Main West Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Turlock, California.
- Location
- 812 West Main Street, Turlock, California 95380
- CMS Provider Number
- 055475
- Inspections on file
- 28
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Main West Postacute Care during CMS and state inspections, most recent first.
During a transition from contracted to in-house rehab services, five residents with physician orders and established care plans for PT and/or OT did not receive their prescribed treatments for multiple weeks. Orders for therapy to address muscle weakness, gait and mobility abnormalities, and pelvic issues were in place, but no PT or OT staff were available to evaluate residents or continue existing treatment plans after the contract ended. The ADM and DON confirmed that therapy services were unavailable during this period, that plans of care and orders were not followed, and that physicians were not notified to clarify or adjust treatment orders, contrary to facility policies requiring timely, coordinated, and documented therapy services.
The facility failed to properly dispose of garbage and refuse, resulting in a cluttered area at the rear of the facility with items like stained mattresses and clothing bags. These items had been accumulating for months, and staff interviews confirmed the need for regular disposal. The area, although not accessible to residents, posed a potential pest risk.
A resident reported missing candy bars, but the grievance was not escalated to the Grievance Officer for investigation. The CNA informed a nurse, but no further action was taken. The LVN involved did not notify anyone else, assuming the issue was resolved when the resident's family brought more candy. The facility's policy required grievances to be documented and reported immediately, which was not followed.
Two residents reported abuse incidents to the police, but the facility failed to notify the Administrator and the state agency as required. One resident alleged being restrained by staff, while another claimed a CNA pushed them. The facility's policy mandates immediate reporting of such allegations, but staff did not adhere to this, resulting in a deficiency.
A resident with a history of anxiety and depression reported being pushed by a CNA, but the facility failed to properly investigate the allegation. The incident was brought to the facility's attention by a police officer, yet there was no evidence of a thorough investigation or reporting to the Administrator or state agency, contrary to facility policy.
The facility failed to complete timely comprehensive assessments for four residents, including those with dementia, COPD, and metabolic encephalopathy. The MDS Nurse identified a backlog of incomplete assessments, while the DON was unaware of the issue. The Administrator expected adherence to the RAI Manual for timely assessments.
The facility failed to complete quarterly MDS assessments every 92 days for three residents, as required by federal guidelines. A resident with dementia, another with pneumonia, and a third with type 2 diabetes mellitus did not have timely assessments. The MDS Nurse, new to the facility, acknowledged the backlog of assessments, while the DON was unaware of the issue. The Administrator expected adherence to the RAI Manual for timely MDS completion.
A facility failed to ensure the accuracy of the MDS for a resident with schizophrenia and major depressive disorder. The MDS inaccurately indicated the resident was not considered to have a serious mental illness, despite active diagnoses. Interviews with staff revealed a lack of awareness of the inaccuracies, and the Administrator confirmed the expectation for accurate MDS assessments.
A facility failed to ensure the accuracy of a PASARR for a resident with a history of mental disorders, including schizophrenia and bipolar disorder. The PASARR incorrectly indicated the absence of serious mental disorders, despite the resident's documented medical history. Interviews revealed that the admissions person was responsible for reviewing the PASARR, but no staff member was currently designated to verify its accuracy.
A resident with chronic respiratory conditions was observed administering their own nebulizer treatments without nurse supervision, contrary to the facility's policy. Nursing staff admitted to leaving the resident alone during treatments, and the DON was unaware of this practice.
A facility failed to implement a pharmacist's recommendation for a resident's medication order. The resident, with a history of constipation, was prescribed multiple bowel care medications. The pharmacist suggested adding a directive to hold the medication for loose stools, but this was not done. Interviews revealed that charge nurses did not act on pharmacy reviews, and the responsibility was left to RN supervisors or the DON. The administrator acknowledged the oversight, indicating a lapse in the process.
A resident with oral health issues did not receive timely dental care due to the facility's failure to arrange necessary appointments. Despite recommendations for dental procedures, such as bridge replacement and extractions, the resident's needs were unmet due to barriers in accessing care. Facility staff acknowledged the oversight, indicating a lapse in ensuring adequate dental services.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. A resident with a surgical wound did not receive proper EBP during wound care, as the nurse did not wear a gown. Another resident with a gastrostomy tube did not receive proper EBP during medication administration, as the LVN wore gloves but not a gown. Both instances were contrary to the facility's policy, which requires gown and glove use for residents with open wounds or gastrostomy tubes.
The facility failed to submit MDS assessments to CMS within the required 14 days for several residents, with delays ranging from 20 to 39 days. Staffing changes and gaps in the MDS Coordinator role contributed to the issue, as the new MDS Nurse was still in training and the DON was unaware of the need to sign and lock assessments completed before the new nurse's tenure. The facility's policy and federal guidelines were not adhered to, leading to these deficiencies.
The facility failed to provide the required minimum square footage per resident in 17 rooms, with measurements ranging from 75.6 to 78.7 square feet per resident. Staff interviews confirmed awareness of the deficiency, and a waiver was mentioned for the non-compliant rooms.
A resident in the facility did not receive the necessary splint and finger sleeve as indicated in their care plan, which was essential to prevent contractures in their right hand. Despite having a clear care plan, the nursing staff failed to provide these items, and there was no follow-up to ensure the interventions were implemented. The resident, who was cognitively intact, had a history of Type 1 Diabetes Mellitus and other conditions affecting their right hand.
A resident with multiple chronic conditions and mental health disorders was planned to be discharged to a homeless shelter, causing significant distress and anxiety. The facility failed to provide adequate preparation and support, leading to increased medication and mood swings. Interviews revealed inconsistencies in the resident's functional assessment, highlighting the potential for an unsafe discharge.
A resident's MDS assessment inaccurately indicated independence in mobility, affecting her care and placement. Despite the MDS showing she could walk 50 and 150 feet independently, interviews with staff and the resident revealed she only walked short distances within her room. The DON and MDS Consultant acknowledged the discrepancies, suggesting the MDS entries were erroneous.
A resident diagnosed with HIV did not receive requested HIV treatment due to a lack of coordination between the facility and the hospice provider. The facility's staff assumed the hospice was responsible for the medication, while the hospice indicated no communication from the facility regarding the resident's request. This resulted in the resident not receiving necessary HIV treatment.
A resident experienced significant weight loss and low meal intake, but the RD was not notified in a timely manner, preventing necessary nutritional interventions. The facility's failure to communicate the weight loss compromised the resident's nutritional status.
Failure to Provide Ordered PT/OT Services During Therapy Provider Transition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered Physical Therapy (PT) and Occupational Therapy (OT) services for five residents during a transition from contracted to in-house therapy services. Physician orders and therapy plans of care were in place for all five residents, but PT and OT services were not delivered as prescribed for multiple weeks. For Resident 1, who had a BIMS score of 15 indicating no cognitive impairment, PT and OT were ordered on 12/26/25 for muscle weakness, with a plan for services five times per week from 12/26/25 to 1/22/26. Resident 1 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in eight missed PT and eight missed OT treatments. Resident 2, also with a BIMS score of 15 and no cognitive impairment, had PT and OT ordered on 1/20/26, and a PT plan dated 1/21/26 for muscle weakness with services five times per week from 1/21/25 to 2/4/26. Resident 2 did not receive PT during the weeks of 1/26/26 and 2/2/26, totaling seven missed PT treatments, and there was no OT evaluation or OT treatments documented. Resident 3, with a BIMS score of 7 indicating severe cognitive impairment, had PT and OT ordered on 12/26/25 and a PT/OT plan dated 12/28/25 for muscle weakness, with services five times per week from 12/28/25 to 1/24/26. Resident 3 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT treatments and fifteen missed OT treatments. Resident 4, with a BIMS score of 4 indicating severe cognitive impairment, had PT and OT ordered on 12/21/25 and a PT/OT plan dated 12/23/25 for abnormalities of gait and mobility, with services five times per week from 12/23/25 to 1/19/26. Resident 4 did not receive PT or OT during the weeks of 1/5/26, 1/12/26, and 1/19/26, resulting in thirteen missed PT and fifteen missed OT treatments. Resident 5, with a BIMS score of 13 indicating no cognitive impairment, had PT and OT ordered on 12/13/25 and a PT/OT plan dated 12/15/25 for pelvic issues and abnormalities of gait and mobility, with services five times per week from 12/15/25 to 1/11/26. Resident 5 did not receive PT or OT during the week of 1/5/26, resulting in five missed PT and five missed OT treatments. Interviews with facility leadership and therapy staff confirmed that PT and OT services were not available from 1/5/26 to 1/22/26 due to the termination of contracted therapy services before in-house therapists were hired. The Consultant Administrator stated that PT and OT services should have continued without disruption after the contracted services ended on 1/5/26, but actual services did not restart until after 1/22/26. The DON confirmed that therapy services are expected to be evaluated and initiated within 72 hours of orders and that there was no PT or OT available during the identified period to conduct evaluations or continue treatment plans for the five residents. The PT, who was hired on 1/22/26 and had previously worked with the contracted provider, stated that residents did not receive therapy services from 1/5/26 to 1/22/26 because no one was hired to provide them and expressed concern about how the contract termination was handled. The Administrator acknowledged that the plans of care and physician orders for the five residents were not followed according to the medical record and that therapy services policies were not followed. The Administrator also stated that the primary physicians should have been notified of the delays and orders clarified to readjust treatments, but this did not occur. The OT, hired on 1/20/26 and providing services via telehealth, stated she could not speak to what occurred before her hire date but described the current process of instructing staff during telehealth sessions. Facility policies reviewed by surveyors, including "Scheduling Therapy Services" and "Care Plans, Comprehensive Person-Centered," require that therapy be scheduled and provided in accordance with the resident’s treatment plan, coordinated with nursing, documented in the medical record, and incorporated into a comprehensive care plan with measurable objectives and timetables. These documented expectations contrasted with the period in which no PT or OT services were provided despite active orders and treatment plans for the five residents. The DON and Administrator both described that from the time contracted services ended until in-house therapists were hired, there was no PT or OT available to evaluate residents or continue existing treatment plans. Nursing staff were responsible for notifying therapy of new orders, but there were no therapists available to receive or act on those notifications. As a result, the ordered rehabilitative services for muscle weakness, gait and mobility abnormalities, and pelvic issues were not delivered as planned for the five residents during the specified weeks, constituting the failure to provide specialized rehabilitative services as required by physician orders and facility policy.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a survey. At the rear of the facility, there was a cluttered area containing 13 bags of clothing items, seven stained mattresses, a dusty plate warmer, and pallets. These items had been accumulating for three to six months, according to the Housekeeping Supervisor, and were the responsibility of the maintenance staff to clean. The Maintenance Assistant confirmed that the facility rented a dumpster every six to eight months to dispose of such items, as the facility's single dumpster could not accommodate all the refuse. Interviews with various staff members, including the Laundry Staff, Maintenance Director, Director of Nursing, and the Administrator, revealed that the cluttered area contained items either needing repair or disposal. The Maintenance Director acknowledged that the area could attract pests, and the Director of Nursing and Administrator both agreed that the area needed to be cleaned. Despite the area not being accessible to residents or their families, the presence of clutter and potential pest attraction posed a risk to the facility's environment.
Failure to Report and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure that a resident's grievance was reported to the designated Grievance Officer, preventing an investigation from being initiated. The facility's policy required that all grievances be investigated and corrective actions taken. However, in the case of a resident who reported missing chocolate candy bars, the grievance was not properly escalated. The resident, who had intact cognition and was dependent on staff for all activities of daily living, reported to a CNA that their candy bars were missing. The CNA informed a nurse, but no further action was taken to report the grievance to the Grievance Officer. The LVN involved acknowledged that the resident had mentioned the missing candy bars, but he did not notify anyone else, assuming the issue was resolved when the resident's family brought more candy. The Interim Social Services Director and the Director of Nursing both stated that grievances should be documented and reported immediately, but this process was not followed. The Administrator also expected staff to adhere to the grievance process, which was not done in this instance, leading to a failure in addressing the resident's grievance according to the facility's policy.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse to management and the state survey agency for two residents. Resident #57, who had a history of traumatic events and intact cognition, called the police alleging that a staff member restrained them. Despite the police informing the facility staff of the call, the Administrator, who was the Abuse Coordinator, was not notified within the required two-hour timeframe. The Director of Nursing (DON) and Registered Nurse (RN) #9 were aware of the police visit but did not report the incident to the Administrator immediately, as required by the facility's policy. Resident #69, who also had intact cognition, reported to the police that a CNA pushed them, but did not inform the facility staff. The facility's investigation packet lacked evidence that the allegation was reported to the Administrator or the state agency. The Administrator later stated that the state agency was not notified because the staff's account did not align with the resident's allegation, suggesting the incident was not considered abuse. The facility's policy mandates immediate reporting of abuse allegations to the Administrator and the state agency, especially if it involves serious bodily injury. However, in both cases, the facility staff failed to adhere to this policy, resulting in a deficiency. The lack of timely reporting and investigation of these allegations highlights a significant lapse in the facility's abuse prevention and reporting protocols.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to properly identify and investigate an allegation of abuse involving a resident who reported being pushed by a CNA. The incident came to light when a police officer visited the facility after the resident called to report the alleged abuse. Despite the facility's policy requiring immediate investigation and reporting of abuse allegations, there was no evidence that the allegation was reported to the Administrator or the state agency. The Director of Nursing (DON) acknowledged that investigations should begin immediately, and involved staff should be suspended pending the investigation. The resident involved had a history of obstructive sleep apnea, major depressive disorder, and anxiety disorder, and was noted to have intact cognition. The resident's care plan indicated a tendency to become upset when staff entered their room at night, and there were interventions in place to manage these behaviors. However, the facility's investigation packet lacked documentation of a thorough investigation, including interviews with staff and witnesses, as required by their policy. The Administrator confirmed that the expectation was for all abuse allegations to be reported, but this did not occur in this instance.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for four residents within the required timeframes, as mandated by federal regulations. Resident #89 was admitted with a diagnosis of dementia, and the last comprehensive MDS was completed shortly after admission, with no subsequent assessments conducted. Resident #9, diagnosed with chronic obstructive pulmonary disease, had their last comprehensive MDS completed over a year ago, with no further assessments documented. Resident #23, with a history of metabolic encephalopathy, also lacked a comprehensive assessment since their last significant change in status MDS. Additionally, Resident #66, admitted with pneumonia, did not have an admission MDS completed at all. Interviews with facility staff revealed a lack of awareness and oversight regarding the overdue assessments. The MDS Nurse, who began employment in early 2025, acknowledged the backlog of incomplete assessments and identified the residents who were overdue for their annual MDS. The Director of Nursing was unaware of the incomplete assessments, and the Administrator stated that the expectation was for staff to adhere to the RAI Manual and complete assessments timely. This deficiency highlights a significant lapse in the facility's adherence to regulatory requirements for resident assessments.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments at least every 92 days for three residents, as required by federal guidelines. The facility's policy, dated January 2018, mandates adherence to federal and state submission timeframes for resident assessments. However, the facility did not complete a quarterly MDS for Resident #24 in January 2025, despite the resident having a medical history of dementia. Similarly, Resident #66, who was admitted in May 2023 with a diagnosis of pneumonia, did not have a quarterly MDS completed in January 2025. Resident #93, admitted in October 2024 with type 2 diabetes mellitus, had a quarterly MDS with an Assessment Reference Date of January 26, 2025, but it was not completed until March 4, 2025. Interviews with facility staff revealed a lack of awareness and oversight regarding the completion of MDS assessments. The MDS Nurse, who began employment on January 27, 2025, acknowledged that many MDS assessments were overdue or incomplete and expressed a plan to catch up on these assessments. The Director of Nursing (DON) was unaware of the incomplete MDS assessments, and the facility Administrator stated that the expectation was for staff to follow the Resident Assessment Instrument (RAI) Manual and complete MDS assessments in a timely manner. This deficiency indicates a failure in the facility's processes to ensure timely and accurate resident assessments.
Inaccurate MDS Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident reviewed for preadmission screening and resident review (PASARR). The resident, admitted on 05/03/2019, had a medical history of schizophrenia and major depressive disorder. An annual MDS assessment dated 06/10/2024 indicated the resident had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. However, the MDS inaccurately stated that the resident was not considered by the state level II PASARR process to have a serious mental illness or intellectual disability, despite active diagnoses of depression and schizophrenia. Interviews with the MDS Nurse and Director of Nursing revealed a lack of awareness regarding any inaccuracies in the MDS assessments, and the Administrator confirmed the expectation for MDS assessments to be accurate.
Inaccurate PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) for a resident with a medical history that included unspecified psychosis, schizophrenia, major depressive disorder, bipolar disorder, and anxiety disorder. The resident's PASARR Level I Screening, dated August 7, 2023, incorrectly indicated that the resident did not have a serious diagnosed mental disorder, despite their documented medical history. Interviews with the Director of Nursing (DON) and the Administrator revealed that the admissions person was responsible for reviewing the PASARR for accuracy, but there was no current staff member designated to verify the accuracy of the PASARR at the facility.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses stayed with a resident to ensure all medication was administered as ordered by the physician. Resident #8, who was admitted to the facility with a medical history including chronic obstructive pulmonary disease and acute respiratory failure, was observed administering their own nebulizer treatments without a nurse present. The resident had intact cognition, as indicated by a BIMS score of 15, and was observed on multiple occasions taking their breathing treatment alone, with aerosol vapor coming from the nebulizer machine. Interviews with the nursing staff revealed that the nurses placed the medication in the nebulizer machine for the resident and left them to administer the treatment independently. RN #3 admitted to placing the medication in the machine and leaving the room, while LVN #4 also acknowledged not staying with the resident for the entire duration of the treatment. The Director of Nursing was unaware of this practice and stated that it was expected for nurses to stay with residents during nebulizer treatments, as per the facility's medication administration policy.
Failure to Implement Pharmacist's Recommendation for Medication Order
Penalty
Summary
The facility failed to implement the pharmacist's recommendation for a resident who was reviewed for unnecessary medications. The resident, who was admitted with a diagnosis of constipation, was prescribed multiple medications for bowel care management, including polyethylene glycol 3350, senna, and docusate sodium. The consultant pharmacist recommended adding a directive to hold the medication for loose stools, but this recommendation was not incorporated into the resident's medication order. Interviews with facility staff revealed a lack of follow-through on pharmacy recommendations. The Licensed Vocational Nurse indicated that charge nurses did not act on pharmacy reviews, leaving it to the RN supervisor or the Director of Nursing. The Director of Nursing confirmed that charge nurses and supervisors were responsible for following up on pharmacy recommendations. An RN stated that pharmacy recommendations should be completed within one to two days if the physician agreed, but this was not done for the resident in question. The facility administrator acknowledged that pharmacy recommendations should be followed, indicating a lapse in the process.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to address the dental needs of a resident, who was admitted on February 15, 2024, and had a care plan indicating oral/dental health problems due to poor oral hygiene and missing and broken teeth. Despite having an order for a dental consult and treatment dated September 27, 2024, there was no evidence that the recommended dental procedures, such as bridge replacement and multiple extractions, were completed. The resident, who had intact cognition, expressed concerns about their dental issues and reported asking the social worker for assistance, which had not been provided. The facility's policy required social services to make necessary dental appointments, but the resident's records showed multiple barriers to accessing dental care. The resident was a gurney patient, and local dental offices were unable to accommodate them, with the only option being an alternate county that was fully booked for the year. Despite recommendations for full mouth extractions, there was no evidence that these procedures were scheduled, and the resident continued to experience dental problems. Interviews with facility staff, including the Interim Social Service Director, DON, and Administrator, revealed that the social services department failed to arrange timely dental appointments for the resident. The DON and Administrator acknowledged that the resident's dental needs should have been addressed promptly, and alternative arrangements should have been made when the in-house vendor could not meet the resident's needs. The deficiency highlights a failure in the facility's process to ensure timely and adequate dental care for residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, leading to deficiencies in infection prevention and control. Resident #93, who was admitted with a medical history including type 2 diabetes mellitus and a surgical wound from a transmetatarsal amputation, did not receive proper EBP during wound care. The Treatment Nurse did not wear a gown while providing care, despite the facility's policy requiring gown and glove use for residents with open wounds. The nurse acknowledged the oversight, stating she believed EBP was only necessary for draining wounds, despite the Director of Nursing's expectation that EBP should be implemented for any wound care. Similarly, Resident #252, admitted with a diagnosis of dysphagia and a gastrostomy tube, did not receive proper EBP during medication administration. The Licensed Vocational Nurse (LVN) administering medications via the gastrostomy tube wore gloves but failed to wear a gown, contrary to the facility's policy. The LVN admitted the mistake, and the Director of Staff Development confirmed that staff had been instructed to wear gowns and gloves for residents with gastrostomy tubes. The Director of Nursing reiterated the expectation for staff to adhere to EBP when administering medications through a gastrostomy tube.
Delayed MDS Submissions Due to Staffing and Process Gaps
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare & Medicaid Services (CMS) system within the required 14 days after completion for several residents. The report highlights that multiple residents had their MDS assessments completed but not submitted in a timely manner, with delays ranging from 20 to 39 days past the completion date. This issue affected at least nine residents, including Residents #31, #79, and #88, among others. The delays in submission were attributed to staffing changes and gaps in the MDS Coordinator role. The MDS Nurse, who started at the facility in late January 2025, was still undergoing training and was responsible for managing both current and overdue assessments. The Director of Nursing (DON) was not initially aware of the need to sign and lock assessments completed before the new MDS Nurse's tenure, which contributed to the delays. The facility's policy and the Long-Term Care Facility Resident Assessment Instrument Manual require timely submission of MDS assessments, which was not adhered to in these cases. Interviews with the MDS Nurse and the DON revealed a lack of clear communication and understanding of the submission process. The MDS Nurse was relying on electronic medical record software for scheduling, while the DON was new to the process and learning alongside the MDS Nurse. The Administrator expected timely transmission of MDS assessments within 14 days, as per the facility's policy and federal guidelines, but this expectation was not met due to the aforementioned issues.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage per resident, as observed in 17 out of 43 rooms. Specifically, rooms 6 through 11 and rooms 17 through 27 did not provide the mandated 80 square feet per resident, with measurements ranging from 75.6 to 78.7 square feet per resident. This deficiency was identified during an observation on March 3, 2025, and confirmed through a Client Accommodations Analysis conducted on March 6, 2025. Interviews with facility staff, including the Director of Nursing, Maintenance Director, and Administrator, revealed an acknowledgment of the deficiency. The Director of Nursing expressed an expectation for residents to have adequate space and mentioned the facility's intention to request a waiver for non-compliant rooms. The Maintenance Director confirmed the existence of a waiver for the 17 rooms in question, where three residents were housed in each room. The Administrator also acknowledged the issue of rooms not meeting the required square footage.
Failure to Implement Care Plan Interventions for Resident
Penalty
Summary
The facility failed to ensure that the interventions indicated in the care plan for a resident were being provided by the nursing staff in accordance with professional standards of practice. Specifically, the resident's splint and finger sleeve were not available, which was necessary to prevent contractures in the resident's right hand. The resident had a diagnosis of Type 1 Diabetes Mellitus, essential primary hypertension, stiffness of the right hand, and other muscle spasms, and was cognitively intact with a BIMS score of 15. During an observation and interview, it was noted that the resident did not have the required finger sleeve or splint on their right hand. The Licensed Vocational Nurse (LVN) acknowledged that these items should have been applied as per the care plan. The LVN admitted that the staff failed to provide the necessary items listed in the care plan interventions, placing the resident at risk for potential contractures. Further interviews revealed that the interventions were ordered but never received, and there was no follow-up to ensure the care plan was implemented. The Director of Nurses (DON) confirmed that the nursing staff did not follow the physician's orders and care plan interventions. There was confusion regarding the splinting, and the staff failed to follow up on ordering the necessary apparatus. The facility's policy and procedure emphasized the importance of following comprehensive, person-centered care plans and ensuring that residents' activities of daily living do not diminish unless unavoidable. However, the staff did not adhere to these policies, resulting in the deficiency.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge for a resident with complex medical and physical needs. The resident, a female with multiple chronic conditions including Multiple Sclerosis, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was planned to be discharged to a homeless shelter. This decision was made after the resident's insurance provider indicated that she no longer required the level of care provided by the facility. However, the resident expressed significant distress and anxiety about the discharge plan, which was not adequately addressed by the facility. The resident's medical records indicated a history of mental health disorders, including Generalized Anxiety Disorder and Bipolar Disorder, which were exacerbated by the discharge plan. The facility's staff, including the Social Services Director and Director of Nursing, were involved in the discharge planning but failed to provide a suitable alternative to the homeless shelter. The resident's condition required continuous oxygen, blood glucose monitoring, and multiple medications, which raised concerns about her ability to manage her health independently in a homeless shelter environment. Interviews with the resident, her family member, and facility staff revealed inconsistencies in the assessment of her functional abilities. The resident and several staff members reported that she was unable to walk outside her room and required assistance with daily activities, contradicting the facility's documentation that she was independent in certain activities. The resident's emotional state deteriorated, as evidenced by increased anxiety, mood swings, and angry outbursts, leading to an increase in her antipsychotic medication. The facility's failure to adequately prepare and support the resident for discharge resulted in a potential for an unsafe discharge and significant emotional distress.
Inaccurate MDS Assessment Leads to Potential Misplacement
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, which had the potential to affect her care and facility placement. The resident, a female who had been admitted to the facility six years ago, was issued a 30-day discharge notice after her health insurance provider determined she no longer required the level of care provided by the facility. This decision was based on her MDS assessment, which inaccurately indicated that she was independent in her mobility, specifically in walking 50 feet with two turns and 150 feet, despite evidence to the contrary. Interviews with various staff members, including the Social Services Director, Director of Nursing (DON), Medical Records Director, Registered Nurse (RN), and Certified Nursing Assistants (CNAs), revealed that the resident had not been observed walking in the hallway or performing the activities as indicated in the MDS. The resident herself confirmed that she had not walked up and down the hallway in years and required oxygen to walk short distances from her wheelchair to the bathroom. Staff members consistently reported that the resident only walked within her room, covering distances much shorter than those recorded in the MDS. The MDS Consultant acknowledged that the sudden improvement in the resident's mobility, as recorded in the MDS, should have been verified by facility staff. The DON admitted to not knowing why the MDS was coded to reflect such independence in mobility and suggested that it could be an error. The inaccuracies in the MDS assessments, spanning from December 2023 to June 2024, were not consistent with the resident's actual capabilities as observed by the staff and reported by the resident herself.
Failure to Provide HIV Treatment for Hospice Resident
Penalty
Summary
The facility failed to follow its policy and procedure regarding the provision of hospice services for a resident diagnosed with HIV. The resident requested HIV treatment, but the facility did not collaborate with the hospice provider or the resident's primary physician to ensure the treatment was provided. The facility's Director of Nurses (DON) and a Registered Nurse (RN) both assumed that the hospice was responsible for providing the HIV medication, while the hospice indicated that the facility had not reached out to them regarding the resident's request. This lack of communication and coordination resulted in the resident not receiving the necessary HIV treatment, despite being eligible for it according to the hospice provider. The resident's family member and the resident himself expressed concerns about the lack of HIV treatment. The resident, who was cognitively intact according to his Minimum Data Set (MDS) assessment, stated that he wanted the treatment but was not receiving it. The facility's policy indicated that it was responsible for coordinating with the hospice to meet the resident's needs, including administering prescribed therapies. However, the facility did not follow this policy, leading to the resident's increased risk of weakened immunity due to untreated HIV.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status when the Registered Dietitian (RD) was not notified of the resident's significant weight loss of 6.8 pounds (9.6%) over three weeks and a by mouth (PO) intake of 60%. This lack of communication prevented the RD from providing timely recommendations to prevent further unplanned weight loss. The resident's compromised nutritional status was not addressed, which had the potential to lead to further medical complications. The resident was admitted to the facility with diagnoses including hypertension, long-term use of insulin, and muscle weakness. The RD's nutrition assessment indicated the resident was at high risk for unintended weight loss and required 1800 to 2150 calories and 75 to 85 grams of protein per day. Despite the resident's significant weight loss and low meal intake, the RD was not informed of the weight loss during the Interdisciplinary Team (IDT) meeting on 1/30/24. The RD only became aware of the weight loss during her monthly assessment on 2/7/24, at which point she recommended health shakes to provide extra calories. The facility's policy required the RD to be notified of significant weight changes, but this did not occur. The Dietary Supervisor and Director of Nurses confirmed that the RD was not notified of the weight loss despite attending weekly IDT meetings. The facility's failure to communicate the resident's weight loss to the RD resulted in a delay in implementing necessary nutritional interventions, thereby compromising the resident's nutritional status and overall health.
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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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