Meadowbrook Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Hemet, California.
- Location
- 461 E. Johnston Avenue, Hemet, California 92543
- CMS Provider Number
- 055401
- Inspections on file
- 43
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Meadowbrook Post Acute during CMS and state inspections, most recent first.
Surveyors found that two residents were living with a bedroom and shared bathroom that had unpainted primer patches, damaged drywall, peeled and chipped paint, and missing tiles and grout, contrary to facility policy requiring clean, comfortable, safe, and homelike bedrooms. One resident, who was alert, oriented, and wheelchair-bound with a history of CVA, MS, and ataxia, reported that the damaged and unfinished walls and tiles in his room and bathroom were not homelike, while the other alert and oriented resident sharing the bathroom similarly stated that the bathroom did not look good.
A resident with a history of cerebral infarction, multiple sclerosis, and ataxia, who required assistance with mobility and ADLs, did not receive a physician-ordered PT evaluation and treatment. The resident reported never having PT since admission, and both a CNA and an LVN confirmed they had not observed any PT services provided. Record review showed an active order for PT evaluation and treatment, and the administrator acknowledged that this order was not followed, despite a facility policy requiring provision of PT upon written physician order.
Surveyors found that a shared bathroom call light used by two residents in wheelchairs was nonfunctional, providing no visual or audible alert when activated. A CNA, an LVN, the Maintenance Assistant, and the Administrator each confirmed the bathroom call light did not work, despite facility policy requiring a functional call system in toileting and bathing areas. One resident, with MS, stroke history, and ataxia, reported needing assistance in the bathroom and stated he would use the call light if it worked. The other resident, with hereditary neuropathy and kyphosis, also confirmed the shared bathroom call light was not working and noted it would be useful if functional.
Surveyors found the kitchen’s double prep sink area in an unsanitary condition, with both basins covered yet containing dried food particles, a red bucket of yellowish gray fluid under one sink, and a wet blanket on the floor nearby. The DM and ADM reported the sinks had been non-operational for several days due to a collapsed drainage pipe, with unsuccessful in-house repair attempts and plumber evaluations confirming the issue. During this time, staff used plastic bus tubs to clean fruits and vegetables instead of the prep sinks. The Cook confirmed the dirty condition and acknowledged the kitchen was not sanitary, while the DON reported no resident complaints or hospital transfers for food-borne illness, despite a facility policy requiring all kitchen areas to be kept clean and free of garbage and debris.
A resident with dementia and a history of falls experienced multiple unwitnessed falls and injuries due to the facility's failure to implement and document required supervision and monitoring interventions. Despite care plans specifying frequent checks and visual monitoring, staff did not consistently follow or record these measures, and concerns raised by CNAs about the resident's safety were not addressed by nursing leadership.
The facility did not post complete daily nurse staffing information, as only projected hours were displayed and actual direct care service hours were left blank. The DSD confirmed that actual hours were not calculated or posted daily due to lack of timely access to payroll data, resulting in incomplete staffing information being available to residents and the public.
The facility did not provide or document wound care treatments as ordered by physicians for four residents with complex medical conditions, including diabetes, osteomyelitis, congestive heart failure, and gangrene. On multiple occasions, the Treatment Administration Record lacked evidence that wound care was performed, and staff interviews confirmed the treatments were missed. Facility policy requires documentation of all treatments, but this was not followed for the affected residents.
A resident with multiple chronic conditions was transferred to a hospital for gangrene of the right foot, but the facility did not notify the LTC Ombudsman as required. Review of records and staff interviews confirmed the omission, despite facility policy mandating ombudsman notification for transfers.
Surveyors found a gallon of chocolate syrup with an open date more than six months prior stored on the kitchen counter and available for use. The Dietary Manager and Registered Dietician confirmed that facility guidelines require opened chocolate syrup to be discarded after six months, but this was not done, resulting in expired food being accessible in the kitchen.
Surveyors found the outdoor dumpster overflowing with trash and the lid not fully closed. Both the DM and facility owner confirmed that the dumpster should not be overflowing and the lid should be closed, in accordance with facility policy.
Two residents with respiratory needs did not have their oxygen cannulas and nebulizer masks changed, labeled, or stored according to infection control protocols. Equipment was found undated, left exposed, or not replaced as required by physician orders and facility policy. Staff interviews confirmed that weekly changes and proper storage in plastic bags were not consistently performed.
The facility failed to track and document controlled medications, leading to unaccounted medications for several residents. The DON was informed of missing medication count sheets and cards, and an investigation revealed discrepancies in documentation. The facility lacked a process to monitor receipt and reconciliation of controlled medications, resulting in potential misuse or diversion.
The facility failed to accurately code the MDS for several residents, including those with PASRR Level II evaluations and an indwelling catheter. A resident with severe cognitive impairment and a PASRR Level II was not coded correctly, and another resident with an indwelling catheter was not identified in the MDS. These oversights were acknowledged by the MDS Coordinator and highlighted by the DON and Administrator.
A resident with a urinary catheter was observed without a privacy bag on two occasions, exposing the urine and compromising their dignity. Despite facility policy and staff acknowledgment that privacy bags should be used, the resident's catheter bag remained uncovered. The resident had a history of hemiplegia, hemiparesis, skin infection, and sepsis, and required the catheter for urinary retention and wound management.
The facility failed to create care plans for two residents with urinary catheters, despite their medical histories and hospital interventions. One resident had an indwelling catheter placed for urinary retention, and another had a suprapubic catheter due to a UTI and sepsis. The absence of orders led to the lack of care plans, as care plans were based on MDS triggers. The DON acknowledged the oversight and took responsibility.
The facility failed to obtain orders and create care plans for urinary catheters for two residents upon admission. One resident returned with a suprapubic catheter after a hospital stay, and another was readmitted with an indwelling catheter. Both cases lacked documentation and care plans until identified during a survey. The DON and staff acknowledged the oversight, attributing it to failures in the admission and reassessment processes.
A resident with a history of respiratory issues had an order for supplemental oxygen at 2 lpm, but observations showed the oxygen was set higher than prescribed. The DON confirmed the discrepancy, stating changes should only occur with a new physician's order. The LVN was unaware of the reason for the increased setting, and the Administrator stressed the need to follow all orders.
A facility failed to properly assess and monitor a resident's condition before and after dialysis treatments and did not maintain effective communication with the dialysis center. The resident, with a history of end-stage renal disease, had incomplete Dialysis Assessment Records, missing critical information such as vascular access site assessments and vital signs. Significant incidents, like vomiting and low blood pressure, were not documented, leaving the dialysis center uninformed of these health changes. Staff interviews revealed a lack of communication and protocol adherence, contributing to the deficiency in providing safe dialysis care.
The facility implemented a policy to charge residents $25 if they required staff assistance to outside appointments, potentially deterring necessary medical visits. A resident with multiple diagnoses expressed concern about the charge, and facility leadership confirmed the policy.
Failure to Maintain Homelike Bedroom and Shared Bathroom Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment in a resident bedroom and a shared bathroom. During an unannounced complaint investigation, surveyors observed a white patch of dry primer on the wall near the foot of one resident's bed that was not painted to match the rest of the room. In the shared bathroom used by this resident and another resident, surveyors observed peeled paint above the sink, damaged drywall and missing paint around the light switch, missing tiles and grout in the shower area, and a patch of dry, white primer around the toilet that was not painted like the rest of the bathroom. These conditions were confirmed on observation and interview with a CNA, the Maintenance Assistant, and the Administrator, all of whom acknowledged that the bedroom and bathroom did not look like a homelike environment. The resident whose bedroom and bathroom were observed was alert and oriented and was seen in a wheelchair in his room. His medical record showed diagnoses including cerebral infarction (stroke), multiple sclerosis, and ataxia. He stated he did not like the damaged drywall, missing tiles, and unpainted areas in his bathroom and bedroom and that it was not a homelike environment. Another alert and oriented resident, who shared the same bathroom, was observed in a wheelchair outside his room and reported that his bathroom had damaged drywall, missing tiles, chipped paint, and did not look good. The facility’s written policy on bedrooms, dated January 2025, stated that all residents are entitled to clean, comfortable, safe, and homelike bedrooms, which was not met in these observed conditions.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
Surveyors found that the facility failed to provide specialized rehabilitative services as ordered by the physician for one resident. During an unannounced complaint investigation, the resident was observed in a wheelchair, alert and oriented, and reported having multiple sclerosis and not receiving any physical therapy (PT) evaluation or treatment since admission. The resident stated that PT could help with his condition. A certified nursing assistant and a licensed vocational nurse both stated that the resident required assistance with mobility and activities of daily living and that they had not seen the resident receive PT during his stay. Record review showed the resident was admitted with diagnoses including cerebral infarction, multiple sclerosis, and ataxia, and had a physician’s order dated October 30, 2025, for “Physical Therapy evaluation and treatment as indicated.” The administrator confirmed that the resident had not received a PT evaluation or treatment since admission and acknowledged that the physician’s PT order was not followed. The facility’s policy on Specialized Rehabilitative Services, dated December 2009, stated that the facility would provide rehabilitative services, including PT, upon written order of the attending physician, but this policy was not implemented for this resident.
Nonfunctional Bathroom Call Light in Shared Resident Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional bathroom call light system for two residents who shared the same bathroom. During an unannounced complaint investigation on April 7, 2026, surveyors observed that the bathroom call light in the shared bathroom between two rooms did not produce any visual or audible alert when activated. A CNA, an LVN, the Maintenance Assistant, and the Administrator each entered the bathroom, tested the call light, and confirmed it was not working, despite the facility’s written policy stating that the resident call system must remain functional at all times and that residents must have a means to call staff from toileting and bathing areas. Resident 1, who was alert and oriented and used a wheelchair, reported having multiple sclerosis and needing assistance in the bathroom to get in and out of his wheelchair. He stated that the bathroom call light was not working and that he would use it if it were functional. Resident 1’s record showed diagnoses including cerebral infarction, multiple sclerosis, and ataxia. Resident 2, also alert and oriented and using a wheelchair, confirmed that he shared the bathroom and that the bathroom call light was not working, stating it would be nice to have a functioning call light in case he needed to use it. Resident 2’s record reflected diagnoses of hereditary neuropathy and kyphosis. These observations and interviews demonstrated that the facility did not maintain a working call system in the shared bathroom as required by its policy.
Unsanitary Kitchen Prep Sink and Improper Maintenance of Food Preparation Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary conditions and improper maintenance of the kitchen’s double preparation sink. During an initial kitchen tour with the Dietary Manager (DM), both basins of the double prep sink were found covered by a long cookie sheet, with signs posted above each basin stating “DO NOT USE UNDER REPAIR,” yet both sinks contained multiple dried food particles. Under the first prep sink, surveyors observed a red bucket filled with yellowish gray fluid, and a wet yellow blanket was seen on the floor in the corner at the end of the double prep sinks. The DM reported that the prep sinks had a drainage issue beginning on March 18, 2026, that the maintenance supervisor had attempted repairs without success, and that two separate plumbers had determined the drainage pipe under the double prep sink was collapsed beneath the courtyard cement. The DM also stated that kitchen staff were using plastic bus tubs to clean fruits and vegetables during this period. In a concurrent observation and interview with the Administrator (ADM), DM, Cook, and Director of Nursing (DON), the ADM acknowledged that the double prep sinks had been non-operational since March 18, 2026, and confirmed the presence of dirty sinks, the red bucket with yellow-grey water, and the wet yellow blanket on the floor. The Cook stated that the sinks had been non-operational and dirty with old, dried food, with the red bucket of yellow-grey liquid and the wet yellow blanket in place since March 18, 2026, and acknowledged that the kitchen should be sanitary at all times and was not. The DON reported there had been no resident complaints or transfers related to signs or symptoms of food-borne illness. The facility’s written policy on sanitization stated that all kitchens, kitchen areas, and dining areas are to be kept clean and free from garbage and debris, which contrasted with the observed conditions in the prep sink area.
Failure to Provide Adequate Supervision and Prevent Accident Hazards
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision for a resident with dementia, anxiety, a history of falls, and impulsive behavior. Despite being identified as high risk for falls and self-harm, the resident experienced eight unwitnessed falls over a period of several months. The care plans for the resident included specific interventions such as being checked and changed every two hours, frequent visual monitoring, and later, checks every 30 minutes. However, there was no documented evidence that these interventions were consistently implemented or monitored by staff. On multiple occasions, the resident was found on the floor or under her roommate's bed, sometimes with visible injuries such as hematomas, skin tears, and severe bruising to the face and hands. Staff interviews revealed that CNAs were aware of the resident's behaviors and risks, but failed to consistently report significant findings, such as swollen eyes, to the nursing staff in a timely manner. Additionally, CNAs reported that their concerns about the resident's safety and the need for increased supervision, such as a one-on-one sitter, were communicated to nursing leadership but not acted upon. Record reviews confirmed the lack of documentation for required monitoring and supervision as outlined in the resident's care plans. The DON acknowledged that the facility did not follow its own policies and procedures for ensuring resident safety and that the falls could have been avoided with proper monitoring. The facility's policy required targeted interventions and adequate supervision to reduce accident risks, but these were not effectively implemented for this resident.
Incomplete Daily Nurse Staffing Data Posting
Penalty
Summary
The facility failed to ensure that daily posted nurse staffing data was complete and accurate, as required. During an unannounced visit, it was observed that the posted documents for nurse staffing, specifically the Census and Direct Care Services Hours Per Patient Day (DHPPD), only included projected (estimated) hours and did not have the actual direct care service hours, average patient census, actual DHPPD, or actual CNA hours filled in for the reviewed dates. The section of the form designated for actual hours was left blank, despite instructions that it must be completed at the end of each 24-hour patient day. Interviews with the Director of Staff Development (DSD) revealed that actual DHPPD hours were not calculated or posted daily because the DSD did not have access to payroll hours until the day after paydays, which occur twice a month. As a result, only projected staffing hours were posted, and actual staffing data was not made available to residents and the public on a daily basis as required. This omission was verified during both document review and staff interviews.
Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to provide wound care treatments in accordance with physician orders for four residents. For one resident with diagnoses including diabetes, hypertension, osteomyelitis, and chronic kidney disease, the Treatment Administration Record (TAR) showed that wound care for a right foot stump was not documented as provided on three specific dates, despite active orders for daily or every-other-day treatment. Another resident with low back pain, congestive heart failure, and hypertension had no documentation of ordered wound care for a left heel wound on three separate dates, as indicated by the TAR. A third resident, diagnosed with diabetes, chronic obstructive pulmonary disease, and dysphagia, had no documentation of wound care for a left great toe on two dates, despite an order for daily treatment. The fourth resident, with subdural hemorrhage, gangrene, and on palliative care, had no documentation of wound care for a gangrenous toe on one date, even though the order specified treatment every 48 hours. In each case, the TAR lacked evidence that the prescribed wound care was performed as ordered. Interviews with the Treatment Nurse and the Director of Nursing confirmed that the wound treatments were not documented or administered on the specified dates for all four residents. The facility's policy requires that all treatments and procedures be documented in the resident's medical record, including details such as date, time, procedure, assessment, and the signature of the individual providing care. The absence of documentation and confirmation from staff indicated that the required wound care treatments were not provided as ordered.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman when a resident was transferred to a general acute care hospital. The resident, who had a medical history including diabetes, hypertension, osteomyelitis of the right foot, and chronic kidney disease, was transferred to the hospital for gangrene of the right foot. Documentation reviewed included the resident's admission record, progress notes, and SBAR, all confirming the transfer and the medical reasons for it. However, there was no evidence in the records that the ombudsman was notified of this transfer. Interviews with the Social Worker, Director of Nursing (DON), and Administrator confirmed that the facility's process requires notification of the ombudsman for all transfers or discharges, and that this notification did not occur in this case. The facility's policy also specifies that notice should be given to the ombudsman as soon as practicable before a transfer. Both the Social Worker and DON acknowledged the omission, and the Administrator verified the lack of documentation regarding ombudsman notification for the resident's transfer.
Expired Chocolate Syrup Found in Kitchen Storage
Penalty
Summary
During a kitchen tour, surveyors observed a gallon of chocolate syrup with an open date of October 19, 2023, stored on top of the kitchen overhead counter and readily available for use. The Dietary Manager confirmed that the chocolate syrup should have been discarded six months after opening, according to the facility's dry goods storage guidelines, but it remained accessible to staff well past this period. The Registered Dietician also stated that no expired food or food stored beyond its shelf life should be present in the kitchen, whether opened or not. The facility's documented guidelines specify that opened chocolate syrup should be discarded after six months, but this was not followed, resulting in the presence of expired food in the kitchen.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During an inspection of the facility's garbage disposal area, surveyors observed that the outdoor trash dumpster located by the parking lot was overflowing with trash and its lid was not completely closed. The Dietary Manager confirmed during the inspection that the dumpster should not be overflowing and that the lid should be fully closed to prevent attracting pests. The facility owner also acknowledged in an interview that the dumpster should not be overflowing and the lid should be closed. A review of the facility's policy on food-related garbage and refuse disposal indicated that outside dumpsters are to be kept closed and free of surrounding litter.
Failure to Follow Infection Control Practices for Respiratory Equipment
Penalty
Summary
The facility failed to follow infection control practices for two residents who required respiratory equipment. For one resident with a history of pneumonia, the oxygen cannula in use was not dated, and a nebulizer mask was found undated and left exposed on the nightstand, rather than being stored in a plastic bag as required. The resident's physician order specified that the nasal cannula and mask should be changed weekly, and facility policy required respiratory equipment to be labeled, dated, and stored in a plastic bag when not in use. Staff interviews confirmed that these procedures were not followed, and the equipment was not properly stored or dated. For another resident, also with a diagnosis of pneumonia, the nebulizer mask had not been changed since admission, despite physician orders and facility policy requiring weekly changes. The mask was observed in a belongings bag with an outdated label, and the resident confirmed that the mask had not been replaced since admission. Staff interviews revealed that the responsibility for changing the equipment was assigned to the night shift, but the change had not occurred as scheduled. The equipment was also not stored according to infection control protocols. Both residents' records and staff interviews indicated a lack of adherence to established infection control policies regarding the maintenance, labeling, and storage of respiratory equipment. The facility's own procedures required weekly changes and proper storage of such equipment to prevent contamination, but these steps were not consistently implemented for the residents reviewed.
Failure to Track and Document Controlled Medications
Penalty
Summary
The facility failed to implement a system to accurately track the movement of controlled medications, leading to the inability to account for missing controlled medications for ten residents. The Director of Nursing (DON) was informed by a Licensed Vocational Nurse (LVN) about missing controlled medication count sheets and medication cards for two residents. An investigation revealed that a total of ten residents were affected by the missing controlled medications. The facility suspected a new hire per diem nurse of diverting the medications, and a police report was filed. However, the facility lacked a process to monitor the receipt of controlled medications, and the DON admitted there was no reconciliation process in place to identify loss or potential diversion. Additionally, during a random controlled medication audit, discrepancies were found in the documentation of medication administration for four residents. The controlled medications were signed out on the count sheet but not documented on the Medication Administration Records (MAR), resulting in inaccurate accountability. For instance, Resident 11 had two doses of Norco unaccounted for, and Resident 12 had eight doses missing. Similar discrepancies were found for Residents 9 and 13 with their Ativan prescriptions. The nursing staff failed to document the administration of these medications on the MAR, as required by the facility's policy and procedure. The facility's policies on controlled substances and medication administration were not followed, contributing to the deficiencies. The policies required that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, and that medication administration be documented immediately on the MAR. The failure to adhere to these policies resulted in unaccounted controlled medications, raising concerns about potential misuse or diversion.
Inaccurate MDS Coding for Residents with PASRR Level II and Indwelling Catheters
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for several residents, leading to deficiencies in the assessment and care planning process. Resident #11, who was admitted with a history of major depressive disorder, schizophrenia, bipolar disorder, and anxiety disorder, had a Preadmission Screening and Resident Review (PASRR) Level II evaluation completed, which was not accurately reflected in the MDS. The MDS Coordinator acknowledged forgetting to code the PASRR Level II, despite the information being available in the resident's electronic health record. Similarly, Resident #18, with a history of major depressive disorder and schizophrenia, also had a PASRR Level II evaluation that was not coded in the MDS. The resident's care plan indicated the use of psychotropic medications for schizophrenia, yet the MDS did not reflect the PASRR Level II status. The Director of Nursing and the Administrator both expressed expectations for accurate MDS coding, but the oversight persisted. Additionally, Resident #39, who had severe cognitive impairment and a PASRR Level II evaluation, was not accurately coded in the MDS. The MDS Coordinator admitted that the PASRR Level II should have been triggered. Furthermore, Resident #26, who had an indwelling urinary catheter, was not coded for the catheter in the MDS, as the MDS Coordinator did not notice the catheter and there were no orders prompting its inclusion. These inaccuracies in MDS coding highlight a pattern of oversight in the facility's assessment process.
Failure to Use Privacy Bag for Urinary Catheter
Penalty
Summary
The facility failed to ensure the use of a privacy bag for a resident with a urinary catheter, compromising the resident's right to a dignified existence. The resident, who was admitted with a medical history of hemiplegia, hemiparesis following a stroke, skin infection, and sepsis, had an indwelling urinary catheter due to urinary retention and wound management. Observations on two separate occasions revealed that the resident's urinary catheter bag was not covered with a privacy bag, exposing the urine. Interviews with facility staff, including CNAs, an LVN, the Director of Nursing, and the Administrator, confirmed that urinary catheter bags should be covered with privacy bags. Despite this policy, the resident's catheter bag was observed without a privacy cover, indicating a lapse in adherence to the facility's policy and the resident's rights. The Director of Nursing acknowledged the requirement for privacy bags and expressed uncertainty about why it was not being used for the resident.
Failure to Develop Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with urinary catheters, as required by their policy. Resident #26 was admitted with a history of hemiplegia, hemiparesis, and sepsis, and had an indwelling urinary catheter placed during a hospital stay for urinary retention. Upon readmission to the facility, there were no orders or care plans related to the urinary catheter, and the MDS Coordinator did not notice the catheter during the assessment, leading to the absence of a care plan. The Director of Nursing (DON) acknowledged that a care plan should have been created for the urinary catheter. Resident #34, with a history of obstructive and reflux uropathy and hydronephrosis, was admitted to the hospital where a urinary catheter was placed due to a UTI and sepsis. Upon returning to the facility, there were no orders or care plans for the suprapubic catheter. The MDS Coordinator stated that care plans were created based on MDS triggers, and since there was no order for the catheter, it was not included in the care plan. The DON admitted that the staff missed the catheter during readmission and took responsibility for the oversight. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that care plans were typically created based on MDS triggers and that nurses had the ability to update them. However, the absence of orders for the urinary catheters led to the lack of care plans for both residents. The Administrator and DON both expressed that care plans should be completed timely and accurately, covering all necessary aspects of resident care.
Failure to Document and Manage Urinary Catheters for Two Residents
Penalty
Summary
The facility failed to ensure that upon admission, orders were obtained for the placement and ongoing care and maintenance of urinary catheters for two residents. Resident #34 was admitted with a suprapubic catheter following a hospital stay for sepsis secondary to pyelonephritis and a right-sided staghorn ureteral calculus. Despite returning to the facility with the catheter, there were no orders or care plans in place for its management until a recertification survey identified the oversight. The Director of Nursing (DON) acknowledged the lapse, stating that the staff missed the catheter during the resident's readmission assessment. Similarly, Resident #26 was readmitted to the facility with an indwelling urinary catheter placed during a hospital stay for urinary retention. The facility's records did not reflect any orders or care plans for the catheter until the deficiency was noted during a recertification survey. The MDS Coordinator and Licensed Vocational Nurse (LVN) #2 both confirmed that the catheter was not documented in the resident's chart, and the DON admitted that the catheter should have been noted during the admission assessment. Interviews with facility staff, including the Administrator, revealed that the admitting nurse should have conducted a full body assessment and contacted the doctor for orders regarding the urinary catheters. The lack of documentation and care planning for the catheters was attributed to failures in the admission and reassessment processes, as well as a lack of communication among the nursing staff.
Failure to Follow Physician Orders for Supplemental Oxygen
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident requiring supplemental oxygen. Resident #17, who was admitted with a medical history of shortness of breath, acute upper respiratory infection, and dependence on supplemental oxygen, had an active order for oxygen therapy at 2 liters per minute (lpm) due to continuously low oxygen saturation. However, observations on two separate occasions revealed that the resident's oxygen was set at higher levels than prescribed, specifically at 4 lpm and 5 lpm. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the oxygen settings were not in accordance with the physician's order. The DON acknowledged that the oxygen should have been maintained at 2 lpm and that any changes to the oxygen settings should have been preceded by obtaining a new order from the doctor. The LVN was unaware of why the oxygen setting was increased, and the facility's Administrator emphasized the importance of following all orders and obtaining a new order if the resident's oxygen saturation levels were low.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident's condition before and after dialysis treatments, as well as maintain effective communication with the dialysis center. The facility's policy required licensed nurses to complete baseline information and pre- and post-dialysis sections of the Nurses Dialysis Communication Record, but these were often incomplete. For Resident #53, who had a history of end-stage renal disease and was dependent on dialysis, several Dialysis Assessment Records lacked critical information such as vascular access site assessments, pre-dialysis weight, and vital signs. The facility also failed to document significant incidents related to the resident's condition. For instance, after returning from dialysis, the resident experienced vomiting, and there was no documentation of this episode in the Dialysis Assessment Record. Additionally, the resident had multiple instances of low blood pressure following dialysis, which were not recorded in the assessment records. These omissions meant that the dialysis center was not informed of the resident's low blood pressure or the new medication order for Midodrine to manage this condition. Interviews with facility staff revealed a lack of communication and protocol adherence. A dialysis technician noted that the facility did not communicate important information, such as low blood pressure readings and medication changes, which could have influenced the dialysis treatment approach. The Director of Nursing and other staff acknowledged that the dialysis center should have been informed of the resident's nausea, vomiting, and low blood pressure to ensure appropriate care. The facility's failure to document and communicate these critical health changes contributed to the deficiency in providing safe and appropriate dialysis care for the resident.
Facility Imposed Charges for Staff Assistance to Outside Appointments
Penalty
Summary
The facility failed to ensure residents were free of imposed charges for services required to achieve their goals and needs safely. Specifically, the facility developed and implemented a policy to charge residents $25 if they required facility staff to accompany them to appointments outside of the facility. This policy was communicated to residents starting February 1, 2024, and had the potential to deter residents from attending necessary appointments due to the additional cost. Resident 1, who has multiple diagnoses including osteoarthritis of the hip, spondylosis, mood disorder, and anxiety, expressed concern about the charge and indicated she might avoid outside appointments because of it. During the investigation, it was confirmed that Resident 1 needed substantial assistance with transfers and used a wheelchair for mobility. The facility's Director of Nursing and Administrator both confirmed the implementation of the $25 charge for staff assistance during outside appointments. The facility's policy and notice letter regarding the escort service fee were reviewed, both indicating the new charge. This policy potentially imposed charges on residents for services that should be covered, thereby violating residents' rights and potentially impacting their access to necessary medical care.
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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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