Northgate Postacute Care
Inspection history, citations, penalties and survey trends for this long-term care facility in San Rafael, California.
- Location
- 40 Professional Center Parkway, San Rafael, California 94903
- CMS Provider Number
- 056430
- Inspections on file
- 26
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Northgate Postacute Care during CMS and state inspections, most recent first.
A resident with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, severe memory impairment, and need for assistance with personal care was not protected from misappropriation of property when a staff member allegedly used the resident’s bank card without authorization. An Ombudsman reported that the resident’s bank had linked the card to a staff member’s phone number and identified thousands of dollars in charges. A bank employee stated that a joint account holder raised concerns about money being taken and that an internal investigation showed fraudulent withdrawals over about a year, totaling more than $4,000. Law enforcement and facility leadership confirmed that the staff member’s phone number was connected to the resident’s card transactions and that approximately $27,571.49 was missing from the resident’s account.
Surveyors found that the facility failed to complete a required criminal background check for an employee with direct access to residents. The personnel file showed that the 7-year county review portion of the background screening was closed as incomplete after the screening agency did not receive needed information from the applicant, and there was no documentation that this issue was ever resolved. In interview, the Administrator acknowledged there was no evidence the background check had been completed, despite facility policies requiring thorough background screening and prohibiting employment of individuals with histories of abuse, neglect, mistreatment, or misappropriation of property.
The facility did not ensure an RN was present for at least eight hours on four days, with some days having no RN coverage at all. This lapse was confirmed by the DON and Administrator, and was not in accordance with facility policy for staffing to meet the needs of a medically fragile population.
A medication error rate of 5 percent or greater was identified, indicating that the facility did not maintain medication administration accuracy within regulatory limits.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, resulting in a deficiency related to food safety and handling.
Three resident bathrooms were found in disrepair, including a scratched toilet seat, a corroded door frame with exposed debris, and a separated baseboard with rust and wall discoloration. The DON acknowledged these issues during surveyor observations, confirming they did not meet facility standards for cleanliness and maintenance.
A LVN provided wound care to a resident with a skin tear, including the application of calcium alginate and A&D ointment, without obtaining a physician's order as required by facility policy. The absence of an active wound care order was confirmed through record review, and staff interviews indicated that the expected protocol was not followed.
A resident receiving hospice care for a dislocated hip prosthesis and Huntington's disease did not have updated wound care orders or care plans in the hospice binder. The hospice RN and DON confirmed the oversight, resulting in a lack of coordinated care and incomplete documentation as required by facility policy and hospice contract.
The facility did not complete required annual performance evaluations for two CNAs, as confirmed by record review and staff interviews. The Director of Staff Development and DON both acknowledged that these evaluations were missing, despite facility policy mandating annual reviews for all employees.
Surveyors found that used fentanyl patches were improperly stored in a medication cart by an LVN instead of being immediately disposed of according to facility policy. The DON confirmed that the patches should have been brought directly for proper disposal, and the pharmacist stated that patches must be rendered non-retrievable to prevent misuse.
A medication cart was left unlocked and unattended by an LVN, and an open bottle of Senna syrup without an expiration date or original packaging was found in a medication cart. Both issues were confirmed by the DON and pharmacist as not meeting facility policy, which requires medication carts to be locked when not in use and medications to be stored in their original packaging with expiration dates.
Garbage and refuse were not properly disposed of, with overflowing dumpsters left open and trash bags and boxes observed on the ground. The Certified Dietary Manager confirmed that this practice was unacceptable and contrary to facility policy, which requires sealed containers and closed lids to prevent pest attraction.
A hospice RN left a resident exposed from the waist down and visible to the public for over 20 minutes while delaying a wound change, and also exhibited unprofessional behavior by crying and yelling in the resident's presence, causing distress. The DON confirmed these actions did not meet professional standards or facility policy for maintaining resident dignity.
A resident with multiple open wounds, including a traumatic amputation and a sacral wound, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. PPE and EBP signage were not present outside the room, and both the IP and DON confirmed the oversight during interviews.
A broken, rust-covered laundry machine and a resident's bed with non-functioning locks were not promptly repaired or maintained, resulting in delays in laundry services and potential safety concerns. Staff and department heads confirmed the lack of regular maintenance and the importance of keeping equipment, such as laundry machines and bed locks, in safe working order, especially for residents with significant medical histories.
A handrail in the east wing hallway was observed to have a crack and was not firmly secured to the wall. Upon inspection by the MDR, the handrail separated from the wall, confirming it was unstable. Facility policy requires the maintenance department to keep equipment safe and operable at all times.
A resident was not given advanced written notice of two daily rate increases or a required security deposit, as required by facility policy. The resident and her representative did not receive an admission agreement or documentation of these financial changes, and billing statements lacked itemization for the security deposit. Staff interviews confirmed that notifications were not provided in writing and that required documentation was missing, resulting in financial hardship for the resident.
The facility did not maintain signed admission agreements for three residents and failed to provide a copy of the agreement to a resident who was cognitively intact and experiencing billing confusion. Admission agreements for two residents were signed long after admission, and one resident's agreement was missing entirely, contrary to facility policy requiring signed agreements and copies for all residents.
The facility failed to properly investigate and address allegations of misappropriation of property involving two residents, who reported missing debit cards and unauthorized transactions. The investigation was incomplete, lacking interviews with key staff, and the facility did not implement protective measures for other residents. Additionally, the facility failed to maintain a theft and loss log and did not incorporate these incidents into their QAPI program.
A resident with hemiplegia and hemiparesis following a cerebral infarction did not receive timely physician visits as required by the facility's policy. Despite the resident's MDS score indicating no cognitive impairment, there was no documented evidence of physician or nurse practitioner visits for several months. The resident reported not having a physician for a period, and the facility's Administrator confirmed the lack of documentation, potentially delaying necessary care.
The facility failed to maintain documentation and present evidence of its ongoing QAPI program. Unlicensed staff were unaware of the Quality Committee or QAPI projects. The Administrator could not initially find the QAPI binder, which later revealed only outdated documentation. The Director of Nursing mentioned a pest control project, but documentation was incomplete. The facility did not provide requested QAPI policies, attendance sheets, minutes, or agendas.
The facility failed to control a cockroach infestation in the kitchen and resident rooms, with live and dead roaches observed in food preparation areas and around residents' beds. Despite pest control measures, recommendations were not followed, and gaps in infrastructure allowed pest entry. Two residents were directly affected, with one refusing facility food after finding a roach on her meal plate and in her CPAP machine. The issue had been ongoing for about a year, with inadequate responses to pest control recommendations.
A resident with generalized anxiety disorder was not invited to participate in quarterly care conferences for 12 months. Despite the DON's recollection of the resident attending a meeting, there was no evidence in the clinical records to confirm the resident's participation or invitation to the conferences.
A facility failed to ensure a resident with generalized anxiety disorder was seen by a physician every 60 days. The resident's clinical record showed only two physician progress notes in the past year, and the DON could not provide evidence of regular visits or documented refusals. The resident confirmed not receiving regular physician visits.
Misappropriation of Resident Funds by Facility Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a staff member made unauthorized charges to the resident’s bank card. The resident was admitted with major depressive disorder, mild neurocognitive disorder with behavioral disturbance, anxiety disorder, and a need for assistance with personal care. An MDS assessment indicated the resident had severe memory impairment and was only oriented to self. An Ombudsman reported to the DON that the resident’s bank had identified the resident’s bank card as being connected to a phone number belonging to a facility employee (Staff 1), with charges greater than $4,000. The facility’s abuse and neglect prohibition policy stated that misappropriation of property for all residents is prohibited. A police report documented that between mid-January and early November, the resident’s debit card had been fraudulently used by an employee of the facility, and the bank had accounted for approximately $27,571.49 missing from the resident’s account. In interviews, the Administrator and DON confirmed that Staff 1’s phone number was connected to the charges on the resident’s credit card, and the Administrator acknowledged that Staff 1’s employment had been separated based on this incident. A bank employee reported that a joint account holder had contacted the bank about money being taken from the resident’s account and that the bank’s investigation showed the fraud had been occurring for about a year and exceeded $4,000. A police officer stated that Staff 1 was definitely involved in the misappropriation of the resident’s property and confirmed the amount of the charges as $27,571.49, with the investigation ongoing.
Incomplete Criminal Background Screening for Direct-Care Employee
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough criminal background screening for an employee, identified as Staff 1, prior to or during employment. Record review showed that Staff 1’s criminal background check results indicated the 7-year county review “need attention” and that the service was closed as incomplete because the screening agency attempted to obtain information from the applicant/client but did not receive the needed information. Despite this notation, there was no further documentation in Staff 1’s personnel file showing that the incomplete background check was ever resolved or completed. During an interview, the Administrator stated that he would not have moved an applicant forward until the background check matter had been satisfied, yet he confirmed there was no documentation in Staff 1’s file indicating completion of the background check. The facility’s Abuse and Neglect Prohibition Policy requires screening of potential hires for a history of abuse, neglect, mistreatment, or misappropriation of property and prohibits employment of individuals found guilty by a court of law of such conduct. The facility’s Background Screening Investigations policy further requires employment background screening, reference checks, and criminal investigation checks on all applicants with direct access to residents, and states that applicants with convictions for abuse, neglect, mistreatment, or misappropriation of property are not to be employed. The incomplete and unresolved background check for Staff 1 was inconsistent with these written policies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for at least eight hours a day on four separate days in July 2025, as confirmed by review of the RN time sheet and interviews with the Director of Nursing (DON) and the Administrator. Specifically, on July 6 and July 20, the RN coverage was less than eight hours, and on July 12 and July 13, there was no RN present at all. The DON confirmed that neither she nor the MDS RN worked on those weekends and was unaware of the missed coverage. The facility's policy requires adequate RN staffing to meet residents' needs, but this was not met for a medically fragile population of 48 residents during the identified days.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and review of medication administration practices, which revealed that the error rate exceeded the regulatory threshold.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling protocols. The report does not provide specific details about the individuals involved or the exact nature of the food procurement or handling issues observed.
Failure to Maintain Resident Bathrooms in Safe and Homelike Condition
Penalty
Summary
Surveyors observed that three out of thirteen resident bathrooms were not properly maintained, resulting in conditions that did not meet standards for a safe, clean, and homelike environment. During observations with the DON, one shared bathroom had a toilet seat with numerous scratches, which the DON acknowledged was abnormal and required replacement. Another shared bathroom had a door frame that was corroded at the baseboard, exposing a large black hole filled with debris, which the DON stated needed immediate repair. In a third shared bathroom, the baseboard was separated from the wall, exposing rust on the toilet plumbing and discoloration on the wall, with the DON noting the baseboard needed to be reattached. Review of facility policies confirmed requirements for maintaining cleanliness and repair of interior areas, which were not met in these instances.
Wound Care Provided Without Physician Order
Penalty
Summary
A Licensed Vocational Nurse (LVN) provided wound care to a resident without a physician's order. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and sepsis, was observed with a skin tear on her left hand. The LVN removed the resident's bandage, cleansed the wound, applied A&D ointment, placed a calcium alginate dressing, and covered it with an island dressing. Review of the Treatment Administration Record (TAR) confirmed there was no active wound care order for this resident at the time of the treatment. During interviews, the LVN acknowledged that a physician should have been contacted to obtain a new wound care order before providing treatment. The Director of Nursing (DON) confirmed that staff are expected to update the physician and obtain appropriate orders for wound care. The facility's wound care policy also requires verification of a physician's order prior to performing wound care procedures. The pharmacist noted that improper use of calcium alginate could delay wound healing.
Failure to Ensure Collaborative Hospice Care and Updated Care Plans
Penalty
Summary
The facility failed to ensure collaborative care with the contracted hospice agency for a resident who was admitted with a dislocated internal left hip prosthesis and Huntington's disease. During an observation and interview, the hospice registered nurse case manager was found without the necessary wound care orders and had not updated the hospice binder with the resident's wound care plans. The director of nursing confirmed that there were no wound orders or care plans for the resident in the hospice binder, which was an oversight and impacted the resident's comfort of care. Further review of facility policies and the hospice contract revealed that hospice providers are required to maintain updated and coordinated care plans, including the most recent hospice plan of care and all relevant physician orders. The facility is responsible for ensuring collaboration and that the hospice agency's nursing care plan is included in the resident's record. In this case, the lack of updated documentation and care plans in the hospice binder led to a breakdown in communication and coordination of care for the resident.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two certified nursing assistants (CNAs), as required by its policy. During interviews and record reviews with the Director of Staff Development, it was found that neither CNA had a documented annual performance evaluation for the 2024/2025 period. The Director of Staff Development confirmed that these evaluations should have been completed. Additionally, the Director of Nursing was unaware that multiple staff members were missing evaluations and acknowledged that annual evaluations were necessary. The facility's policy, dated January 2018, specifies that performance evaluations must be conducted at the end of the 90-day probationary period and at least annually thereafter, with completed evaluations to be filed in the employee's personnel record.
Improper Disposal of Used Fentanyl Patches
Penalty
Summary
The facility failed to properly dispose of used fentanyl patches, a potent opioid medication, as observed during a survey. Nine opened and used fentanyl patches were found stored in a plastic cup inside a medication cart by an LVN, who stated that the patches were awaiting disposal by the DON. The DON confirmed that used fentanyl patches should not have been stored in the medication cart and should have been brought directly to the DON for proper disposal. The facility pharmacist explained that used fentanyl patches should be cut up and placed into a disposal bin containing liquid to ensure they cannot be reused, noting that residual medication on the patches could be dangerous if touched. Review of the facility's policy indicated that destruction of controlled substances must render them non-retrievable, permanently altering their properties so they cannot be used or diverted.
Unattended Unlocked Medication Cart and Improper Medication Labeling
Penalty
Summary
A medication cart was observed left unlocked and unattended in the hallway by an LVN, who walked away into a resident's room, leaving the cart accessible. The LVN later confirmed that the cart was left unlocked and unattended, acknowledging this was a mistake. The facility's policy and procedure require that medication carts be locked when not in use to prevent unauthorized access, and the DON confirmed that carts should always be locked when unattended. Additionally, an open bottle of Senna syrup was found in a medication cart without an expiration date and not in its original packaging. The LVN present stated that the Senna syrup needed to be discarded due to the missing expiration date and lack of original packaging. The DON and the facility's pharmacist both confirmed that medications should be kept in their original packaging with the expiration date visible, and the facility's policy supports this requirement.
Improper Disposal and Storage of Garbage
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations in the garbage storage area where a trash dumpster was found with both lids unsecured and open due to overflowing garbage. Multiple bags and boxes of trash were also seen on the ground in the same area. During an interview, the Certified Dietary Manager acknowledged that leaving trash unsecured and on the ground was unacceptable because it attracts pests and rodents. A review of the facility's policy and procedure on garbage and trash indicated that all food waste must be placed in sealed, leak-proof, non-absorbent, tightly closed containers and disposed of as necessary to prevent nuisance or unsightliness, with no debris on the ground and lids closed. These requirements were not met during the observation.
Failure to Ensure Resident Dignity and Professional Conduct During Hospice Care
Penalty
Summary
A deficiency occurred when a hospice registered nurse (HRN) failed to maintain a resident's dignity and privacy during care. The resident, who had a dislocated internal left hip prosthesis and Huntington's disease, was left exposed from the waist down and visible to the public for approximately 22 minutes while waiting for a wound change. The HRN was present in the room but did not begin the procedure, and the Director of Nursing (DON) confirmed the resident remained unclothed during this period, which was not in accordance with the facility's policy on accommodating resident needs and maintaining dignity. Additionally, the HRN displayed unprofessional conduct by crying and yelling unprovoked in the resident's room, causing the resident to appear confused and scared. The DON intervened and asked the HRN to leave the room, later confirming that the HRN's behavior was unprofessional and made the resident feel scared. The facility's policies and hospice contract require contracted hospice providers to meet professional standards and ensure resident dignity, which was not upheld in these instances.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
A deficiency occurred when the facility failed to identify the need to place a resident with multiple open wounds on Enhanced Barrier Precautions (EBP), an infection control strategy designed to prevent the spread of multidrug-resistant organisms (MDROs). The resident, who was admitted with a complete traumatic amputation of the left midfoot, had an open wound on the left foot with moderate serosanguineous drainage and a sacral wound with light serosanguineous drainage. During observation, there was no personal protective equipment (PPE) or EBP signage posted outside the resident's room, despite the resident receiving wound care for both the left foot and buttocks. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the resident was not on EBP, even though facility policy required EBP for residents with wounds. The DON stated she was unaware that the resident was not on EBP and acknowledged that the resident should have been placed on these precautions due to the presence of wounds. Review of the facility's policy indicated that PPE should be available outside the resident's room and clear signage should be posted, neither of which was observed during the survey.
Failure to Maintain Safe and Operable Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition, as evidenced by two specific deficiencies. In the laundry room, one of the laundry machines was observed to be broken and covered in rust. The Maintenance Director (MDR) confirmed the machine was not functioning and acknowledged that maintenance was only performed when equipment was already malfunctioning, rather than on a regular schedule. The Housekeeping Staff stated that the broken machine had been out of service for an extended period, causing delays in the laundry process for residents. Additionally, the MDR was unable to locate the laundry machine manual, which was noted as important for troubleshooting. In a resident's room, Certified Nursing Assistants (CNAs) were unable to lock the bed due to malfunctioning bed locks. The MDR and the Director of Nursing (DON) both confirmed that the bed locks were not working and emphasized the importance of functioning bed locks to prevent falls and injuries. The resident involved had a history of left hip prosthesis dislocation, Huntington's disease, and a previous fall from a chair. Review of the facility's maintenance policy indicated that the maintenance department was responsible for ensuring all equipment was kept in a safe and operable manner at all times, including providing regularly scheduled maintenance.
Unsecured Handrail in Hallway
Penalty
Summary
During an observation in the east wing hallway, a handrail located between two rooms was found to have a crack along its seam and was not firmly secured to the wall. When the Maintenance Director inspected the handrail, it separated from the wall upon being tugged, confirming it was not properly attached. The Maintenance Director acknowledged that the handrail should have been secured and required reinforcement. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring that buildings, grounds, and equipment are maintained in a safe and operable manner at all times.
Failure to Provide Written Notice of Rate Increases and Security Deposit
Penalty
Summary
The facility failed to provide a resident with advanced written notice of increases in the daily room and board rate on two separate occasions, as well as failed to provide written notice or documentation regarding a required security deposit. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two rate increases—first from $412 to $525 per day, and then from $525 to $680 per day—without receiving the required 30-day written notice. The increases were communicated verbally, if at all, and there was no documentation to support that proper notification was given. Additionally, the resident was required to pay a security deposit without prior written notice or agreement, and the amount was not itemized or documented in billing statements or the admission agreement. The admission agreement for the resident was not completed at the time of admission and was only signed much later, with key financial sections such as the daily room rate and security deposit left blank or marked as not applicable. The resident and her power of attorney both confirmed that they did not receive an admission agreement or written notification of rate changes or deposit requirements. Billing records showed retroactive charges for the increased rates and a lack of itemization for the security deposit, further indicating a lack of transparency and proper communication regarding the resident's financial responsibilities. Interviews with facility staff, including the Medical Records Director, Accounts Receivable Director, Admissions Coordinator, and Administrator, revealed a lack of awareness and documentation regarding the notification process for rate increases and security deposits. Staff confirmed that written notice was not provided, and there was no documentation to show that the resident agreed to the new rates or the security deposit. Facility policies required written notification and itemized billing, but these procedures were not followed in this case, resulting in financial hardship for the resident.
Failure to Maintain and Provide Signed Admission Agreements
Penalty
Summary
The facility failed to maintain signed admission agreements for three out of five sampled residents and did not provide a copy of the admission agreement to one resident. Specifically, one resident, who was cognitively intact with a BIMS score of 13, reported not receiving information about a required security deposit and was unable to reference the terms of her admission, including the daily room rate and security deposit amount. The resident experienced confusion and difficulty regarding billing, as she was asked to pay a security deposit after being in the facility for over a year and did not receive clear answers from staff. Record reviews and staff interviews confirmed that admission agreements for two residents were signed years after their initial admissions, only after an audit was prompted by a surveyor's request. Additionally, the facility could not produce an admission agreement for a third resident, and the Admissions Coordinator acknowledged that copies of agreements were not consistently provided or documented as offered. Facility policy required a signed admission and financial agreement for every resident, with a copy to be given to the resident and another kept in permanent records, but this procedure was not followed.
Failure to Investigate and Prevent Misappropriation of Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of property involving two residents who reported missing debit cards and unauthorized transactions. The investigation conducted by the Administrator was incomplete, as it lacked interviews with key staff members, including the alleged perpetrator, the Social Services Director. The facility's policy required comprehensive interviews with all relevant staff, but this was not adhered to, resulting in an inadequate investigation process. Additionally, the facility did not implement measures to protect other residents from potential theft. The inventory of personal effects for the residents was not properly itemized, which is crucial for tracking and safeguarding residents' belongings. Despite an in-service training conducted to address this issue, the inventory process remained insufficient, as evidenced by another resident's inventory lacking detailed documentation of wallet contents. The facility also failed to maintain a theft and loss log for the past 12 months, which is a requirement according to their policy. This log is essential for tracking incidents and ensuring accountability. Furthermore, the incidents of misappropriation were not incorporated into the facility's Quality Assurance and Performance Improvement (QAPI) program, as they were not discussed in recent QAPI committee meetings. This omission indicates a lack of systematic review and improvement efforts regarding theft and loss prevention within the facility.
Failure to Ensure Timely Physician Visits for a Resident
Penalty
Summary
The facility failed to ensure timely physician visits for a resident diagnosed with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was admitted to the facility with these conditions, had a Minimum Data Set (MDS) score indicating no cognitive impairment. Despite the facility's policy requiring physician visits upon admission and every 30 days for the first 90 days, followed by at least once every 60 days thereafter, there was no documented evidence of physician or nurse practitioner visits for the resident during the months of August, September, October, and November of 2024. During interviews, the resident expressed that there was a period when she did not have a physician and had gone a long time without seeing one. The facility's Administrator confirmed the expectation for physician visits but acknowledged the lack of documentation for the specified months. This oversight had the potential to delay the detection of declining health and the provision of necessary care for the resident.
Failure to Maintain QAPI Documentation and Awareness
Penalty
Summary
The facility failed to maintain documentation and present evidence of its ongoing Quality Assessment and Performance Improvement (QAPI) program implementation and activities. During interviews, multiple unlicensed staff members were unaware of the Quality Committee or QAPI, and they did not know of any current quality improvement projects. The Administrator was unable to locate the QAPI binder initially and later provided one that only contained documentation from December 2024. She admitted to not knowing the current QAPI status or any performance improvement projects the facility was working on. The Director of Nursing stated that the QAPI Committee met monthly and at least quarterly, mentioning a project related to pests in the kitchen. However, a review of the facility's Quality Assessment and Assurance Committee Quality Assurance Performance Improvement Plan indicated incomplete documentation for a pest control plan dated December 3, 2024, with no data collection or results. The facility failed to provide requested policy and procedures for QAPI, attendance sheets, minutes, and agendas by the end of the survey.
Cockroach Infestation in Facility Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of cockroaches in both the kitchen and resident areas. Observations revealed live and dead cockroaches in the pantry and food preparation areas, with gaps and damages in the kitchen infrastructure that allowed pest entry. Food particles and uncovered garbage were also noted, contributing to the pest problem. Despite the presence of insect bait traps, the pest control measures were inadequate, and recommendations from pest service reports were not followed. Two residents were directly affected by the infestation, with cockroaches observed in and around their beds. One resident reported finding a cockroach on her meal plate, leading her to refuse facility-prepared food. The resident also discovered roaches inside her CPAP machine, which was confirmed by staff observations. The facility's administrator was unaware of the pest issues until a grievance was filed, and a log for pest sightings was initiated but remained blank. Interviews with staff and the pest control technician revealed that the roach infestation had been ongoing for about a year. The technician noted that the facility had not implemented his recommendations for repairs and cleaning. The Environmental Health Services conducted an inspection in response to the complaint, and the facility's policy on pest control was found to be ineffective in preventing the infestation.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to ensure that Resident 1 was invited to participate in quarterly care conferences, which are interdisciplinary meetings to review and revise residents' care plans. Resident 1, who was admitted with a primary diagnosis of generalized anxiety disorder, was not invited to participate in these meetings for the past 12 months. This was confirmed through a review of Resident 1's clinical records and interviews with both Resident 1 and the Director of Nursing (DON). Despite the DON's claim of having seen Resident 1 in one of the care conferences, there was no documentary evidence to support that Resident 1 was invited or attended any of the care conferences held on 3/14/23, 6/15/23, 9/14/23, 12/14/23, and 3/6/24.
Failure to Ensure Regular Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least every 60 days, as required. The resident, who was admitted with a primary diagnosis of generalized anxiety disorder, had only two physician progress notes documented in the past 12 months. During a review of the resident's clinical record, the Director of Nursing (DON) was unable to provide evidence of regular physician visits, offering only three additional progress notes over the same period. The DON claimed that the resident refused physician visits but could not provide documentation to support this claim. In an interview, the resident confirmed not receiving regular physician visits and could not recall the last time they were seen by a physician at the facility.
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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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