands-On CPR Certification for Licensed Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed nurse maintained appropriate Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and American Heart Association (AHA) guidelines. One licensed nurse, hired as a registry nurse, obtained CPR certification through an online provider that offered training based solely on written exams without any hands-on skills validation. Review of the online provider’s website showed that while the course followed AHA 2020 cognitive guidelines and allowed unlimited test attempts at any time, it did not include any in-person or virtual instructor-led skills assessment, nor did it require demonstration of CPR techniques on a mannequin. During an interview, the Administrator stated that all licensed nurses, including registry nurses, were required to maintain CPR certification with hands-on training, specifically involving performance of skills on a mannequin, to validate proper technique. The facility’s written policy on Cardiopulmonary Resuscitation, dated 2022, required that licensed nursing staff maintain current CPR for Healthcare Providers through a provider whose training includes a hands-on session, either in a physical or virtual instructor-led setting, in accordance with accepted national standards. The surveyor concluded that the facility failed to ensure this requirement was met for one of two licensed nurses, which decreased the facility’s potential to implement life-saving measures and effective clinical interventions for all residents in the event of a respiratory or cardiac emergency.
Failure to Assess, Obtain Orders, and Appropriately Respond to Resident Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to provide nursing care that met professional standards for a resident with COPD and asthma who experienced a significant change in respiratory status. The resident’s care plan directed licensed nurses to administer ordered aerosol or bronchodilators, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. The facility’s orientation materials and Change in Condition policy required licensed nurses to promptly assess changes in condition, complete an S-BAR, notify the practitioner immediately, and document the assessment, interventions, and physician notification. The resident also had orders for CPR in the event of cardiac or respiratory arrest and for shift-by-shift lung sound documentation, which were later discontinued after the resident’s death. On the day of the incident, CNA 1 reported that at the start of her shift the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 measured the resident’s O2 saturation, which fluctuated between 85–95% on room air, and repeatedly notified LN 1, who responded that the resident was fine and did not initially assess him. CNA 1 stated she reported the resident’s worsening condition three or four more times as his breathing sounds deteriorated, but LN 1 continued to say he was fine. When the resident’s O2 saturation later dropped to 35%, CNA 1 asked CNA 2 to help get LN 1 to assess the resident because LN 1 had not been listening to her concerns. CNA 2 corroborated that CNA 1 had been worried from the beginning of the shift, that the resident was gurgling with very low O2 saturation, and that she notified LN 1 of these concerns. There was no documented assessment or change-of-condition note in the medical record for the period between approximately 3 p.m. and 6:30 p.m., and no documentation of physician notification, treatment provided, or monitoring of treatment effectiveness during that time. LN 1 later documented in a progress note that around 6:40 p.m. she was notified by CNA 1 that the resident was breathing rapidly, that his O2 saturation was 93%, and that she asked if he wanted to go to the hospital and he said no; CNA 1 later stated she did not hear LN 1 ask the resident about going to the hospital. LN 1 also documented, in a late entry, that she administered a breathing treatment at approximately 6:45 p.m. while on the phone, and that the resident started to code while she was on the call. However, there was no documentation of what medication was given, and the Medication Administration Record showed no albuterol nebulizer doses given that month. The DON confirmed the resident had medicated breathing treatments in the cart but no active order, as the prior order had expired. Around 7 p.m., CNA 1 reported to LN 2 that the resident had shortness of breath and an O2 saturation of 63% on room air; LN 2 recorded an O2 saturation of 72% on the monitor, found the resident unresponsive with labored, rapid breathing and a very faint pulse, and instructed LN 1 to call 911. LN 2 stated she specifically told LN 1 to call 911, but LN 1 instead called a non-emergent ambulance, and when questioned why she did so in an emergency, LN 1 did not respond. LN 2 documented that chest compressions were initiated, oxygen was applied via mask, and EMS arrived and took over CPR. The ER provider note indicated EMS reported the resident was found down and apneic by facility staff about 30 minutes before arrival, with last known normal at 6:30 p.m. The resident’s physician stated she had not been notified by LN 1 earlier in the day about the resident’s shortness of breath, had not been asked for a respiratory treatment order, and only received a call after the resident had coded and been sent to the hospital. The facility’s policies required assessment, timely physician notification, documentation of change in condition, and calling 911 in a cardiopulmonary emergency, all of which were not followed by LN 1 in this case.
Failure to Assess, Obtain Orders, and Accurately Document Resident Respiratory Change in Condition
Penalty
Summary
The deficiency involves a licensed nurse’s failure to complete and maintain an accurate medical record and to document a change in condition (COC) and related assessments and treatments for a resident with chronic respiratory disease. The resident had COPD and asthma and a care plan that directed licensed nurses to administer aerosol or bronchodilators as ordered, monitor and document side effects and effectiveness, and monitor, document, and report signs and symptoms of acute respiratory insufficiency and respiratory infection. Facility policy and contract orientation information for the nurse required that when a change in condition was identified, the assigned licensed nurse complete an SBAR, notify the licensed independent practitioner immediately, and document the date, time, details of the event, assessment, physician notification, and any orders received. On the day in question, CNA 1 reported that at the start of her shift at 3 p.m. the resident appeared to have difficulty breathing, with noisy, mucus-like breathing and complaints of shortness of breath. CNA 1 stated the resident’s O2 saturation fluctuated between 85–95% on room air and that she escalated these concerns to LN 1, who responded that the resident was fine. CNA 1 reported that as time passed, the resident’s breathing sounds worsened and that she notified LN 1 three or four more times that the resident was getting worse, but LN 1 continued to say the resident was fine. CNA 2 corroborated that CNA 1 was worried about the resident early in the shift, that the resident was acting differently and gurgling, and that the O2 saturation was very low, the lowest CNA 2 had ever seen. CNA 1 stated that when the O2 saturation read 35%, she asked CNA 2 to help get LN 1 to physically assess the resident, and that LN 1 did not assess the resident until nearly four hours after the initial notification. The medical record review showed no documented assessment, COC entry, physician notification, treatment, or monitoring of treatment effectiveness related to the resident’s respiratory status between 3 p.m. and 6:30 p.m., despite an active order requiring staff to add a progress note each shift regarding lung sounds. The only documented COC by LN 1 was a progress note time-stamped 7:43 p.m., which stated that around 6:40 p.m. CNA 1 notified LN 1 that the resident was breathing rapidly, that the resident’s O2 saturation was 93%, and that LN 1 asked if the resident wanted to go to the hospital and the resident declined. LN 2’s note documented that upon arriving on shift at 6:53 p.m., CNA 1 reported the resident had shortness of breath and an O2 saturation of 63% on room air, that the monitor showed 72% on room air, that LN 2 instructed LN 1 to call 911, and that the resident was unresponsive with labored, rapid breathing and a very faint pulse, with CPR initiated by staff and then taken over by EMS. Further record review and interviews revealed discrepancies and omissions in documentation of a breathing treatment. The ER provider note indicated the resident’s last known normal was 6:30 p.m. and listed an albuterol nebulizer order as a PRN medication the resident was not taking. A late-entry progress note by LN 1, dated two days later at 3:34 p.m., stated that at approximately 6:45 p.m. on the day of the event, LN 1 administered a breathing treatment and that while LN 1 was on the phone, the resident started to code and the non-emergent transfer call was switched to 911. There was no documentation in that note of what specific medication was given or that it was administered on the correct date. The MAR showed no evidence that albuterol nebulization solution was administered on any day that month, and the physician confirmed she had not been notified of the resident’s shortness of breath that day and had not been called for a respiratory treatment order prior to the code. A physician’s order for a one-time albuterol nebulizer dose was created later that evening and then discontinued with the reason that the resident expired in the emergency department. The facility’s medical records department confirmed there were no other notes by LN 1 that day beyond the 7:43 p.m. entry, and the DON stated nurses were expected to document COCs, assessments, interventions, physician notifications, and resident responses, and to obtain and document orders for oxygen and breathing treatments when O2 saturation was critically low.
Lack of Onsite Registered Dietitian and Inadequate Oversight of Dietary Services
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff with appropriate competencies, specifically the lack of a dedicated onsite Registered Dietitian (RD) for a census of 87 residents. Surveyors identified multiple dietary and kitchen-related issues during the recertification survey, including recipes not being followed, a dumpster lid not being closed, and problems with kitchen sanitation, cleanliness, maintenance, equipment, and food storage. The Dietary Supervisor (DS) reported that one RD worked remotely, participating in weekly virtual meetings or email exchanges to discuss resident weight changes and diets, but did not physically come to the facility to assess residents’ nutritional status or consult on kitchen operations. Interviews with the DS, Regional Consultant (RC), and Regional Registered Dietitian (RRD) confirmed that the last full-time onsite RD worked from March to June of the previous year and that the RRD’s visits were infrequent, with the last visit occurring earlier in the prior year and no set visitation schedule in place. The RC stated that an RD was required to be physically present at the facility once a week, but this did not occur. A review of training documentation showed that a kitchen training on IDDSI requirements was attended only by the DS and one cook, and job descriptions for both the facility RD and the Regional Dietitian outlined responsibilities such as overseeing clinical nutrition operations, inspecting food service areas, ensuring regulatory compliance, and conducting regular facility visits—duties that were not being fulfilled onsite as required. This lack of consistent onsite RD presence and oversight contributed to the identified deficiencies in dietary services and kitchen operations.
Failure to Follow Standardized Recipes and Measure Ingredients During Meal Preparation
Penalty
Summary
The deficiency involves the facility’s failure to ensure menus and standardized recipes were followed and that meals were prepared using methods that conserved nutritive value, flavor, and appearance for a census of 87 residents. During a kitchen observation, a cook was preparing lunch items, including herb crusted beef roast, mashed potatoes with gravy, zesty spinach, and garlic bread, without any recipes present at the cook’s station. The cook was seen adding an unmeasured amount of butter to a butter, garlic, and parsley mixture for garlic toast and later combining four tablespoons of garlic powder with one pound of melted butter to be used for zesty spinach intended to serve 72 residents, omitting red pepper flakes and salt that were included in the written recipe. The cook also poured unmeasured amounts of milk into dry breadcrumbs to prepare pureed garlic bread, despite the dietary supervisor confirming that a specific recipe existed for pureed bread products and that it should have been used. Further observation showed the cook spilling boiled spinach into the sink while attempting to drain it, leaving portions in the pot, strainer, and sink, after which the dietary supervisor intervened to strain the remaining spinach. The cook then added an unmeasured amount of the garlic and butter mixture to the spinach and stated she did not know how much was added. Both the cook and the dietary supervisor stated they did not add salt to anything, and the dietary supervisor said, "Yeah, we don't use salt," despite the zesty spinach recipe specifying salt and red pepper flakes. In interviews, the dietary supervisor and the regional registered dietitian both stated that recipes must be visible, used, and followed, and that measuring tools should be used to ensure correct ingredient amounts and nutrient content. The cook admitted she did not always follow recipes, did not like the recipe book on the table, and acknowledged that measurements were supposed to be precise. Review of facility recipes and the standardized recipes policy confirmed that standardized recipes, including specific ingredient amounts for zesty spinach and pureed bread products, were required to be used, but were not followed during the observed meal preparation.
Widespread Dietary Sanitation and Equipment Failures in Food Service Operations
Penalty
Summary
The deficiency involves the facility’s failure to procure, store, prepare, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 87 residents. Surveyors observed multiple dietary staff in the kitchen without required hair restraints and with prohibited jewelry while handling and preparing food. Several dietary aides and cooks were seen without hair nets, and one cook with facial hair longer than one inch was not wearing a beard net. Another cook was observed wearing hoop earrings and a watch while preparing meals. The Dietary Supervisor and Infection Preventionist both confirmed that hair nets and beard nets were required in the kitchen and that watches and dangling earrings should not be worn due to contamination concerns. Facility policies and job descriptions reviewed by surveyors required staff to maintain a safe and sanitary work environment, cover hair and facial hair with effective restraints, and prohibit watches in food service areas. The physical condition and cleanliness of the kitchen and related equipment were also found to be deficient. Surveyors observed a wall near the stovetop and oven with multiple areas of scratched and chipped paint in different colors, with paint chips present on the floor beneath these areas. The Dietary Supervisor acknowledged the chipped and scratched paint and stated the wall should be repainted because paint chips could fall and possibly get into food. In addition, a three-drawer storage bin used to store cooking utensils such as measuring cups, spoodles, spatulas, and scoops was found with gray to dark brown and black smears and scuffs on the exterior, sticky drawer handles, and crumb-like particles inside one of the drawers. The Dietary Supervisor confirmed the bin was dirty inside and out and appeared to contain food crumbs. Further observations showed that the kitchen floor and dining room utility equipment were not maintained in a sanitary condition. The floor under and around a handwashing sink and adjacent food preparation tables contained black residue and grime, dark-colored particles of unknown substances, small objects such as a paper clip, dime, rubber band, and bread closure tab, and dried brown fluid on the wall behind one table. Paint chips were also seen on the floor near the stovetop and oven. The Dietary Supervisor confirmed these areas were dirty, described the floor as hard to clean, and stated the floors needed deep cleaning. A three-tiered utility cart in the dining room, used for beverage and food service, was observed with crumbs, dried orange-colored crusted particles, and large dust particles on all shelves while holding beverage pitchers. The cart remained uncleaned during meal service. The Dietary Supervisor and Director of Staff Development confirmed the carts were used for food and beverage service and should be cleaned after each use, but the Dietary Supervisor could not produce the cleaning log that was supposed to document daily cleaning tasks. Surveyors also identified improper handling and condition of food-contact utensils and equipment. Approximately four scoops used for food preparation and tray line were found stored wet in the same three-drawer storage bin, and the Dietary Supervisor confirmed they should not have been stored wet because a wet environment could increase bacterial growth. A can opener stationed on a food preparation table had label remnants on the pointed blade tip and visible peeling metal, and the Dietary Supervisor stated it was dirty, needed cleaning, and that the blade needed to be changed because metal could come off into food. Multiple cutting boards of different colors were observed with black discoloration and deep blade grooves that could be felt by touch; the Dietary Supervisor confirmed these boards were hard to clean, could harbor bacteria, and should not be used. FDA Food Code sections reviewed by surveyors indicated that can openers that become uncleanable must be replaced, cutting surfaces that are scratched and scored may harbor pathogenic microorganisms, and equipment and utensils must be air-dried before storage to prevent microbial growth. In addition, the facility failed to maintain its emergency dietary supplies in accordance with its own policies. During an observation with the Maintenance Director and Dietary Supervisor, the facility’s emergency water supply was found to be expired, with an expiration date that had already passed. Both the Maintenance Director and Dietary Supervisor confirmed the emergency water was expired and needed replacement. Review of the facility’s disaster planning and food storage policies showed that disaster food supplies were to be rotated at least every six months and that dry storage stock was to be rotated, but this had not been done for the emergency water. These combined observations and confirmations by facility staff demonstrated that the facility did not maintain food storage, preparation, equipment, and the kitchen environment in a sanitary and professionally compliant manner.
Failure to Follow Medication Guidelines, Change-of-Condition Monitoring, Care Planning, and Neuro Check Protocols
Penalty
Summary
The deficiency involves failure to administer medications according to professional standards and facility policy for one resident with hypothyroidism. The resident had physician orders for levothyroxine 88 mcg by mouth in the morning for hormone regulation and famotidine 20 mg by mouth in the morning for GERD. A medication regimen review dated 12/26/25 documented a pharmacist recommendation that famotidine could be given without regard to meals but should not be given at the same time as levothyroxine, and suggested changing famotidine administration time to 9 a.m. Review of the medication administration records from 12/21/25 to 1/29/26 showed both medications were administered together at 6 a.m. throughout this period. The consultant pharmacist confirmed that levothyroxine should not be given with other medications because it could bind with them and decrease effectiveness, and a licensed nurse also acknowledged that levothyroxine should not be given with other medications and that such an order should be clarified with the physician or pharmacist. The deficiency also includes failure to complete required 72‑hour monitoring after a change of condition (COC) for two residents. One resident with hemiplegia, hemiparesis following cerebral infarction, diabetes mellitus, and intact cognition reported multiple episodes of diarrhea over several days, including at least three brief changes in one day and decreased oral intake due to diarrhea and upset stomach. An SBAR communication form documented that this resident reported five episodes of green, mucus-like diarrhea without foul odor, constituting a COC. Review of progress notes from the time of the COC through several days later showed that the resident was only monitored on two occasions, rather than every shift for 72 hours as required by the facility’s Change in Condition policy. The DON confirmed that no 72‑hour monitoring was completed on multiple shifts following this COC. Another resident, admitted with fractures of the first cervical vertebra, left pubis, and multiple ribs and with moderately impaired cognition, experienced unwitnessed falls on two separate dates. Progress notes showed that following these COCs related to falls, the resident was monitored only on a limited number of dates and times, rather than each shift for at least 72 hours as required by policy. The DON confirmed that 72‑hour monitoring was not completed on specified shifts after the first fall and that the resident fell again several days later, after which 72‑hour monitoring was again not completed on certain shifts. The facility’s Change in Condition policy required the licensed nurse to update the care plan to reflect the resident’s current status and to document each shift for at least 72 hours when there is a change in the resident’s condition, and the LVN job description required completion of all required documentation and assistance in developing and updating plans of care. The deficiency further includes failure to initiate or revise a care plan following a COC for the resident with diarrhea. Review of the resident’s undated care plan report showed no evidence that a care plan was initiated or updated to address the diarrhea COC documented on the SBAR form. In interviews, the treatment nurse stated that every COC required a care plan to be initiated and/or updated and that care plans guided staff on how to care for residents, what to expect, and what to monitor. The DON also stated that a COC was required to be care planned so there would be a plan of care in place to know how to treat the COC, and confirmed that the resident’s care plan was not initiated or revised following the documented COC. Additionally, the deficiency includes failure to complete neurological checks according to facility policy following an unwitnessed fall for the resident with multiple fractures. The facility’s Neurological Flow Sheet and Fall Management Program policy required vital signs and neuro checks every 15 minutes for one hour, every 30 minutes for one hour (or two hours per the fall policy), every one hour for four hours, and then every four hours for the remainder of a 72‑hour period after an unwitnessed fall, unless discontinued by a physician. Review of the resident’s neurological checklists showed that post‑fall neuro checks were documented only at four time points over approximately 18 hours following the fall and hospital transfer/return, rather than at the frequencies specified in the neurological flow sheet and fall management policy. The DON stated that for an unwitnessed fall, neuro checks were expected to be ongoing for 72 hours after the fall, to begin immediately post‑fall and continue when the resident returned from the hospital, and confirmed that the assessments were not completed to her expectations and not in accordance with the timing flow chart.
Failure to Complete CNA Competency Reviews and Required Abuse/Dementia Training
Penalty
Summary
Surveyors identified that the facility failed to complete required annual performance reviews and competency/skills checks for two of five sampled CNAs. Review of CNA 4’s employee training file with the Director of Staff Development (DSD) showed that the last annual skill/competency assessment was completed on 9/16/24, making it four months overdue at the time of review. For CNA 6, the training file contained a skills/competency checklist with no employee signatures or dates, and the DSD could not confirm that CNA 6 had completed this or any other annual skills/competency assessment. The facility’s policy titled “Staff Competency Evaluation,” effective 6/04/24, required staff to have competency validation based on job description or assigned duties, with re-education and re-evaluation for staff unable to satisfactorily perform skills. The facility assessment, reviewed on 1/26/26, also specified yearly review of select clinical competencies. Surveyors also found that the facility did not ensure required abuse and dementia training for two additional CNAs in the sample. During review of CNA 3’s and CNA 7’s training files with the DSD, there was missing evidence of abuse and/or dementia training for each of these CNAs. The DSD acknowledged that these omissions meant the employees might not be able to respond properly to abuse situations or have the knowledge to effectively communicate with and care for certain residents. The facility assessment indicated that training requirements included dementia management training and abuse prevention training, and the DSD stated there were known training issues that needed to be addressed.
Failure to Implement Consultant Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to act upon and implement consultant pharmacist (CP) medication regimen review (MRR) recommendations in a timely manner for multiple residents. The CP completed an MRR covering 12/01/25 to 12/31/25 and documented specific recommendations for Residents 1, 3, 6, 14, 16, 17, 18, 19, 24, 57, 76, 83, and 85. These recommendations included clarifying administration times, adding hold parameters, specifying monitoring instructions, and documenting hazardous drug precautions. On review of the residents’ order summaries dated 1/29/26, the surveyors found that none of these recommendations had been implemented or communicated to the prescriber as required by facility policy. For Resident 1, admitted with BPH, the CP recommended specifying that tamsulosin 0.4 mg be given 30 minutes after the same mealtime each day and that capsules be swallowed whole without crushing, chewing, or opening. Resident 3, admitted with hereditary spastic paraplegia and receiving docusate sodium 100 mg two capsules twice daily, had an MRR recommendation to update the order to include “hold for loose stool.” Resident 6 and Resident 24, both receiving finasteride 5 mg daily for BPH, had MRR recommendations noting that finasteride is a hazardous medication that cannot be crushed or opened without appropriate PPE, and that the orders should be updated to state “Hazardous Drug – Please use appropriate PPE.” These changes were not reflected in the active orders at the time of review. Resident 14, with hypothyroidism and GERD, had orders for famotidine 20 mg and levothyroxine 88 mcg both given in the morning; the CP recommended changing the famotidine administration time to 9 a.m. so it would not be given at the same time as levothyroxine. Resident 16, with HTN and on lisinopril 20 mg at bedtime, had an MRR recommendation to add monitoring parameters to the order: “Hold if HR < 60 bpm or SBP < 100 mmHg.” Resident 17, admitted with constipation and receiving senna and PRN acetaminophen, had recommendations to add “hold for loose stool” to the senna order and “do not exceed 3 grams of acetaminophen in 24 hours from all sources” to the acetaminophen order. None of these recommended order clarifications or monitoring parameters had been added. Resident 18, admitted with gout and receiving allopurinol 300 mg daily, had an MRR recommendation to change the order to include “give with food/meals” and to add this to the directions to ensure compliance. Resident 19, with metabolic encephalopathy and multiple constipation medications (docusate sodium, polyethylene glycol, and senna), had recommendations to add “hold for loose stool” to the laxative orders and to specify for polyethylene glycol “stir in four to eight ounces juice or other liquids.” Resident 57, with type 2 diabetes and on melatonin 3 mg at bedtime, had a recommendation to change the indication to “for Circadian Rhythm Regulation.” Residents 76, 83, and 85, all receiving docusate and/or senna for constipation, had MRR recommendations to add “hold for loose stool” to their laxative orders. These changes were not present in the residents’ active orders on 1/29/26. During interviews, the DON confirmed that none of the CP’s recommendations from the 12/26/25 MRR had been implemented or provided to the physician, and acknowledged that the CP recommendations should be followed because they prevented potential medication errors from happening. The CP stated that he performed the MRR on 12/26/25 and that his expectation was that recommendations would be reviewed within two weeks and, if not addressed, escalated by the DON. The Administrator stated that the last MRR review signed by the physician was dated 11/21/25 and that her expectation was that the 12/26/25 CP recommendations should have been followed and implemented in a timely manner. Review of facility policies showed that findings and recommendations from the CP are to be reported to the DON, attending physician, medical director, and Administrator, and that recommendations are to be communicated and acted upon in a timely fashion, with responses expected prior to the next MRR. These policy requirements were not met in relation to the December MRR recommendations for the identified residents. The facility’s written policies titled “Medication Regimen Review” and “Documentation and communication of consultant pharmacist recommendations” specified that resident-specific irregularities and clinically significant risks associated with medications must be documented in the active record and reported to the DON, medical director, and prescriber as appropriate. The policies further required that the facility establish a system to ensure CP observations and recommendations are communicated to those with authority to implement them and that recommendations are acted upon and documented in an appropriate and timely fashion, enabling a response before the next MRR. Despite these policies, the survey findings showed that the December CP recommendations for the 13 residents were neither implemented nor documented as acted upon by facility staff or prescribers by the time of the survey on 1/29/26.
Improper Medication Storage and Labeling in Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices for a census of 87 residents when medications were not stored and labeled according to accepted professional standards and the facility’s own policy. During an inspection of the C wing medication cart with the DON, surveyors found 10 loose pills inside the cart, which the DON acknowledged could potentially be mistakenly administered to residents or taken by staff. Six medications were found without open dates, despite the facility’s policy requiring nurses to place a date opened sticker on medications when the manufacturer’s seal is broken, and the DON stated that open dates were necessary to ensure medications were not outdated and that administering such medications could potentially cause adverse effects or be less therapeutic. Additionally, six used insulin pens belonging to different residents were found comingled in the same drawer, and the DON confirmed that the pens should be prevented from touching each other because that could cause cross contamination. These observations, interviews, and record review demonstrated that the facility failed to follow its policy titled “Storage of Medications,” which required medications to be stored safely and properly, medication storage areas to be kept clean and free of clutter, and opened medications to be dated when first used.
Improper Garbage Containment and Open, Overflowing Dumpster
Penalty
Summary
The facility failed to properly contain garbage and refuse for a census of 87 residents when one of two dumpsters was observed overflowing with trash, left open without lids, and surrounded by litter. During an observation with the Dietary Supervisor, plastic bags filled with garbage were piled above the top of the dumpster, the lids were not in place to close the dumpster, and a bag of garbage and a box were on the ground next to it; the Dietary Supervisor confirmed the dumpster was too full to close and acknowledged that lids were supposed to be closed to keep pests and critters out. In a separate interview, the Maintenance Director stated that the dumpster lids were supposed to be able to close to prevent birds from getting into the dumpster and for infection control reasons, and further stated that the lids were to remain closed at all times. Review of the facility’s “Medical Waste-Containers & Storage- Infection Control Manual” policy, revised 1/1/12, indicated that medical waste containers are to be kept covered at all times, must be closable, and that medical waste is to be stored so it is protected from animals and does not provide a breeding place or food source for insects and rodents. This failure had the potential to expose the facility environment to odors, insects, pests, and disease, which could have caused harm to residents. No specific residents, medical histories, or individual conditions were described in the report; the deficiency pertained to environmental sanitation and infection control practices related to waste storage and disposal.
Failure to Maintain Accessible and Functional Room Lighting for a Resident
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident when the resident’s bed light was not in working condition and was not accessible. The resident had spinal stenosis, strabismus, and vascular dementia, with a Minimum Data Set showing moderate cognitive impairment and a need for partial to moderate assistance with bed mobility, transfers, and ambulation. During observation and interview, the resident reported that there was no usable pull cord on the light behind the head of the bed; the cord was observed to be approximately three inches long, and the resident stated she could not reach it. She further explained that even if she could reach the cord, the wall switch by the door had to be turned on first, and that when the switch was turned on, the light still did not function. The resident stated she had no control over turning her light on or off, consistently had to ask others to operate the light, and found this frustrating, especially when the sun set. A CNA confirmed that the resident could not reach the light switch, verified the pull cord length of about three inches, and confirmed that pulling the cord did not turn the light on. The Maintenance Director initially stated the issue had never been brought to his attention, but upon observing the light, confirmed it was only partially working and that the resident could not reach the pull cord. In contrast, the Business Office Manager stated that the Maintenance Director was aware the light required repair, that the issue had been mentioned multiple times in staff morning and stand-down meetings, and that it had been discussed for approximately four months without being fixed. The Regional Consultant also confirmed the Maintenance Director was aware the light required repair and stated that it was important for the resident to have access to her light to promote quality of life, that the issue affected the resident’s independence, and that it was a hazard for her not to be able to see. Facility policies and the Director of Environmental Services job description required providing a safe, hazard-free, home-like, and comfortable environment, which was not met in this situation.
Failure to Update Care Plans and Complete Post-Fall Monitoring
Penalty
Summary
Licensed nurses failed to initiate or update care plans following a resident-to-resident abuse incident involving two residents, both of whom had severe cognitive impairment and behavioral issues. One resident, diagnosed with Alzheimer's disease and known for physical aggression, grabbed another resident with hemiplegia and severe cognitive impairment, causing distress. Despite staff witnessing the event and facility leadership acknowledging that care plans should have been created or updated, no such documentation or guidance was provided to staff regarding appropriate interventions after the incident. Additionally, after a resident with metabolic encephalopathy and severe cognitive impairment experienced a fall and was sent to the emergency department, licensed staff did not complete the required 72-hour monitoring upon the resident's return. Facility policy required documentation of the resident's status each shift for at least 72 hours following a change in condition, but 48 hours of monitoring were missing. These lapses in nursing services and documentation did not meet professional standards of quality as required by facility policy.
Failure to Accurately Assess Fall Risk and Develop Person-Centered Care Plan
Penalty
Summary
The facility failed to accurately assess a resident's fall risk status and develop a person-centered care plan upon admission, despite the resident's recent history of falls and significant orthopedic injuries. The resident was admitted following a fall at home that resulted in a right distal femur fracture and a fracture around an internal prosthetic knee joint. Upon admission, the fall risk evaluation incorrectly assessed the resident as moderate risk, omitting the recent fall history that led to hospitalization. The care plan interventions were based on this inaccurate assessment and did not reflect the resident's actual high risk for falls. Subsequent documentation and interviews revealed that the resident had moderate cognitive impairment, limited mobility, and required moderate assistance for transfers, as confirmed by physical therapy records. Despite these needs, the care plan only indicated general fall prevention measures and did not specify the level of assistance required. The resident later experienced a fall while attempting to transfer from the commode, resulting in a nondisplaced distal radial fracture. Staff interviews and record reviews confirmed that the facility's fall prevention protocol, which requires individualized assessment and care planning, was not properly followed for this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that food items were properly labeled and dated, as observed during a kitchen tour with the Dietary Manager (DM). During the initial tour, several items in the reach-in refrigerator, including a quart-sized bag of sliced carrots, a quart-sized bag of vegetable patties, and a covered bowl of fruit, were found without labels indicating their contents or open/use-by dates. The DM confirmed that these items should have been labeled and dated according to the facility's policy on food storage and handling. A follow-up tour revealed a gallon-sized bag of Salisbury steaks in the reach-in freezer, also lacking a label or open/use-by date. Interviews with the DM and other staff members confirmed that all opened food items were expected to be labeled with the product name, open date, and use-by date. The Director of Nursing and the Administrator both stated their expectations that all food items be properly labeled and stored, highlighting a consistent understanding of the policy across the facility's leadership.
Inaccurate PASRR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening and Resident Review (PASRR) accurately reflected the presence of diagnosed mental disorders for a resident. The resident was admitted to the facility with diagnoses of depression and post-traumatic stress disorder (PTSD), which were not accurately documented in the PASRR Level I Screening completed by the Medical Records Director. The screening incorrectly indicated that the resident did not have a diagnosed mental disorder, resulting in a negative Level I Screening and the absence of a required Level II Evaluation. Interviews with facility staff revealed that the Minimum Data Set (MDS) nurse was primarily responsible for the accuracy of PASRRs. The MDS nurse confirmed that the resident had a diagnosis of PTSD upon admission, and if the Level I Screening had accurately reflected this, a Level II Evaluation would have been necessary. The Director of Nursing and the Administrator both expressed expectations for staff to ensure the accuracy of PASRRs, highlighting a lapse in the facility's processes for reviewing and completing these screenings.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care for a resident, leading to the development and worsening of pressure injuries. The resident, who was admitted with moisture-associated skin damage (MASD), did not receive showers as scheduled, which could have contributed to missed skin impairments. The facility's records showed that the resident received only one shower out of eight scheduled in April and none in May, with only a few bed baths provided. This lack of regular hygiene care may have contributed to the resident's skin condition deteriorating. The facility also failed to initiate and consistently follow treatment plans for the resident's skin conditions. Upon admission, there was no treatment order for the resident's MASD, and subsequent treatment orders for pressure injuries were not consistently signed off by nursing staff, indicating that treatments may not have been administered as ordered. The resident's care plan for skin breakdown was not developed until over a month after admission, despite the resident being at risk for skin impairment as indicated by the Braden Scale scores. This delay in care planning and treatment likely contributed to the resident developing a Stage 3 pressure injury, which later worsened to a Stage 4 injury with infection. Additionally, the facility did not ensure that the resident was turned and repositioned every two hours as required to prevent pressure injuries. Observations showed the resident lying on their back for extended periods, and there were missing signatures on the electronic treatment administration record for turning and repositioning orders. The facility's documentation of the resident's skin condition was also inaccurate and inconsistent, with conflicting reports on the presence and location of pressure injuries. These failures in care and documentation contributed to the resident's pressure injuries worsening and developing an infection that required hospitalization.
Inadequate Staffing Leads to Delayed Care and Resident Concerns
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by complaints from residents and staff, as well as a review of staffing records. Four residents expressed concerns about the lack of staff, which resulted in delayed responses to call lights and feelings of insecurity during potential medical emergencies. The residents, who required assistance with personal care, reported waiting up to an hour for help, which they attributed to the facility being short-staffed. The residents' medical conditions included muscle weakness, chronic pain syndrome, general anxiety disorder, muscular dystrophy, multiple sclerosis, hyperlipidemia, and hypertension. Interviews with six staff members, including CNAs and licensed nurses, confirmed the facility's staffing issues. Staff reported that the shortage of personnel made it difficult to complete tasks and provide safe care, increasing the risk of falls, injuries, and elopements. The staffing coordinator admitted to not using any formal guidelines for staffing decisions and acknowledged that the facility was not meeting its target of 3.5 nursing hours per patient day. The Director of Nursing was aware of the staffing deficiencies and expressed concern about the impact on resident care. A review of the facility's records showed that the Direct Care Service Hours Per Patient Day (DHPPD) were below the required levels for 8 out of 10 days in the specified period. The facility's policy required a minimum daily average of 3.5 nursing hours per patient day, but the actual DHPPD ranged from 2.63 to 3.43 during the reviewed period. This failure to meet staffing requirements contributed to the residents' dissatisfaction and concerns about their safety and well-being.
Inadequate Nursing Competencies and Documentation
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies to provide adequate care for residents, as evidenced by inaccurate documentation and failure to recognize critical health conditions. Specifically, the licensed nurses did not accurately document the skin impairment and its location for a resident, leading to discrepancies in the treatment records. The Director of Nursing (DON) confirmed that the documentation was inconsistent and inaccurate, which raised concerns about whether the nurses were properly assessing the resident's wounds. The inaccurate documentation included several instances where the resident's skin was reported as intact despite having a pressure injury. Additionally, the licensed nurses failed to monitor and recognize signs and symptoms of a urinary tract infection (UTI) and sepsis in the same resident. The DON verified that there was no laboratory test requested to check for a UTI, and there were no nursing progress notes indicating that the resident was being monitored for these conditions. This oversight resulted in the resident experiencing a fall, which led to a severe hip fracture requiring surgical intervention. The DON confirmed that the fall was caused by sepsis secondary to an untreated UTI. The facility did not provide specific policies for resident care concerning UTIs and sepsis, nor did they have a policy on assessment and accurate documentation. The lack of these policies contributed to the deficiencies observed, as the nurses were not adequately guided in monitoring and documenting the resident's condition. The American Nurses Association emphasizes the importance of clear, accurate, and accessible documentation as a critical component of safe and quality nursing practice.
Failure to Provide Scheduled Showers Leads to Resident's Skin Infection
Penalty
Summary
The facility failed to ensure that a resident received showers twice a week as scheduled, which was necessary for maintaining skin integrity and preventing infections. The resident, who had severe cognitive impairment and was dependent on staff for personal hygiene, only received one shower and one bed bath in April, and no showers with only three bed baths in May, out of the scheduled showers. This lack of regular bathing was contrary to the facility's policy and was confirmed by multiple staff members, including the Infection Preventionist, Certified Nursing Assistant, and Licensed Nurses, who acknowledged the importance of regular showers to prevent skin breakdown and infections. The deficiency was further highlighted when the resident was transferred to the emergency department for wound evaluation and treatment, including debridement and IV antibiotics for a sacral wound infected with Methicillin-resistant Staphylococcus aureus (MRSA). The Director of Nursing confirmed the transfer and the resident's condition, emphasizing the critical need for regular showers to prevent such severe outcomes. The facility lacked a specific policy and procedure for shower and ADL care, contributing to the oversight in the resident's care.
Failure to Monitor UTI and Sepsis Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to recognize and monitor signs and symptoms of a Urinary Tract Infection (UTI) and Sepsis in one of the residents, leading to a fall and subsequent injuries. The resident, who had a history of muscle weakness, hyperlipidemia, and bipolar disorder, was admitted with severely impaired cognition and required substantial assistance with daily activities. Despite being identified as a fall risk due to intermittent confusion, poor vision, and balance problems, the facility did not implement specific interventions to prevent falls. On the day of the incident, the resident fell from the bed, resulting in a skin tear and an acute comminuted right femoral intertrochanteric fracture, which required surgical intervention. The hospital discharge summary confirmed that the fall was caused by sepsis secondary to a UTI, which had not been diagnosed or treated by the facility. The Director of Nursing verified that there were no laboratory tests conducted to check for a UTI, and the nursing staff did not monitor the resident for signs of infection prior to the fall. The facility's policy on fall management required a new fall risk assessment upon a significant change in condition, but this was not conducted. Additionally, there was no specific policy for managing UTIs and Sepsis, which contributed to the oversight. Interviews with licensed nurses revealed an awareness of the increased fall risk associated with confusion from infections, yet the necessary precautions and monitoring were not in place.
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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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