Oak Grove Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 4545 Shelley Court, Stockton, California 95207
- CMS Provider Number
- 055201
- Inspections on file
- 87
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 68
Citation history
Health deficiencies cited at Oak Grove Post Acute during CMS and state inspections, most recent first.
Two residents with anxiety disorders and identified elopement risk, including one with multiple sclerosis and exit-seeking behavior, had physician orders and care plan interventions for wander guard devices that were not followed. Both residents were observed without wander guards in place, which was confirmed by the ADON, and staff could not explain when or why one device had been removed. MAR reviews showed that required checks of wander guard placement and function were not consistently documented on multiple day shifts, despite facility policy requiring application, continuous use, and routine checking of wander guards for residents at risk for elopement.
Kitchen walls, ceiling areas, and floor tiles were damaged, and multiple food-service items were worn or damaged, including a can opener, a gouged cutting board, and pitted fry pans. Food was also found exposed to air in the freezer and refrigerator. In addition, a resident refrigerator had repeated temperatures above the safe range without documented intervention, and another resident refrigerator had ice buildup in the freezer compartment.
Dumpster Lid Not Fully Closed: One of two outdoor garbage dumpsters was observed not fully closed, with a two-inch gap between the lids. The DM stated the opening would allow pests to get inside the dumpster. Facility policy required external receptacles to be covered when not in use, and the US Food Code states outside receptacles must have tight-fitting lids or covers.
A resident with CKD and dependence on HD had repeated nursing documentation of a negative AV fistula thrill and bruit, but the DON verified there was no change-of-condition assessment or MD notification. Another resident was observed on oxygen via NC even though the order summary had no oxygen order, and the ADON confirmed the care plan was not followed. Two residents with activity care plans for 1 to 1 room visits did not receive the planned visits, and a resident on EBP for a PICC line had no EBP care plan; the IP and DON both confirmed the missing plan.
An LPN obtained FSBS samples from three residents with diabetes without discarding the first drop of blood after alcohol cleansing, despite the facility procedure requiring the first drop to be discarded. In a separate event, an LPN prepared multiple crushed and liquid meds for a resident with a GT, left the meds unattended on the bedside table, and administered GT meds without checking tube placement or residual as ordered. The DON and IP confirmed the expected practices during interview, and the resident had dysphagia, a stroke history, and severe cognitive impairment.
Two residents had long fingernails and were not documented as receiving routine nail care as part of ADL assistance. A CNA confirmed one resident’s nails should have been trimmed and that the resident could scratch herself, while another CNA confirmed a second resident’s nails were long and should have been trimmed. Record review showed both residents needed help with personal hygiene and other ADLs, and staff stated there was no documentation that nail care had been provided recently.
Medication storage practices were not maintained in the North and South medication rooms. Expired IV antibiotic bags were kept with active meds, a CS staff member was found alone in a med room, and the South med room stored enteral feedings, overflow meds, and e-kits without a daily temp log. An opened e-kit was not replaced within the required timeframe, the med refrigerator had frost buildup and out-of-range temps, two medication bottles lacked readable labels, one label was handwritten, and the pharmaceutical waste container was unsecured with recognizable discarded meds.
A facility failed to follow infection control practices for multiple residents. A resident with COPD had oxygen tubing found on the floor, disconnected from the concentrator, and undated. A nurse used the same glucometer for three residents with DM and did not disinfect it according to policy between uses. The facility also did not have EBP in place for two residents who had orders for gown and glove use, and staff confirmed missing signs, PPE supplies, and precaution indicators.
A resident with schizophrenia, major depressive disorder, and severe cognitive impairment received multiple psychotropic medications, including an antidepressant, mood stabilizer, anticonvulsant used as a mood stabilizer, and antipsychotics, before the prescribing practitioner’s consent process was confirmed with the resident’s conservator. The MAR and provider notes showed the medications were administered without documented informed consent, and staff interviews confirmed that consent was required before administration.
A facility failed to keep call lights within reach for two residents. One resident with multiple chronic conditions, including hepatic failure and osteoarthritis, was found in bed with the call light on the floor while stating he was thirsty. Another resident with heart failure, weakness, and hemiplegia was also found in bed with the call light on the floor under the bed and said she could not find it. Staff confirmed the call lights were not within reach, despite care plans directing that they be kept accessible.
A facility failed to maintain a calm, homelike environment when one resident with schizophrenia repeatedly yelled, laughed loudly, slammed doors, and threw items, disrupting nearby residents’ sleep and causing staff to move another resident out of his room. The survey also found broken drawers in three residents’ rooms, including missing drawer faces and drawers that would not close properly, with staff and the DON acknowledging the condition was not appropriate for resident rooms.
A resident with an above-knee amputation, muscle weakness, and moderate cognitive impairment was verbally abused by a contracted housekeeper while the resident was wheeling through an area being mopped. CNA and LPN witnesses reported profanity, derogatory language, and a threatening statement about beating residents, and the resident record identified the event as staff-to-resident abuse.
A resident with HTN, CKD, and dependence on renal dialysis had repeated nursing documentation of negative thrill and bruit, showing the AV fistula was not properly functioning. The DON verified that no change-of-condition assessment was completed and the MD was not notified, despite the expectation that licensed nursing staff report the change; the DON stated this placed the resident at risk of missing HD as scheduled.
Failure to Provide Required One-to-One Activities: Two residents with care plans for one-to-one room visits and activities did not receive the planned activity support when they were unable to attend group events. One resident with TBI, schizophrenia, and insomnia had no one-to-one activities during a documented week, and another resident with failure to thrive, delusional disorder, and insomnia reported that her visits had stopped and she felt sad because she was bedbound. The ADA verified the missed activity participation in the record.
A resident with traumatic brain injury, schizophrenia, and insomnia was observed receiving oxygen via nasal cannula even though the order summary showed no physician order for oxygen. The ADON confirmed the oxygen was being given without an order and stated an order should have been in place so nursing staff could monitor its use.
Failure to notify the physician when a resident’s AV fistula was negative for thrill and bruit. A resident with HTN, CKD, and dependence on renal dialysis had repeated nursing documentation showing no thrill or bruit at the fistula site, but no change-of-condition assessment was completed and the physician was not notified. The DON confirmed this was contrary to expected nursing practice and the facility’s dialysis care policy.
Non-controlled medication destruction records were not co-signed by licensed nurses in 29 out of 29 pages reviewed in a medication room. LN 10 confirmed the missing signatures, and the DON stated that 2 nurses should sign the records to witness destruction. The facility policy required non-controlled medication destruction to occur in the presence of 2 licensed nurses with witness signatures entered on the medication disposition form.
A nurse administered HumaLOG to a resident with DM2 using an insulin pen that actually belonged to another resident. The nurse verified the resident’s FSBS and gave the ordered dose, but the pen label showed a different resident and a different insulin order. The nurse, Pharmacy Consultant, and DON all acknowledged the pen did not match the resident, and facility policy required verification of the correct resident, medication, and dose before administration.
Failure to Provide Recommended Pneumococcal and Influenza Vaccinations: A resident admitted with Myasthenia Gravis, moderate persistent asthma, and muscle weakness did not receive the pneumococcal or flu vaccine. The IP confirmed both vaccines were not given and stated she tried to contact the Responsible Party for consent but did not follow up. The DON stated residents are expected to receive recommended vaccines promptly after admission, and facility policy required residents to be assessed and offered these vaccines.
Failure to Provide COVID-19 Vaccination: A resident with Myasthenia Gravis, asthma, and muscle weakness did not receive the COVID-19 vaccine, and the immunization record showed no documentation of vaccination. The IP confirmed the vaccine was not given and stated she tried to contact the Responsible Party for consent but did not follow up, while the DON stated residents were expected to receive recommended vaccines promptly after admission.
Failure to honor a resident's choice regarding room deep cleaning. A resident with functional quadriplegia and intact cognition requested a schedule for terminal cleaning and limited which HSK staff could enter the room. Despite being told to have no direct contact and to stay out of the room, an HSK employee entered anyway to discuss changing the cleaning schedule, and the resident became upset and felt harassed.
The facility failed to report an allegation of staff-to-resident abuse within the required two-hour timeframe. A resident with muscle weakness and osteoporosis was the subject of a suspected abuse report that was dated on one day but not faxed to the state agency until several days later, and the Ombudsman did not receive it until an additional delay. The DON confirmed there was no fax confirmation of timely reporting and acknowledged that, according to facility policy, the SOC 341 form should have been completed and faxed to the Department and Ombudsman within two hours of the allegation.
The facility failed to ensure that a CNA had the required orientation, competency validation, and personnel documentation before and during providing care. The AP/PR coordinator confirmed there was no employee file for this CNA, despite facility policy requiring on-site personnel records with hiring documents, licenses/certifications, orientation checklists, and competency records. The DSD stated that staff competencies are kept in employee files and that, without these records, she could not verify whether staff had the skills to care for residents. The CNA reported working for 10 months without receiving facility orientation, watching training videos, or taking required tests, while other CNAs hired later did receive training. The report states that this failure placed residents at risk of receiving care from staff who did not meet required competencies.
The facility failed to follow its own TB screening policy by allowing a nursing assistant to be hired and begin orientation without documented baseline TB testing or symptom evaluation. Review of the personnel file with the Payroll Coordinator showed no initial TB test result, despite a policy requiring all employees to be screened for latent TB infection and active TB disease before employment. The IP confirmed the absence of an initial TB test in the record and emphasized the importance of TB testing due to immunocompromised residents, while the DON stated that staff were expected to have TB screening completed before orientation and resident care.
Surveyors found that a resident with severe cognitive impairment and ADL deficits lacked documented evidence of required ADL care, including turning/repositioning, ROM, mouth care, personal hygiene, and toileting on multiple shifts. A resident with a stage 3 coccyx pressure ulcer had an order for Medihoney and dry dressing three times weekly, but was observed without a dressing, and the TAR showed missing nurse initials on several ordered treatment days. Another resident with multiple stage 4 and unstageable pressure ulcers to the hip, shoulder, and trochanter had daily wound care orders for cleansing, silver alginate or Silvadene, and dry dressings, yet was observed with no dressings in place and had a missing treatment entry on the TAR, with the DON confirming that undocumented care was considered not done.
Surveyors found that the facility failed to maintain a clean, sanitary kitchen and food storage area and did not act on repeated pest control recommendations. Pest control reports documented ongoing food debris on shelves, food particles and grease under ovens, tables, and equipment, and wet organic matter in floor cracks that were not corrected over several months. During inspection, surveyors observed food splatter, grease buildup, cobwebs with dead flies, dirty and dusty traps with dead insects, dirty floors with embedded food particles, and food items on the pantry floor. Interviews with the AKM, MTD, CDM, and ADM confirmed that weekly pest control reports were distributed, that the CDM was unaware of the recommendations, and that the kitchen conditions did not meet the facility’s stated expectations or policy for environmental cleanliness.
Two residents who required assistance with ADLs did not receive adequate hand and fingernail hygiene. One resident, dependent on staff for bathing and needing substantial help with personal hygiene, repeatedly requested nail trimming over several weeks but remained with long nails and brown debris under them. Another cognitively intact resident needing assistance with bathing and supervision for personal hygiene was observed with visibly dirty hands and long nails caked with brown and black material; he reported staff told him they were not allowed to cut his nails and that he could not get help. A CNA confirmed both residents’ poor nail condition, did not assist one resident with hand hygiene before a meal, and cited perceived restrictions on nail trimming, despite facility expectations and policies, an existing nail-care order for one resident, and no documented refusals of hand or nail care in the medical record.
A resident with hemiplegia, peripheral vascular disease, and a standing physician order for routine nail care had very long, sharp, discolored, and dirty toenails on one foot that had not been trimmed for several months, causing pain and preventing the use of a sock and shoe. The resident reported repeatedly requesting nail trimming and being told by CNAs and LNs that staff could not cut the toenails and that there would be a charge for the service. Staff interviews showed that LNs could trim toenails with a doctor’s order and that residents could be added to a monthly podiatry list, but the resident was not on that list, and there was no documentation of any refusals of care or nail care provided, contrary to facility ADL and nail care policies.
Surveyors found that the facility failed to maintain a sanitary dumpster area used by multiple departments. Trash, including used PPE, wipes, and a bag of residents’ personal refuse with soiled briefs, was observed scattered on the ground next to overfilled, open dumpsters. The IP confirmed that staff were expected to place trash in designated barrels and that CNAs and housekeepers should transport full barrels to the dumpsters, but trash was instead left on the ground. Dietary staff reported using outdoor bins and the main dumpster near the kitchen doors, and the DSM and Maintenance Director both acknowledged that all departments used the dumpsters and that lids should be kept closed, consistent with facility policies requiring closed, litter-free dumpsters and an IPCP to maintain a safe, sanitary environment.
Surveyors found an unattended, unlocked treatment cart in a hallway near resident rooms while multiple residents were present and moving about. The cart contained identifiable prescription creams, Betadine, gauze, bandages, and a nail clipper. An LN later locked the cart and acknowledged it had been left open, stating staff are required to keep it closed before and after each use and that it contained residents' medical information and medications. The DON confirmed that medication and treatment carts must always be locked and that leaving them open allows residents access to sterile solutions and medications, contrary to the facility’s Medication Labeling and Storage policy requiring all medications and biologics to be stored in locked compartments and carts not to be left unattended if open.
Two residents with a history of pressure injuries were found lying on low-air loss mattresses that were not set according to their current weights, as required by physician orders and manufacturer guidelines. Nursing staff and the DON confirmed that the mattresses were set at significantly higher weights than documented, and that staff did not monitor or adjust the settings as specified in the care plans.
A resident with multiple diagnoses, including stage 3 pressure ulcers and a history of skin breakdown, had an active order and was observed using a low air loss (LAL) mattress for skin management. However, review of care plans and staff interviews confirmed that the use of the LAL mattress was not documented in the care plan, despite facility policy requiring all interventions and physician orders to be included. The DON acknowledged that this omission did not meet facility policy for individualized, comprehensive care planning.
Two residents with histories of behavioral disturbances and psychiatric diagnoses were involved in separate altercations, resulting in one resident sustaining a mouth injury and another falling from a wheelchair. Despite physician orders for 1:1 supervision due to aggressive behaviors, staff failed to provide adequate oversight, allowing the incidents to occur. Facility policy required close monitoring and intervention for residents at risk of altercations, but these measures were not effectively implemented.
A resident was readmitted with new skin scrapes and a known scratching behavior, but staff did not initiate a comprehensive care plan to address these issues. Despite documentation of the skin problems and staff awareness of the scratching, only monitoring was ordered, and no interventions or behavior monitoring were implemented. Facility policy required care plans for new issues and behaviors, but this was not followed.
Two residents with complex medical needs had incomplete documentation in their Treatment Administration Records, with licensed nurses failing to record multiple treatment orders and wound care interventions as required. Staff interviews and record reviews confirmed that treatments were either not documented or only partially documented, contrary to facility policy requiring clear and accurate nursing documentation.
A resident receiving palliative care with multiple diagnoses, including dementia and legal blindness, did not receive a new routine morphine sulfate order for 35 days after the hospice agency communicated the change to the facility. Despite clear documentation and communication from hospice, the facility continued to administer only PRN pain medication, resulting in unmanaged pain and distress for the resident. Facility staff interviews confirmed a miscommunication led to the failure to implement the scheduled pain management.
A resident with multiple pressure ulcers and complex medical needs was found using a Low Air Loss (LAL) mattress without a physician's order or documented monitoring of the mattress's function and settings. Review of records and staff interviews confirmed the absence of required orders and monitoring, despite facility policy requiring documentation and review of support surfaces for pressure ulcer management.
A resident with a mental disorder, psychosocial adjustment difficulty, or a history of trauma and/or PTSD did not receive the necessary treatment and services tailored to their needs, resulting in a deficiency related to inadequate care and interventions.
A resident with a history of stroke, end stage renal disease, and aphasia was observed to have an enteral feeding bag and tubing that were not labeled with the date and time of use, resident name, or feeding solution. An LPN confirmed the omission, and the ADON stated that labeling is required by facility policy to ensure proper identification and timely changing of feeding bags.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with major depressive disorder and spinal stenosis was found to have splintered wood and protruding screws from a broken rail left on the wall near their bed. Both an LPN and a maintenance assistant confirmed the presence of these hazards, which were not removed or reported, contrary to facility policy requiring a safe environment.
A resident with a documented history of substance abuse was admitted without proper assessment or care planning for substance use, despite clear evidence in medical and social service records. The omission led to a lack of targeted interventions, and the resident later experienced a sudden health event requiring hospital transfer, where drug screening confirmed recent methamphetamine use.
Multiple residents experienced physical and verbal abuse from another resident with a known history of aggression, despite being placed on 1:1 supervision. Staff failed to maintain required supervision, allowing altercations to occur during group activities and in common areas. Documentation and staff interviews confirmed that lapses in supervision and failure to follow established protocols led to repeated incidents of abuse.
Two residents dependent on staff for ADLs were left in soiled briefs for extended periods, with one resident experiencing pain after being slapped on the leg by a CNA despite instructions not to touch her sore legs. These failures resulted in inadequate hygiene, potential for skin breakdown, and emotional distress, as confirmed by staff and care plan reviews.
An Activity Assistant provided cannabis products to two residents, both of whom had significant medical histories including hypertension, COPD, diabetes, history of falls, and heart failure. The residents reported the incident to staff, and urine tests confirmed cannabinoid use. Staff observed behavioral changes in one resident after consumption. The AA's actions violated facility policy prohibiting the distribution of illegal substances, and the facility acknowledged that this placed the residents' safety at risk.
Two residents with mental health and cognitive diagnoses were subjected to repeated physical and verbal abuse by another resident known for aggressive behavior, including water splashing, spitting, and unauthorized room entry. Despite staff awareness of the aggressor's history and resident reports of feeling unsafe, effective interventions such as one-to-one supervision were not implemented, resulting in ongoing incidents and compromised resident well-being.
A resident with PTSD and bipolar disorder did not receive a psychological evaluation as recommended by the IDT and requested by the resident after a physical altercation with another resident. Despite updates to the care plan and repeated reports of feeling unsafe, the evaluation was not initiated, as confirmed by facility staff.
A CNA tied the door of a room shared by two residents with a garbage bag, preventing one resident with dementia and anxiety from leaving due to agitation. The other resident, with congestive heart failure and chronic kidney disease, was also confined. Staff confirmed the incident, acknowledging it as abuse and involuntary seclusion, violating facility policies on resident rights and dignity.
The facility failed to maintain a sanitary and homelike environment in two shared bathrooms used by eleven residents. Observations revealed peeling paint, open gaps, missing baseboards, and chipped trim. Staff complaints about the conditions were not addressed, posing safety hazards and failing to provide a welcoming environment. The Maintenance Director and Administrator acknowledged the issues, which were not aligned with facility policies.
A facility failed to implement and revise a care plan for a resident with a history of falls and poor safety awareness. The care plan included interventions such as keeping the bed in the lowest position, ensuring the call light was within reach, and using bed rails. However, these interventions were not implemented, posing a potential safety risk. The ADON confirmed the necessity of these interventions and noted that the care plan should have been updated following a bed rail assessment.
Failure to Follow Wander Guard Orders and Monitoring for Elopement-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment free of hazards for residents at risk for elopement by not following physician orders and care plan interventions related to wander guard devices. Resident 1 was admitted with diagnoses including anxiety disorder and multiple sclerosis and had a physician order dated 4/9/2026 to check the wander guard for placement every shift, with a care plan focus identifying risk for wandering/elopement and an intervention specifying a wander guard to the right upper extremity. During observations on 4/22/2026, Resident 1 was seen at bedside without a wander guard, which was confirmed by LN 1 and the ADON; Resident 1 stated she did not know where the device was. The ADON stated that a wander guard was indicated for Resident 1 due to her behavior of trying to go out and her ability to propel her wheelchair, and that staff were expected to monitor the device’s placement and function. Resident 2 was admitted with an anxiety disorder and had physician orders dated 4/6/2026 to monitor the wander guard for functioning every shift and to monitor its placement daily every shift. Resident 2’s care plan identified a risk for elopement related to wandering, with an intervention to monitor function and placement of the wander guard daily every shift. On 4/22/2026, Resident 2 was observed without a wander guard, which the ADON confirmed; the ADON stated they did not know when the device had been removed. LN 1 reported not receiving any report from the night shift explaining why Resident 2’s wander guard was removed and stated he had just seen the device on the medication cart. LN 1 also stated that when a wander guard was missing or not functioning, the nurse needed to notify the DON for replacement, but he was unsure if another device was available for Resident 2. Record review further showed inconsistent documentation of wander guard monitoring for both residents. For Resident 1, review of the April 2026 MAR with the ADON showed that while the night shift documented a check of wander guard placement and function on 4/21/2026, the day shift did not document placement and function on April 11, 12, 15, 16, 17, and 18. For Resident 2, review of the April MAR showed that the night shift documented the wander guard as functioning on 4/21/2026, but the day shift left documentation of wander guard function blank on April 11, 12, 15, 16, and 17. The DON confirmed that Resident 1 had exit-seeking behavior, had tried to leave the facility to go to the store, had an order for a wander guard, and that nurses were responsible for checking placement and function every shift and informing her or a supervisor if a wander guard was missing or not functioning. Facility policies stated that wander guards are to be used for residents at risk for elopement, applied to the wrist or ankle and not removed until replacement is needed, checked daily on night shift, and that residents at risk for leaving without notice may require application of a wander guard as part of their care plan.
Food Storage, Equipment, and Refrigerator Temperature Deficiencies
Penalty
Summary
Food storage, preparation, and kitchen sanitation were not maintained in accordance with professional standards for the 102 residents who ate facility-prepared meals. During kitchen observations, the walls were noted to have chipped paint, the floor tiles near the refrigerators were broken with missing sections, and the ceiling drywall over the food preparation area had gouges, chipped and cracked paint, and stains around the ceiling vents. A white item, approximately 4 inches long, was hanging from the center kitchen vent. The Maintenance Director and Food Service Director both acknowledged the observed conditions, and the report cited the facility’s maintenance policy and FDA Food Code requirements for maintaining physical facilities in good repair and with smooth, easily cleanable surfaces. Food-contact equipment and surfaces were also observed in poor condition. A can opener had a discolored blade with a brownish worn area along the cutting surface, and the Food Service Director stated the blade needed to be replaced. A red cutting board used for beef preparation had deep gouges and was acknowledged as worn and needing replacement. Two fry pans had dark buildup and discoloration covering portions of the sides, and a saucepan stored in the cook’s preparation area had deep pitting in the metal. The Food Service Director stated the pans should not be used because the scratches could contain bacteria. The report cited FDA Food Code provisions requiring food-contact surfaces to be smooth, free of cracks, chips, pits, and similar imperfections. Food items were also found stored in a manner that left them exposed to air. A box of sausage patties in the freezer had its plastic covering left open, and a small steam table pan of rice in the reach-in refrigerator had foil with a punctured hole exposing the rice. The Food Service Director confirmed both observations and stated the rice should have been discarded. In addition, the resident refrigerator in the center nurse’s station had temperature logs showing readings from 38 degrees F to 48 degrees F, including 48 degrees F on multiple days and 42 degrees F on two other days, with no actions documented in response. The north nurse’s station refrigerator had ice buildup covering the freezer compartment. Staff stated that refrigerator issues were to be reported through the computer system to create a work order, and the Assistant DON stated that temperatures above the acceptable range could allow food to spoil and cause stomach issues. The report also cited the facility policy requiring daily monitoring of visitor food refrigerators and freezer temperatures and the FDA Food Code requirement for cold holding of TCS foods.
Dumpster Lid Not Fully Closed
Penalty
Summary
The facility failed to ensure that one of two outdoor garbage dumpsters was maintained with a lid that properly covered the contents. During an observation on 4/6/26 at 10:08 AM, two outdoor garbage dumpsters were seen, and one bin was noted to not be fully closed. During a later observation and interview on 4/8/26 at 4:27 PM with the Dietary Manager, the outdoor garbage dumpster was observed with an opening between the lids and was not tightly closed. A two-inch gap between the lids was observed, and the Dietary Manager stated that the opening would allow pests to get inside of the garbage dumpster. Review of the facility policy titled, Dispose of Garbage and Refuse, revised 2/25, indicated that all trash will be properly disposed of in external receptacles with lids covered when not in use. Review of the US Food Code 2022, section 501.116, stated that outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of garbage or refuse, the breeding of flies, or the entry of rodents.
Incomplete care planning and order follow-through for dialysis access, oxygen use, activities, and infection precautions
Penalty
Summary
Resident 1 had diagnoses including hypertension, chronic kidney disease, and dependence on renal dialysis. The resident’s AV fistula care plan dated 1/13/26 directed staff to monitor the skin condition around the catheter insertion site and report to the physician as indicated. During record review with the DON, the MAR for March 2026 showed licensed nursing staff documented the AV fistula as negative for thrill and bruit on 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31, and the DON verified that a change of condition assessment or physician notification was not done. Resident 15 had diagnoses including traumatic brain injury, schizophrenia, and insomnia. During observation, the resident was seen lying in bed with oxygen running through a nasal cannula. Review of the resident’s care plan showed an instruction to apply oxygen as ordered, but the order summary did not contain an oxygen order. The ADON verified that the resident was receiving oxygen despite the absence of an order and stated the care plan was not followed. Resident 15’s activity care plan directed 1 to 1 bedside or in-room visits and activities if the resident was unable to attend out-of-room events, and the participation record showed no one-to-one activities during the reviewed period. Resident 54 had diagnoses including adult failure to thrive, delusional disorders, and insomnia, and her activity care plan directed one-to-one room visits 1-3 times per week. The participation record showed no one-to-one visit or activity during the reviewed period, and the ADA confirmed the resident only participated in one-to-one activities. Resident 123 was admitted with sepsis, bacteremia, and Bell’s palsy, and the order listing included Enhanced Barrier Precautions for a PICC line. The IP confirmed there was no care plan for Enhanced Barrier Precautions for Resident 123.
Medication Administration Errors and Enteral Tube Procedure Failures
Penalty
Summary
The facility failed to provide appropriate care and services to three residents with diabetes during fingerstick blood sugar (FSBS) testing. Resident 92, Resident 107, and Resident 63 each had physician orders for blood sugar monitoring, and Licensed Nurse 4 obtained FSBS readings for all three residents during medication administration. In each instance, the nurse cleaned the fingertip with an alcohol pad, punctured the fingertip with a lancet, and collected the blood sample without wiping away the first drop of blood before using the sample for the glucometer reading. During interview, Licensed Nurse 4 stated the first blood drop should have been wiped off before collecting the sample and acknowledged that not doing so could result in an inaccurate reading. The Infection Preventionist also stated that the initial sample should be wiped away and that collecting the second drop would help ensure an uncontaminated sample and more accurate blood glucose readings. The facility procedure for obtaining a fingerstick glucose level stated to discard the first drop of blood if alcohol is used to clean the fingertip because alcohol may alter the results. The facility also failed during medication administration for Resident 95, who had diagnoses including dysphagia, cerebral infarction, and attention to gastrostomy, and whose MDS indicated severe problems with thinking and memory and that the resident had a feeding tube. Licensed Nurse 5 prepared multiple crushed tablets, liquid medications, and capsule contents into separate medicine cups, diluted the solid medications with water, and brought the cups into the resident's room. The nurse then left the room to get a towel and left the medications unattended on the bedside table. Licensed Nurse 5 later confirmed the medications were left unattended and stated they should not have been left there. For Resident 95, the nurse also administered GT medications without first checking GT placement and without checking residual, despite physician orders to check GT placement before giving medications, feedings, and flushes and to check residual before feeding. Licensed Nurse 5 stated she did not check placement by auscultation or residual before administration and acknowledged the resident was at risk for medications going to the wrong place and aspiration. The DON stated nurses needed to check GT placement before administration, and the facility policy for enteral tube medication administration addressed safe and effective administration of medications via enteral tubes.
Failure to Provide Nail Care as Part of ADL Assistance
Penalty
Summary
The facility failed to ensure two sampled residents were assisted with nail care as part of ADL support when both residents had long fingernails. During observation, one resident was seen with long fingernails and green substance underneath the nails, and a CNA confirmed the nails should have been trimmed short. The CNA also stated she had trimmed that resident’s fingernails in the past and that the resident could hurt herself by scratching with long fingernails. The second resident was observed with long fingernails and stated he wanted short fingernails. A CNA confirmed the nails were long and stated she did not know when they had last been trimmed. She stated the resident should have had his fingernails trimmed and could get skin tears by scratching himself with long fingernails. The resident’s record showed diagnoses including disorder of urea cycle metabolism, Todd’s paralysis, type 2 diabetes mellitus, hepatic failure, and osteoarthritis of both hands, and his care plan and MDS reflected substantial assistance needs with personal hygiene and other ADLs. Record review and staff interviews showed no documentation that either resident’s nails had been clipped short in the prior 30 days. Staff stated both CNAs and LNs were responsible for keeping fingernails trimmed and clean, and that nail care provided by CNA should be documented in the medical record. The facility’s policy stated nail care includes daily cleaning and regular trimming, and that trimmed and smooth nails prevent accidental scratching and injury.
Medication Storage and Security Deficiencies
Penalty
Summary
Safe medication storage practices were not maintained in the facility’s medication rooms and medication refrigerators. In the North station medication room, four expired IV antibiotic bags were stored in the medication refrigerator with active medications. Two bags had an expiration date of 3/23/26 and two had an expiration date of 3/29/26. The LN confirmed the resident for whom the IV antibiotics were prescribed was still a current resident, and stated the expired antibiotics should not have been kept with active medications and should have been discarded. In the North station medication room, a CS staff member was found alone in the medication room without a licensed nurse present. The CS staff stated he routinely entered the medication room by himself to replenish supplies and OTC medications and that he checked medication rooms twice a week. The LN confirmed he was alone, and the DON and ADON stated that only licensed nurses or authorized staff accompanied by licensed nursing staff should have access to medication rooms. In the South station medication room, multiple enteral feedings, active overflow medications, and five e-kits with red tags and one e-kit with a yellow tag were stored. The room temperature was 72 degrees Fahrenheit, and there was no daily temperature log to monitor the medication room. The e-kit with the yellow tag had been opened and an antibiotic removed on 3/28/26, and the ADON confirmed it was not replaced within 72 hours. The South medication refrigerator also had extensive frost buildup and recorded temperatures out of range on multiple days, and it stored two medication bottles without readable labels and one bottle with a handwritten label. The same room also contained a pharmaceutical waste container without a seal, with discarded medications that were recognizable and retrievable by hand.
Infection Control Measures Not Implemented for Oxygen Equipment, Glucometer Disinfection, and EBP
Penalty
Summary
The facility failed to implement infection prevention and control measures for multiple residents. Resident 50 had diagnoses including COPD and malignant neoplasm of the uterus, and the MDS showed a BIMS score of 9 out of 15. The resident had an active order for oxygen at 2 LPM via nasal cannula as needed for shortness of breath, and the care plan addressed impaired gas exchange related to COPD. During observation, the resident’s oxygen tubing was found on the floor, disconnected from the oxygen concentrator, and without a date indicating when it had been changed. The CNA confirmed the tubing belonged to the resident and stated it should not have been on the floor or disconnected. The ADON and IP both stated the tubing should not be on the floor and should be dated and stored in a plastic bag when not in use. The facility also failed to properly clean and disinfect a shared glucometer between uses for Resident 92, Resident 107, and Resident 63, all of whom had type 2 diabetes and orders for blood sugar monitoring. A nurse used the same glucometer for each resident in sequence. After each use, the nurse wiped the glucometer with one germicidal alcohol wipe and then laid the device on top of the wipe until the next use. The nurse stated he did not wrap the glucometer with the wipe as he described, and acknowledged the device was not cleaned properly and could still be contaminated. The IP stated the correct process was to clean all surfaces and then wrap the glucometer with a second wipe for 30 seconds to ensure proper disinfection. The facility policy and wipe instructions required the meter to remain visibly wet for one minute and to air dry. The facility also did not implement Enhanced Barrier Precautions for Resident 11 and Resident 123. Resident 11 had diagnoses including contact dermatitis, allergic rhinitis, and a stage 3 pressure ulcer to the coccyx, and the order and care plan indicated EBP. Staff observed that there was no yellow dot by the resident’s name outside the room, and CNA 6 stated he was not using EBP because the dot was absent. LN 7 confirmed the resident required EBP but there was no yellow dot, and the IP stated staff might not use PPE if the dot was missing. Resident 123 had diagnoses including sepsis, bacteremia, and Bell’s palsy, and had an order for EBP related to a PICC line. The resident stated staff were not using EBP PPE, and LN 1 confirmed there was no EBP sign, no PPE supplies outside the room, and no yellow dot by the resident’s name. The IP and DON both confirmed the resident should have had EBP in place.
Psychotropic Medications Given Without Confirmed Informed Consent
Penalty
Summary
The facility failed to ensure that Resident 8 was fully informed and understood the resident’s health status, care, and treatments when psychotropic medications were administered without confirmed informed consent from the prescribing practitioner and the resident’s conservator. Resident 8 was admitted with diagnoses including schizophrenia and major depressive disorder and was under conservatorship. The resident’s MDS showed a BIMS score of 3, indicating severe cognitive impairment. Resident 8’s medication orders included fluoxetine, lithium, oxcarbazepine, risperidone, and quetiapine. The record showed that consent for fluoxetine, lithium, risperidone, and quetiapine was not obtained from the conservator until after the medications had already been ordered and administered, and the facility did not confirm representative consent until later. There was no psychotropic medication administration disclosure form completed for oxcarbazepine 300 mg twice daily. The MAR showed that Resident 8 received fluoxetine, lithium, oxcarbazepine, risperidone, and quetiapine in March 2026 without informed consent, and lithium and oxcarbazepine continued into April 2026 without documented consent. Provider notes documented that the psychotropic medications were continued to treat schizophrenia and depression, but the notes did not show that informed consent had been obtained before administration. Staff interviews confirmed that informed consent was required before psychotropic medications were administered, and the DON acknowledged that Resident 8 received these medications without consent being obtained or confirmed.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate the needs of 2 sampled residents when their call lights were not within reach. Resident 85 was admitted with diagnoses including disorder of urea cycle metabolism, Todd's paralysis, type 2 diabetes mellitus, hepatic failure, and osteoarthritis of both hands. During observation, Resident 85 was lying in bed and stated he was thirsty, while his call light was found on the floor next to the bed. A CNA confirmed the call light was not within Resident 85's reach and stated it should have been within reach. Resident 96 was admitted with diagnoses including hypertensive heart disease with heart failure, muscle weakness, hemiplegia, and hemiparesis. During observation, Resident 96 was lying in bed and stated she could not find her call light, which was observed on the floor under the bed. An LN confirmed the call light was on the floor and placed it next to Resident 96. Both residents had care plans directing staff to keep the call light within reach, and facility staff stated residents should have their call lights within reach.
Unsafe Noise Levels and Broken Resident Furniture
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment for four sampled residents when one resident’s loud yelling and related behaviors repeatedly disrupted other residents, and when broken drawers remained in multiple resident rooms. Resident 55 was documented as having schizophrenia and was described in the record as laughing out loud, yelling at staff, and exhibiting psychosis-related behaviors. During the survey, staff and residents repeatedly observed Resident 55 yelling loudly, slamming a room door, throwing things on the floor, and disturbing nearby residents. Resident 24, who had diagnoses including anxiety disorder and muscle weakness, stated she could not sleep when Resident 55 yelled and said staff had closed her room door in the past because of the noise. Resident 57, who had diagnoses including hypertensive heart disease with heart failure, hypertension, and low back pain, stated she wore headphones to cancel the noise and that her sleep was interrupted by Resident 55 yelling. Resident 98, who had diagnoses including major depressive disorder and mild neurocognitive disorder, was moved from his room to the activity room when Resident 55 became loud, and staff stated he should have been able to remain in his room. Staff also stated they felt bad that residents’ sleep was interrupted and that other residents might feel uncomfortable or unsafe when Resident 55 yelled. The survey also found broken drawers in Resident 24, Resident 51, and Resident 98’s rooms. Resident 24’s bottom two drawers were broken and could not close properly, with personal belongings visible inside. Resident 51’s bottom drawer face was missing, and Resident 51 stated the drawer had been broken for a long time. Resident 98’s bottom drawer was missing the front drawer cover. The Maintenance Director confirmed the drawers were broken and stated they should have been fixed, while the ADON and DON stated broken drawers were a safety issue and not consistent with a homelike environment. Staff stated they were expected to notify maintenance when repairs were needed, but the Maintenance Director stated no request had been made from staff during the reviewed period.
Verbal Abuse Toward a Resident by Contracted Housekeeping Staff
Penalty
Summary
The facility failed to ensure a resident’s right to be free from verbal abuse when a contracted housekeeping staff member used profanity and threatening language toward a resident while the resident was in a wheelchair on the South Unit. The resident involved, Resident 68, had diagnoses including right above-knee amputation, abnormal posture, and muscle weakness, and his MDS showed a BIMS score of 9 out of 15, indicating moderate problems with thinking and memory. His care plan noted lower extremity weakness due to impaired balance affecting functional mobility and that he was to achieve modified independence with wheelchair mobility. According to staff interviews and the resident record, the incident occurred while the housekeeper was mopping the floor near the nurses’ station and the resident was wheeling himself across the area. CNA 1 stated she heard the housekeeper say profanity and curse at the resident, telling him to get off the floor because it was being mopped. LN 3 stated she heard the housekeeper tell the resident to “move his ass” and to get off the “f*** floor,” and that the housekeeper responded aggressively when told to act professionally. LN 3 also stated the housekeeper said the residents were lucky this was not a prison and that if he were a correctional officer he would beat them. The resident’s record reflected the incident as staff-to-resident abuse and noted that the resident was to experience no psychosocial distress and be encouraged to verbalize feelings. During interviews after the event, Resident 68 stated he did not recall any staff member treating him inappropriately and said he felt safe. The facility’s abuse prohibition policy defined verbal abuse as oral, written, or gestured language that willfully includes disparaging and derogatory terms, including threats of harm and saying things to frighten a patient.
Failure to Assess and Report Nonfunctioning AV Fistula
Penalty
Summary
The facility failed to assess a significant change in condition and notify the physician when Resident 1’s AV fistula was not properly functioning. Resident 1 was admitted with diagnoses that included hypertension, chronic kidney disease, and dependence on renal dialysis. During review of the record, licensed nursing staff documented negative thrill and bruit on 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31, indicating the AV fistula was not functioning as expected. During a concurrent interview and record review with the DON, it was verified that a change of condition assessment was not completed and the physician was not informed of the negative thrill and bruit findings. The DON stated it was her expectation that licensed nursing staff notify the MD of the change in condition, and stated this placed Resident 1 at risk of missing hemodialysis as scheduled.
Failure to Provide Required One-to-One Activities
Penalty
Summary
The facility failed to implement an adequate activities program for two residents who had care plans requiring one-to-one room visits and activities when they were unable to attend group events. Resident 15 was admitted with diagnoses including traumatic brain injury, schizophrenia, and insomnia. His activity care plan dated 5/5/25 stated that he needed one-to-one bedside or in-room visits and activities if unable to attend out-of-room events, but his March 2026 participation record showed that he did not participate in group activity and did not receive one-to-one activities from 3/11/26 through 3/17/26. Resident 54 was admitted with diagnoses including adult failure to thrive, delusional disorders, and insomnia. Her activity care plan dated 1/4/26 indicated one-to-one room visits 1-3 times per week and identified preferred activities as writing and conversing. During interview, Resident 54 stated she had previously received one-to-one visits once or twice a week but that these visits had stopped and she was no longer getting activity visits; she said she felt a little sad and looked forward to the visits because she was bedbound. The assistant director of activities reviewed her March 2026 participation record and verified that from 3/19/26 through 3/29/26, she did not receive a one-to-one visit or attend group activity, and stated that residents who did not receive one-to-one activities when unable to attend group activity could experience loneliness and mood impact.
Oxygen Provided Without Physician Order
Penalty
Summary
The facility failed to implement appropriate respiratory care when Resident 15 received supplemental oxygen without a physician's order. Resident 15 was admitted with diagnoses including traumatic brain injury, schizophrenia, and insomnia. During observation on 4/7/26 at 12:30 p.m., Resident 15 was lying in bed with oxygen running through a nasal cannula. During a concurrent interview and record review at 12:35 p.m., the ADON reviewed Resident 15's order summary and verified there was no order for oxygen. During a concurrent observation and interview at 12:40 p.m., the ADON confirmed the resident was receiving oxygen via nasal cannula without a physician order and stated that an order should have been in place so the use of oxygen could be monitored by nursing staff. The facility policy titled Oxygen Administration stated to verify that there is a physician's order for the procedure.
Failure to Notify Physician of Nonfunctioning AV Fistula
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident who required hemodialysis and had diagnoses including hypertension, chronic kidney disease, and dependence on renal dialysis. The resident’s AV fistula dialysis care plan dated 1/13/26 directed staff to monitor the skin condition around the catheter insertion site and report to the physician as indicated. During interview and record review on 4/9/26, the DON verified that licensed nursing staff documented the resident’s AV fistula as negative for thrill and bruit on 3/14, 3/24, 3/25, 3/26, 3/27, 3/28, and 3/31. The DON also verified that a change of condition assessment was not completed when the fistula was negative for thrill and bruit on those dates, and the physician was not notified. The DON stated it was her expectation that licensed nursing staff notify the physician of the resident’s change in condition when the AV fistula was negative for thrill and bruit. The facility policy stated that the AV shunt site would be inspected for functionality and that nursing staff would keep the attending physician, the resident, and the resident’s family informed of any change in conditions.
Non-Controlled Medication Destruction Records Lacked Required Nurse Co-Signatures
Penalty
Summary
Pharmaceutical services were not maintained for a census of 109 when non-narcotic prescription medication destruction records were not co-signed by a licensed nurse in 29 out of 29 pages reviewed during a medication room inspection in one of four medication rooms. During a concurrent interview and record review in the South Station medication room, the non-narcotic prescription medication destruction records titled, MEDICATION DISPOSITION LOG-NON-CONTROLLED MEDICATIONS FOR FACILITY DESTRUCTION, were reviewed for various dates in March and April 2026. The records showed no signatures of licensed nurses who witnessed the destruction of the non-narcotic medications, and LN 10 confirmed that the records were not co-signed by licensed nurses on any of the 29 pages reviewed. LN 10 stated that licensed nurses should have co-signed the destruction records and that two nurses should sign the records to allow double verification that the non-narcotic medications were destroyed. During an interview, the DON stated the non-narcotic destruction records should be signed by 2 nurses and added that without a co-signature, there would be no witnesses to verify the destruction of the medications. The facility policy titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, revised January 2025, stated that non-controlled medication destruction occurs in the presence of two licensed nurses and that the nurse(s) and/or pharmacist witnessing the destruction ensure signatures of witnesses are entered on the medication disposition form.
Wrong Resident Insulin Pen Used During Medication Administration
Penalty
Summary
A medication error occurred when a nurse administered insulin to Resident 92 using an insulin pen that belonged to Resident 89. Resident 92 was admitted with type 2 diabetes mellitus and had an active order for HumaLOG insulin based on a sliding scale, with 4 units ordered for a finger stick blood sugar of 197. During the medication observation, the nurse checked Resident 92’s FSBS, determined the resident needed 4 units, and prepared insulin from a pen that was in a plastic package labeled for Resident 92. After the insulin was given, further inspection of the pen showed that the label on the pen itself identified Resident 89 and reflected Resident 89’s insulin order. The nurse confirmed that the pen did not belong to Resident 92 and stated that the label on the plastic package and the label on the insulin pen were different and did not match. The nurse stated the pen had the wrong resident and wrong dosage and that this practice resulted in a medication error and the potential risk for cross contamination. The Pharmacy Consultant stated it was wrong practice to use someone else’s insulin injector pen for another resident because it would lead to medication errors. The DON initially stated it was not a medication error and was more an infection control issue, but later stated that the 5 rights of medication administration were not followed when the insulin pen was for the wrong resident with the wrong insulin dose. Facility training and policy stated that medication labels must be verified, insulin must correspond with the physician’s order, and insulin pens are for single-use only and must be clearly labeled for the resident.
Failure to Provide Recommended Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to administer the pneumococcal vaccine and the influenza vaccine to one sampled resident, Resident 46. Resident 46 was admitted with diagnoses including Myasthenia Gravis, Moderate Persistent Asthma, and Muscle Weakness. A review of the resident’s immunization record for 1/1/25-4/30/26 showed no record of either the pneumococcal or influenza vaccination. During a concurrent interview and record review on 4/8/26, the Infection Preventionist confirmed that Resident 46 did not receive the pneumococcal and influenza vaccines. The Infection Preventionist stated that Resident 46 should have received both vaccines. She also stated that she attempted to contact the resident’s Responsible Party for vaccine consent but was unable to make contact, and that she was supposed to follow up with the Responsible Party but did not do so. During an interview on 04/09/26, the Director of Nursing stated that residents are expected to receive all recommended vaccinations promptly following admission to the facility and that residents who do not receive immunizations promptly are at increased risk for illness. Facility policies stated that all residents are to be offered vaccines, that new residents are to be assessed for vaccination status upon admission, and that pneumococcal and influenza vaccines are to be offered within the timeframes described in the policies.
Failure to Provide COVID-19 Vaccination
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to one sampled resident, Resident 46, and the resident had no record of receiving the vaccine. Resident 46 was admitted with diagnoses including Myasthenia Gravis, Moderate Persistent Asthma, and Muscle Weakness. A review of the resident’s immunization record for the stated date range showed no documentation of COVID-19 vaccination. During a concurrent interview and record review, the Infection Preventionist confirmed that Resident 46 did not receive the COVID-19 vaccine and stated that the resident should have received it. The Infection Preventionist said she attempted to contact the resident’s Responsible Party for vaccine consent but was unable to make contact, and she stated that she was supposed to follow up but did not do so. The DON stated that residents were expected to receive recommended vaccinations promptly after admission and that delayed immunizations increased the risk for illness.
Failure to Honor Resident Choice for Room Deep Cleaning
Penalty
Summary
The facility failed to honor the resident's right to choose when it did not respect Resident 27's request for a schedule for deep cleaning of the room and for which housekeeping team member would perform the cleaning. Resident 27, who was admitted with functional quadriplegia and had a BIMS score of 15, had requested that only certain housekeeping staff clean the room and that there be no direct contact with one housekeeping employee. The resident also reported feeling uncomfortable and harassed by the employee's continued attempts to enter the room and discuss the deep cleaning. During the investigation, the Social Services Director stated that Resident 27 would only allow certain housekeeping staff to clean the room and had requested a schedule for the deep cleaning. The Administrator stated that one housekeeping team member had been directed to have no direct contact with the resident and to stay out of the room at the resident's request, but that the employee ignored that directive and entered the room to discuss changing the deep cleaning schedule. The housekeeping employee stated she had been told on 3/16/26 not to enter the room again and that only two specific housekeepers were allowed to clean the resident's area, but she still went into the room to discuss the schedule change, which upset the resident.
Failure to Timely Report Alleged Abuse to State Agency and Ombudsman
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse involving Resident 1 was reported to the appropriate authorities within the required two-hour timeframe. Resident 1, who had diagnoses including muscle weakness and osteoporosis, was the subject of a suspected dependent adult/elder abuse report (SOC 341) dated 2/20/26. Record review showed that this SOC 341 was not faxed to the Department until 2/25/26 at 4:42 PM. During interview, the DON confirmed the facility did not have fax confirmation showing that the SOC 341 had been sent to the Department and the Ombudsman within two hours of the allegation. In an interview, the Ombudsman stated they did not receive the SOC 341 dated 2/20/26 until 2/26/26. In a follow-up interview, the DON acknowledged that, per facility policy, the SOC 341 form was supposed to be completed and faxed to the Department and the Ombudsman within two hours of an abuse allegation, and that waiting six days was too long. Review of the facility’s policies titled “Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating” and “Abuse Investigation and Reporting” confirmed that all alleged violations involving abuse must be reported immediately, and not later than two hours, to the State licensing/certification agency and the local/State Ombudsman.
Failure to Maintain CNA Personnel File and Provide Required Orientation/Competency Validation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a CNA had the required competencies, orientation, and personnel documentation before and during providing care to residents. During interview and record review, the Accounts Payable/Payroll Coordinator (AP/PR Coord) confirmed that the facility did not have an employee file for one of four CNAs (CNA 2). The AP/PR Coord described that an employee file should contain hiring documentation, orientation checklist, annual evaluations, medical information, emergency contact, background check, references, copies of licenses/certifications, CPR card, picture ID, signed job description, and orientation skills, competencies, and quizzes, and stated that all employee files were required to be kept on the premises. The facility’s Employee Handbook indicated that required licenses and certifications would be reviewed regularly and that personnel and medical files are facility property, accessible only to authorized personnel with a legitimate reason to review them. The Director of Staff Development (DSD) stated she was not aware of any staff member without an employee file and explained that employee competencies were kept in those files. The DSD further stated that without a record of competencies, she would not know if an employee had the skills to care for residents. In a separate interview, CNA 2 reported she had been working at the facility for 10 months without receiving any facility orientation. She confirmed she had never sat down to watch training videos or taken any required tests, and noted that CNAs hired after her did receive training. The AP/PR Coord also stated that once a staff member starts working, the facility should provide training. The report states that this failure placed residents at risk for receiving care from staff who did not meet the competencies in skills and techniques required to care for resident needs.
Failure to Complete Required TB Screening for Nursing Staff
Penalty
Summary
The facility failed to follow its tuberculosis (TB) employee screening policy for one of three sampled nursing staff, resulting in an incomplete personnel record for a nursing assistant. Record review with the Payroll Coordinator showed that the nursing assistant was hired on 11/25/25, but there was no documentation of an initial TB screening test in the employee’s personnel file. The facility’s written policy, dated 3/21, required that all employees be screened for latent TB infection and active TB disease, including a baseline test and symptom evaluation, prior to beginning employment. During interviews, the Infection Preventionist confirmed that there was no initial TB test documented for the nursing assistant upon hire and stated that testing nursing staff for TB was important because residents are immunocompromised and at risk of contracting TB. In a separate interview, the DON stated it was important to verify that the nursing assistant had been screened for TB before providing resident care and that her expectation was that employees be screened for TB prior to orientation. These interviews and record reviews established that the required pre-employment TB screening was not completed or documented for the nursing assistant, contrary to facility policy.
Failure to Provide and Document ADL and Wound Care Treatments
Penalty
Summary
Surveyors identified that the facility failed to provide and document required ADL care for one resident with severe cognitive impairment and physical functioning deficits. The resident’s care plan, revised in September 2024, directed staff to provide assistance with ADLs, including hygiene, mobility, passive range of motion, and toileting, and to document the assistance provided. A complainant reported that staff were not providing care to this resident. On two separate observations on the same day, the resident was found in bed on her right side, wearing a hospital gown and covered with a blanket. Review of the resident’s Documentation Survey Report for a period in February 2026 showed no documented evidence that ordered ADL interventions such as turning and repositioning, bed mobility, passive range of motion to bilateral upper extremities, mouth care, personal hygiene (including hair and nail care, washing/drying face and hands), and toileting were provided on multiple day, evening, and night shifts. The Director of Staff Development confirmed that if care was not charted, it was considered not done and acknowledged that ADL care should have been recorded when provided. The facility also failed to consistently provide and document ordered wound care treatments for a resident with a stage 3 pressure ulcer to the coccyx. This resident had a documented diagnosis of a sacral pressure ulcer, stage 3, and a treatment order on the Treatment Administration Record directing cleansing with normal saline, drying, application of Medihoney gel, and covering with a dry dressing three times weekly and as needed. An anonymous complaint alleged the facility was unsafe, and a nurse interview indicated that skin treatments, including pressure ulcer care, were not consistently provided. During an observation in the resident’s room, the stage 3 coccyx ulcer was found without a dressing in place, despite an order for a treated and covered wound. Review of the Treatment Administration Record for the month showed missing nurse initials on several ordered treatment days, and the DON confirmed that the absence of initials meant the treatments were not performed. In addition, the facility did not ensure that ordered daily wound treatments were provided and documented for another resident with multiple advanced pressure ulcers. This resident had diagnoses including a stage 4 pressure ulcer to the left hip, a stage 4 pressure ulcer at another site (left scapula/shoulder), and an unstageable pressure ulcer to the left hip/trochanter. Treatment orders on the Treatment Administration Record required daily cleansing with normal saline, drying, application of silver alginate to the stage 4 wounds, and Silvadene with dry dressing to the unstageable necrotic wound, all to be covered with dry dressings each day shift. During an observation in the resident’s room, the stage 4 ulcers on the left shoulder and left hip and the unstageable ulcer on the left trochanter were found without dressings. Review of the Treatment Administration Record showed no nurse initials for one of the ordered treatment days, and the DON confirmed that the missing initials indicated the treatments were not done. Facility wound care procedures and nurse job descriptions required that wound care be provided as ordered and documented with date and time in the medical record, but this was not carried out for this resident on the identified date. Facility policies on ADLs and wound care stated that residents unable to perform ADLs independently would receive necessary services for hygiene, mobility, and toileting, and that wound care would be provided and documented, including marking dressings with initials, time, and date and recording the date and time of wound care in the medical record. Job descriptions for RNs and LPNs/LVNs required monitoring skin health, providing preventive skin care, administering wound treatments as ordered, and maintaining documentation of all nursing care and services. Despite these written expectations, the survey findings showed multiple instances where required ADL care and wound treatments were either not documented or not in place at the time of observation, leading surveyors and facility leadership to conclude that the care had not been provided on those occasions.
Failure to Maintain Sanitary Kitchen and Pantry and Implement Pest Control Recommendations
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen and food storage areas, despite ongoing contracted pest control services and documented recommendations. Pest control records from October 2025 through early February 2026 showed repeated, unresolved conditions in the kitchen and pantry, including food debris on shelving, food particles and debris under ovens, fryers, coolers, and tables, grease deposits on floors, and wet organic matter accumulated in floor cracks and seams. The pest control service’s documentation from February 6, 2026, specifically noted that previously identified conditions still existed and requested that the facility address these contributing conditions to support the pest management program. During an on-site inspection of the kitchen and food storage areas, surveyors observed multiple unsanitary conditions consistent with the unaddressed pest control recommendations. Behind and beside the stove, there was tan-colored food splatter and white powder on the wall, baseboard, and floor, along with a buildup of grease, brown and black food stains, and food particles under the ovens. Sticky mouse and bug traps behind the oven and ice machine contained dead insects and were covered with accumulated dirt and dust. There were moderate cobwebs with dead flies, dust, dirt, and food particles on pipes behind the ice machine, circular discolorations and particles in floor cracks under and behind the ice machine, and a large amount of food particles, crumbs, food splatter, and grease buildup under the steam table. Additional observations included a food preparation table with clean pots and pans stored on a low shelf that had tan food splatter and black grease buildup underneath, food particles and grease in floor cracks near the central steam table, and dust, food particles, and black and brown grease and grime under kitchen refrigerators. The food storage/pantry floor was dirty with crumbs and dust in walking areas and under storage units, black and red tape on the floor with embedded food particles, and food items such as a mandarin-type orange and packaged crackers on the floor under storage racks. Interviews with the Assistant Kitchen Manager, Maintenance Director, Certified Dietary Manager, and Administrator confirmed that the facility had expectations and policies for maintaining clean and sanitary food preparation and storage areas, that pest control reports with recommendations were distributed weekly, and that the kitchen and pantry pest control recommendations had not been addressed since October 2025, with the Certified Dietary Manager stating she was not aware of the pest control recommendations.
Failure to Provide Adequate Hand and Nail Hygiene Assistance for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically hand and fingernail hygiene, for two residents who required help with personal care. One resident’s MDS dated 1/26/26 showed that he was cognitively able to make reasonable decisions but needed substantial/maximal assistance with personal hygiene and mobility and was totally dependent on staff for bathing or showering. During observation in his room, this resident was found lying in bed with fingernails approximately one-quarter inch long and a brown substance accumulated under them. He stated he did not like his nails that long, confirmed there was dirt embedded under them, and reported that he had asked staff to cut his nails for a few weeks without the request being fulfilled. He also stated he felt gross eating with dirty fingernails. Later the same day, when a CNA brought this resident his lunch tray, the resident again asked for his nails to be cut. The CNA confirmed that his nails were very long and dirty with a brownish substance under them and stated that CNAs were not allowed to cut residents’ fingernails, explaining that nails could be brushed clean during bathing but not trimmed by CNAs. The resident’s care plan for skin inflammation indicated goals for his skin to remain intact, clean, and dry with reduced irritation and included education to avoid scratching, but there was no indication that his ongoing requests for nail care had been addressed. The DON later confirmed that this resident’s nails appeared not to have been trimmed for several weeks or months and that the long, dirty nails did not meet her expectations for hygiene. The second resident’s MDS indicated he was cognitively intact with a perfect BIMS score and required substantial/maximal assistance with showering/bathing and supervision or touching assistance for personal hygiene. During observation in his room, he was noted to have visible brown dirt stuck in the creases and backs of his hands, and long, dirty fingernails extending past the fingertips with brown and black substance caked underneath. He stated he had told CNAs he wanted his fingernails trimmed but was told staff were not allowed to cut his nails, and that his hands and nails were dirty because he could not get staff to help him. Later, when a CNA assisted him with lunch tray setup, the CNA confirmed his hands were dirty and his nails were long with dirt caked under them but did not offer assistance with hand hygiene or nail trimming, stating she had previously encouraged him to clean his hands before meals and that he often refused, so she did not ask. The facility’s own staff and records reflected expectations and orders for nail and hand care that were not carried out for this resident. The CNA stated that facility procedure was to encourage and assist residents with hand hygiene before meals and, if they refused, to involve the nurse and document refusals. The LN stated CNAs were supposed to help residents wash hands before meals and that nail care was to be provided to all residents every Sunday by any CNA or LN. The second resident’s record contained an order allowing nail cutting once every four weeks on Sunday, and his care plans addressed risk for skin issues and self-care deficit, including improving hygiene status and assuring tasks were done to facility standards. The DON confirmed that both residents should have had nails trimmed weekly on Sunday or as needed, that staff did not need an order to trim fingernails unless specified by the physician, and that she expected all residents’ hands to be cleaned before meals with refusals and education documented. Review of the second resident’s record showed only two documented refusals of bathing and no documentation of refusals or education related to hand hygiene or nail care, despite his observed condition and his statements that he could not get staff to help him with his hands and nails. The facility’s policies on ADLs and nail care required that residents unable to carry out ADLs independently receive services necessary to maintain grooming and personal hygiene, including appropriate support and assistance with hygiene and dining, and that staff attempt to identify causes of resistance or refusal and approach residents differently or involve another staff member. The nail care policy required safe, hygienic, and thorough nail care assistance and consultation with an RN for special directions, with documentation of any nail care provided. Observations, interviews, and record review showed that these policies and expectations were not followed for the two residents, resulting in long, dirty fingernails with brown or black substance embedded under them and failure to assist one resident with hand hygiene before a meal.
Failure to Provide Ordered Foot and Nail Care Resulting in Painful Overgrown Toenails
Penalty
Summary
The facility failed to provide appropriate foot and nail care to one resident who had a physician’s order for routine nail care. The resident was admitted with hemiplegia/hemiparesis affecting the left side and peripheral vascular disease, and was assessed as cognitively intact on the MDS, requiring substantial/maximal assistance with bathing and supervision/touching assistance for personal hygiene. A physician’s order dated 5/12/24 directed that nail care could be provided once every four weeks on Sundays, but the resident’s left toenails were observed to be very long, overgrown past the tips of the toes, sharp-edged, dirty, and discolored yellow and dark brown, and had not been trimmed for several months. During observation and interview, the resident was noted to be wearing a sock and shoe only on the right foot, with the left foot bare. The resident reported having repeatedly asked staff to trim his toenails and stated he could not wear a sock or shoe on the left foot because the long toenails caused pain when he tried. The resident further reported that CNAs and licensed nurses told him they could not cut his toenails and that he would be charged $50 for the service. CNA staff confirmed that the resident’s toenails were long, sharp, discolored, and had not been trimmed for a long time, and stated that when a resident refused hygiene care, they were expected to notify the nurse so the nurse could encourage cooperation and explain risks. Interviews with nursing and social services staff showed that the facility had processes for nail care and podiatry services that were not followed for this resident. The LN stated that podiatry visited monthly and that residents could be added to the podiatry list based on nursing assessment or CNA reports, and that LNs could trim toenails with a doctor’s order, with refusals documented in progress notes and the physician notified. The Social Services Director reported that the resident was not on the podiatry list and had no record of prior podiatry visits. The DON confirmed there were no progress notes or other documentation of the resident refusing toenail care, despite staff claims of refusal, and verified the existence of the standing nail care order and the poor condition of the resident’s toenails. Facility policies on ADLs and nail care required provision of hygiene and nail care, consultation with an RN for special directions, and documentation of nail care provided, which were not carried out in this case.
Improper Garbage Disposal and Open Dumpsters Create Unsanitary Conditions
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of garbage and refuse, including residents’ personal trash and food-related waste, in the designated dumpster area. During an observation outside near the parking area, surveyors noted scattered trash on the ground, including used masks, gloves, baby/sanitary wipes, and a trash bag filled with residents’ personal trash containing used diapers with a brown substance. The dumpster containers were left open and overfilled, with trash bags piled up to the top. The Infection Preventionist (IP) stated that nursing staff were expected to place trash in designated barrels, and that CNAs and/or housekeepers should take the filled barrels to the dumpster at the end of each shift or when full, to minimize spills and prevent cross contamination. The IP confirmed that trash scattered on the ground and a trash bag lying next to the open dumpsters were residents’ personal trash, including briefs that appeared to contain stool. From a conference room window facing the dumpster area, the IP again confirmed the presence of a trash bag filled with residents’ trash on the ground next to two open dumpsters, as well as scattered PPE and other trash from residents’ personal refuse. The IP stated that Maintenance was responsible for checking the front of the facility but was unsure if they were also responsible for the back dumpster area, which served as the main trash area. Dietary staff reported that they emptied trash into the dumpster outside the double doors of the kitchen, using their own bins for recycling and trash, and that these bins were placed outside the kitchen door rather than inside. This indicated that multiple departments, including nursing, housekeeping, and dietary, were using the same dumpster area where the unsanitary conditions were observed. The Dietary Services Manager (DSM), observing the same area, confirmed that masks and gloves were on the ground by the dumpster and stated that nursing, housekeeping, central supply, and all departments used the dumpsters and should keep the lids closed to prevent the spread of infection. The Maintenance Director (MS) acknowledged seeing trash, including gloves and masks, on the ground and confirmed that the dumpsters had been left open, stating this was not correct practice for infection control and that city regulations required dumpsters to be kept closed. Review of the facility’s policies showed that food-related garbage and refuse were to be stored in a manner inaccessible to pests, with outside dumpsters kept closed and free of surrounding litter, and that the Infection Prevention and Control Program was a facility-wide effort to provide a safe, sanitary environment and prevent the development and transmission of infections. These observations and statements demonstrate that the facility did not maintain the dumpster area in a sanitary condition or follow its own policies for garbage and refuse disposal for a census of 115 residents.
Unattended, Unlocked Treatment Cart with Medications and Biologics
Penalty
Summary
Surveyors identified a deficiency related to medication and biological storage and labeling when a treatment cart was observed left open and unattended in a hallway near rooms 15A to 24B. During the observation, multiple residents were seen pacing up and down the hallway while the cart remained open, with residents' identifiable prescription creams, Betadine, gauze, bandages, and a nail clipper accessible. A licensed nurse later came down the hallway and locked the treatment cart after it had been observed open. In a concurrent interview, the licensed nurse confirmed the treatment cart had been left open and acknowledged it contained residents' medical information on creams, ointments, and other medications. The nurse stated he could not recall who left the cart open and explained that staff should always close the treatment cart before and after each use. He further stated that open access to the cart posed risks of reactions to chemicals and medications and violations of resident privacy. The DON also stated in an interview that medication and treatment carts should always be locked because they contain sterile solutions and medications with resident identity, and that leaving the cart open allowed residents to grab items from it. Review of the facility’s Medication Labeling and Storage policy indicated that all medications and biologics must be stored in locked compartments and that carts used to transport such items are not to be left unattended if open or otherwise available to others.
Failure to Adjust LAL Mattress Settings According to Resident Weight
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent pressure ulcers for two residents who were observed lying on low-air loss (LAL) mattresses that were not correctly adjusted according to their individual weights. Both residents had orders for LAL mattresses as a preventative intervention due to a history of pressure injuries, and manufacturer guidelines required the mattress settings to be adjusted based on the resident's current weight. Observations and interviews confirmed that the mattresses for both residents were set at weights significantly higher than their actual documented weights, contrary to the requirements outlined in the user manual and physician orders. One resident, with a history of multiple diagnoses including palliative care, vascular dementia, and stage 3 pressure ulcers, was found lying on a LAL mattress set at 265 lbs, while her most recent recorded weight was 112.2 lbs. Nursing staff confirmed that it was their responsibility to ensure the mattress was set according to the resident's current weight and acknowledged that the incorrect setting could compromise the effectiveness of the mattress in preventing skin breakdown. The treatment nurse and DON both verified that the mattress was not set appropriately and that the order specified adherence to manufacturer guidelines. Another resident, with diagnoses including cerebral palsy, obesity, and a history of pressure injuries, was observed on a LAL mattress set at more than 350 lbs, while her documented weight was 153.4 lbs. Nursing staff and the DON confirmed that the mattress was not set according to the resident's current weight, as required. Both residents' care plans and orders specified the use of LAL mattresses for skin management and required monitoring per manufacturer specifications, which was not followed. The DON acknowledged that nursing staff did not meet expectations for monitoring and adjusting the mattress settings as required.
Failure to Include LAL Mattress in Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of a low air loss (LAL) mattress for a resident with a history of pressure injuries and multiple complex diagnoses, including palliative care, senile degeneration of the brain, vascular dementia, and stage 3 pressure ulcers on the sacral region and left buttock. The resident had an active physician order for a LAL mattress for prophylactic skin management, which was initiated to prevent further skin breakdown and manage existing pressure injuries. Despite the presence of the LAL mattress in the resident's room and its documented use, review of the resident's care plans revealed that this intervention was not included. Interviews with nursing staff and the DON confirmed that the care plan did not reflect the use of the LAL mattress, even though it was a significant intervention for the resident's skin integrity. Staff acknowledged that care plans serve as essential communication tools and guides for providing individualized, person-centered care, and that all physician orders and interventions should be documented in the care plan. The facility's policies and procedures required the development of comprehensive, individualized care plans with measurable objectives and timetables to meet each resident's needs, including interventions for skin integrity management. The DON confirmed that the facility's policy was not followed in this case, as the care plan did not include the LAL mattress intervention, which was necessary for the resident's ongoing skin management and prevention of further pressure injuries.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect the rights of two residents to be free from physical abuse, resulting in two separate resident-to-resident altercations. In the first incident, a resident with a history of multiple altercations and diagnoses including paranoid schizophrenia, insomnia, major depressive disorder, and anxiety disorder, was under a physician's order for 24-hour one-on-one supervision due to aggressive behaviors. Despite this, the resident was left unsupervised in the lobby, where he made racial slurs and pushed another resident, causing that resident to fall from his wheelchair. Multiple staff interviews confirmed that the assigned one-on-one caregiver was not present at the time of the incident, and the resident admitted to pushing the other resident due to agitation triggered by loud noises and previous negative interactions. In the second incident, a resident with dementia and behavioral disturbances was struck in the face by another resident diagnosed with schizophrenia. The altercation occurred when the first resident's wheelchair became entangled with the other resident's wheelchair outside the activities room. The striking resident was also on one-on-one care due to combative behavior, but the altercation still occurred, resulting in the injured resident sustaining bleeding in the mouth. Interviews with staff and other residents indicated that both residents had a history of confusion and negative interactions, and this was the second altercation between them. The facility's own policy required adequate supervision and removal of residents who threatened or attacked others, as well as identification and monitoring of residents with a history of disruptive behaviors. However, in both cases, the required supervision was not maintained, and staff failed to prevent the altercations despite known risks and prior incidents. These failures resulted in physical harm to the residents involved.
Failure to Develop Comprehensive Care Plan for Skin Issues and Scratching Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was readmitted with new skin issues and a known behavior of skin scratching. Upon readmission, the resident was found to have scattered skin scrapes on the right and left buttocks and right scrotum, as documented in the medical record. Despite these findings, no care plan was initiated to address the new skin issues, and the only intervention ordered was to monitor the affected areas. Multiple licensed nurses confirmed during interviews that a care plan should have been created at the time of readmission to track wound healing and implement appropriate interventions. Additionally, the resident exhibited a behavior of self-scratching, which was observed by staff and reported by certified nurse assistants. This behavior was known to contribute to the resident's ongoing skin issues, particularly given the resident's history of end stage renal disease and dialysis, which increased the risk of dry skin and open wounds. Despite staff awareness of the scratching behavior, there was no care plan or behavior monitoring order initiated to address or mitigate this behavior. Facility policies required that a comprehensive care plan be developed and updated upon readmission and when new issues or behaviors were identified. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for care plans to be created for both new skin issues and observed behaviors such as scratching. The absence of these care plans was verified through record review and staff interviews, indicating a failure to follow facility policy and standard care planning procedures.
Incomplete Documentation of Resident Treatments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two sampled residents. For one resident with multiple diagnoses including type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis, the Treatment Administration Record (TAR) for a specific month showed missing documentation by licensed nurses on several treatment orders. These included monitoring and treatment of skin scrapes, swelling, discoloration, pitting edema, and application of topical medications. The missing documentation occurred on multiple dates and shifts, and was confirmed by the Treatment Nurse, who stated that blank entries on the TAR indicated the treatment was not done or not documented. The Director of Nursing also verified the missing documentation and stated that it was her expectation for nurses to carry out and document all treatment orders. For another resident with a history of cellulitis and a stage 3 pressure ulcer on the coccyx, the TAR showed missing documentation for daily and as-needed wound care treatments. On certain dates, there was either no documentation or incomplete entries, such as a note to check progress notes without follow-up documentation that the treatment was completed. The nurse assigned to the resident during one of the missing documentation periods confirmed that the treatment was performed but not documented on the TAR as required. The Director of Nursing reviewed the records and confirmed the lack of documentation for the pressure ulcer treatments. The facility's policy on nursing documentation requires that records specify what interventions were performed, by whom, when, and where, and that documentation be clear, concise, and accurate. The failure to document treatments as ordered resulted in incomplete medical records for both residents, as confirmed by multiple staff interviews and record reviews. This deficiency was identified through interviews with nursing staff and review of the facility's documentation policies.
Failure to Implement Routine Pain Medication Order for Hospice Resident
Penalty
Summary
The facility failed to provide adequate pain management for one resident when a new order for routine morphine sulfate was not implemented for 35 days. The resident, who had diagnoses including palliative care, dementia, mild neurocognitive disorder, history of falling, and legal blindness, was admitted to hospice care and had a physician's order for morphine sulfate to be administered every six hours for pain. Despite the hospice agency faxing and verbally communicating the new order to the facility, the order was not carried out, and the resident continued to receive only PRN pain medication instead of the scheduled dose. Family observations and interviews revealed that the resident was found crying, gasping for breath, and appearing to be in pain during a visit. The family member was informed by facility staff that the resident had missed her pain medication and that the morphine was only available PRN. However, the hospice agency confirmed that the order had been changed to a routine schedule and that the facility had been notified. Documentation from the hospice nurse indicated that the resident was experiencing pain and discomfort, and that the facility nurse had been updated about the new order. Interviews with facility staff, including licensed nurses and the Assistant Director of Nursing, confirmed that there was a miscommunication between the hospice and the facility, resulting in the routine pain medication order not being implemented. The facility's own policies required that prescribed therapies, including those determined appropriate by hospice, be administered as part of the resident's care. The failure to carry out the routine pain medication order led to the resident experiencing unmanaged pain for an extended period.
Failure to Obtain Physician Order and Monitor Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a physician's order and appropriate monitoring were in place for a Low Air Loss (LAL) mattress used as a pressure ulcer intervention for a resident with multiple complex medical conditions. The resident's diagnoses included acute respiratory failure with hypoxia, dysphagia, unstageable pressure ulcer of the sacral region, stage 3 pressure ulcer of the left lower back, hemiplegia, and pressure-induced deep tissue damage. During observation, the resident was found resting on a LAL mattress, but review of the Treatment Administration Record (TAR) revealed there was no physician's order for the LAL mattress, nor was there documentation of monitoring the mattress for effectiveness or correct settings. Interviews with the treatment nurse and the Assistant Director of Nursing confirmed that the LAL mattress was in use without a physician's order and that the TAR did not reflect its presence or monitoring. The facility's policy required documentation of current treatments, including support surfaces, and review of their pertinence to the resident's condition. The lack of a physician's order and absence of monitoring for the LAL mattress meant that the intervention was not properly individualized or tracked for effectiveness, as required by facility policy.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when the resident did not receive the necessary care and interventions tailored to their mental health and psychosocial needs, as required by their condition and history. This lack of appropriate services was observed and documented by surveyors during the review.
Failure to Label Enteral Feeding Bag and Tubing
Penalty
Summary
A deficiency occurred when a resident receiving enteral tube feeding did not have their tube feeding bag and tubing labeled with the date and time it was put into use. During an observation, it was noted that the bag lacked a label indicating when the feeding was started, the resident's name, and the type of feeding solution. The licensed nurse present confirmed that the bag was not labeled and acknowledged that this information is necessary for staff to know when the feeding was started, what type of feeding it is, and when to change the bag. The resident involved had a history of cerebral infarction, end stage renal disease, and aphasia, and was receiving a prescribed enteral formula at a specific rate and schedule. The Assistant Director of Nursing stated that it was expected for licensed nurses to label enteral feeding bags with the date and time hung, check resident identifiers, and ensure the correct feeding rate. Facility policy also required that enteral feeding bags be labeled and changed every 24 hours. The lack of labeling was acknowledged as a failure to follow facility policy and procedure.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Remove Accident Hazards Near Resident's Bed
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one of five sampled residents. Specifically, remnants of a broken rail, including two square wood pieces with splintered wood and protruding screws, were left on the wall near a resident's bed. This condition was observed during a survey, and both a licensed nurse and a maintenance assistant confirmed the presence of these hazards. The maintenance assistant explained that the rail was likely damaged when staff raised the height of the resident's bed, and acknowledged that the remaining wood and screws could pose a risk of injury. The resident involved had a medical history that included major depressive disorder and spinal stenosis. Review of facility policies indicated that staff are expected to provide a safe, homelike environment and to identify and report accident hazards. However, in this instance, the hazardous remnants were not removed or reported, resulting in a failure to ensure the environment was free from accident hazards as required by facility policy.
Failure to Assess and Care Plan for Substance Abuse History
Penalty
Summary
The facility failed to assess and document a resident's history of substance abuse upon admission, despite clear indications in the medical record and hospital transfer documents. The resident, who had a documented history of methamphetamine, crack/cocaine, and marijuana use, was admitted for generalized weakness and had recently transferred from another facility and a hospital stay. The physician's History and Physical (H&P) and social services assessment both noted the resident's substance use history, but this information was not entered into the electronic health record under diagnoses, nor was it addressed in the nursing assessment or Minimum Data Set (MDS) documentation. No nursing care plan was initiated to address the resident's substance abuse history, and the issue was not incorporated into the resident's plan of care upon admission. Staff interviews confirmed that the resident exhibited non-compliance with medication, safety routines, and smoking policies, and that his wife brought potentially hazardous items into the facility. The resident was also described as verbally aggressive and uncooperative regarding discussions about substance use. Despite these behaviors and the known history of substance abuse, the facility did not implement targeted interventions or a care plan to address these risks. The deficiency became evident when the resident experienced a sudden change in mental status and vital signs, leading to a hospital emergency room admission where a drug screen was positive for methamphetamine. The lack of a comprehensive care plan and failure to document and address the resident's substance abuse history may have contributed to the health incident and the presence of accident hazards in the facility.
Failure to Prevent Resident-to-Resident Abuse Due to Lapses in 1:1 Supervision
Penalty
Summary
The facility failed to protect four residents from abuse, including verbal, mental, and physical abuse, as evidenced by multiple altercations between residents. Resident 1, who had a documented history of verbal and physical aggression towards both staff and other residents, was involved in several incidents: striking another resident in the face, slapping a resident's forehead, and hitting a resident's ear. These incidents occurred despite Resident 1 being placed on one-to-one (1:1) supervision, an intervention intended to prevent such behaviors and ensure the safety of others. Staff interviews and record reviews revealed that the 1:1 supervision was not consistently maintained. Staff assigned to provide 1:1 care to Resident 1 admitted to leaving him unsupervised or not maintaining visual contact, which allowed Resident 1 to approach and physically harm other residents. The Activities Director and Activities Assistant both acknowledged lapses in supervision during group activities, and the Assistant Director of Nursing confirmed that staff did not follow the required 1:1 care interventions at the time of the altercations. Additionally, another incident involved a verbal altercation between Resident 1 and Resident 4, which escalated to Resident 4 kicking Resident 1. Documentation and interviews indicated that staff were aware of ongoing tensions and previous altercations between these residents but failed to prevent further incidents. Facility policies required staff to institute measures to minimize the possibility of abuse and to ensure that residents on 1:1 supervision were always within line of sight and not left alone, but these protocols were not followed, resulting in repeated resident-to-resident abuse.
Failure to Provide Timely Incontinent Care and Protection from Neglect
Penalty
Summary
The facility failed to protect two residents from neglect related to activities of daily living (ADLs), specifically in the provision of incontinent care and personal hygiene. One resident, who was dependent on staff for bathing and toileting due to advanced dementia and anxiety disorder, was left in a soiled brief for approximately two hours. This incident was reported by the resident's roommate, who stated that she repeatedly asked the assigned CNA to change the soiled brief, but the CNA refused, claiming the resident was not dirty. The roommate eventually used the call light, but the CNA did not return for over an hour, resulting in the resident remaining in a soiled state for an extended period. The care plan for this resident required frequent checks and prompt cleaning after incontinence episodes, which was not followed. Another resident, with diagnoses including anxiety disorder, functional quadriplegia, and a chronic skin condition causing painful sores on the legs, was left without completed incontinent care when the same CNA left the room before finishing. The resident was left with an untaped, soiled brief and uncovered, causing distress. When the CNA returned, the resident requested that her legs not be touched due to pain and dressings, but the CNA slapped or tapped her right leg with an open hand, causing pain and emotional upset. The incident was witnessed and corroborated by an occupational therapist, who also reported the event to facility leadership. Both incidents were confirmed through interviews with staff, residents, and review of facility records. The facility's policies required prompt and thorough incontinent care, as well as measures to prevent neglect and ensure residents' well-being. In both cases, the assigned CNA failed to follow these policies, resulting in residents not being well-groomed and experiencing unnecessary pain and psychosocial distress.
Staff Provided Cannabis to Residents, Creating Accident Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards when an Activity Assistant (AA) provided cannabis products, including edibles and a joint, to two residents. The incident was reported by the residents to various staff members, including a Licensed Nurse (LN), a Certified Nursing Assistant (CNA), and the Social Services Director (SSD). Both residents admitted to voluntarily receiving and consuming the substances from the AA, and urine lab tests confirmed the presence of cannabinoids in their systems. One of the residents involved had a medical history that included hypertension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus with diabetic neuropathy. Observations following the incident noted that this resident was acting differently than usual, including talking slower and laughing more. The resident reported unmanaged pain as a reason for accepting the cannabis edible and expressed concern about being penalized for honesty but denied feeling unsafe. The other resident had a history of falls, degenerative disease of the nervous system, and hypertensive heart failure. This resident also reported receiving cannabis and tobacco products from the AA and described the use as voluntary and recreational, denying coercion or feeling unsafe. Interviews with staff and review of facility documentation confirmed that the AA's actions were not in accordance with facility policy, which strictly prohibits the sale, use, possession, or distribution of illegal substances, including marijuana, on facility property. The AA's job description did not include providing such substances, and the employee handbook emphasized maintaining a drug-free workplace. The facility acknowledged that the residents' safety was placed at risk due to the AA's actions, particularly regarding potential drug interactions, increased risk of falls, and impaired cognition.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in multiple incidents involving two residents who were subjected to aggressive and intrusive behaviors. One resident, with diagnoses including PTSD and bipolar disorder, reported that another resident repeatedly entered her room at night, splashed water on her, and stared at her while she was asleep. Despite informing staff that she did not feel safe, the resident continued to experience these intrusions, and staff reportedly expressed uncertainty about how to address the situation. The aggressive resident had a documented history of agitation, aggression, and altercations with both residents and staff, including throwing liquids and verbal outbursts. Another resident, diagnosed with major depressive disorder and dementia, was also subjected to abuse when the same aggressive resident spat on her in her room. Documentation and interviews confirmed that the aggressive resident frequently wandered throughout the facility, entering other residents' rooms and engaging in confrontational behavior. Staff and other residents corroborated the pattern of aggression, with one CNA noting that the aggressive resident had never been assigned a sitter despite a known history of attacks, and that such supervision could have been beneficial. Care plans for the affected residents identified the need to ensure their safety and emotional well-being, but the interventions described were insufficient to prevent further incidents. The facility's own policies required identification and management of residents at risk for abusive behavior, as well as the provision of a safe environment for all residents. However, the repeated incidents and lack of effective supervision or intervention allowed the aggressive resident to continue abusive behaviors, resulting in residents feeling unsafe and uncomfortable in their living environment.
Failure to Initiate Recommended Psychological Evaluation After Resident Altercation
Penalty
Summary
The facility failed to implement a recommended psychological evaluation for a resident following a resident-to-resident altercation. The Interdisciplinary Team (IDT) had recommended a psychological evaluation for the resident after an incident in which another resident entered her room, yelled at her, and threw water on her. The resident, who had diagnoses of post-traumatic stress disorder (PTSD) and bipolar disorder, also requested a psychological evaluation herself. Despite these recommendations and requests, the evaluation was not initiated. The resident's care plan included interventions for her mental health conditions and specifically called for psychological consultation as needed. After the altercation, the care plan was updated to address the emotional and physical well-being of the resident, including monitoring for signs of fear, anxiety, or agitation. Progress notes and interviews documented that the resident repeatedly expressed feeling unsafe in her room due to ongoing intrusions by the other resident, and staff were aware of her concerns. Interviews with facility staff, including the Social Services Director and the Director of Nursing, confirmed that the psychological evaluation was not completed as recommended by the IDT. Both staff members acknowledged that the evaluation should have been initiated following the incident. The failure to follow through on the IDT's recommendation and the resident's request for a psychological evaluation constituted the deficiency identified in the report.
Unreasonable Confinement of Residents by CNA
Penalty
Summary
The facility failed to protect the rights of two residents, identified as Resident 5 and Resident 6, from unreasonable confinement. Certified Nursing Assistant (CNA 7) tied the door of the room shared by these residents with a garbage bag, preventing Resident 5 from leaving the room. This action was taken because Resident 5, who has dementia and anxiety, was agitated and attempting to leave the room. Resident 6, who has congestive heart failure and chronic kidney disease, was also present in the room at the time. Interviews with various staff members, including CNA 1, Licensed Nurse (LN) 2, and the Director of Nursing (DON), confirmed awareness of the incident. CNA 1 stated that she would have reported the incident immediately if she had witnessed it, as she is a mandated reporter. LN 2 and the DON both acknowledged that tying the door shut was a form of abuse and involuntary seclusion, which is against the facility's policies. The DON confirmed that the incident was reported through a photo and text message sent by another CNA to the Assistant Director of Nursing (ADON). The facility's policies and procedures, including those on the use of restraints, abuse prohibition, resident rights, and dignity, clearly prohibit involuntary seclusion and emphasize treating residents with dignity and respect. The incident was identified as a violation of these policies, as it involved the confinement of residents against their will, impacting their sense of dignity and well-being.
Facility Fails to Maintain Sanitary and Homelike Bathroom Environment
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in two shared bathrooms used by eleven residents. Observations revealed large areas of peeling paint behind the toilets, open gaps behind the toilets, missing baseboards, and chipped trim on the sink counters. These conditions were confirmed by the Maintenance Director, who acknowledged the potential for injury from broken trim pieces and the unsightly appearance that did not provide a homelike environment. Interviews with staff, including a Licensed Nurse and the Assistant Director of Nursing, highlighted ongoing complaints about the bathroom conditions, which were not addressed. The Licensed Nurse expressed concerns about the potential for bacteria growth on the poorly maintained walls, which could affect residents' well-being. The Assistant Director of Nursing noted that any staff member could request maintenance repairs, but the current state of the bathrooms posed a safety hazard and failed to create a welcoming environment for residents. The Administrator confirmed the unacceptable condition of the bathrooms, recognizing them as safety issues that detracted from a homelike environment. The facility's policies on maintaining a homelike environment and providing maintenance services were reviewed, emphasizing the responsibility of the Maintenance Department to keep the building in good repair and free from hazards. However, the lack of communication and action regarding the maintenance requests contributed to the deficiency.
Failure to Implement and Revise Care Plan for Resident
Penalty
Summary
The facility failed to implement and revise a person-centered care plan for a resident, identified as Resident 1, who had a history of falls with recent major injury, poor memory, bouts of confusion, poor safety awareness, and impulsive behavior. The care plan, initiated on May 13, 2024, included interventions such as keeping the bed in the lowest position, ensuring the call light was within reach, and using bed rails when the resident was in bed. However, during an observation on January 6, 2025, it was noted that these interventions were not implemented. The resident's bed was not in the lowest position, the call light was inaccessible, and there were no side rails in place. Licensed Nurse 1 confirmed these observations and acknowledged that the resident would not be able to reach the call light if needed. The nurse also stated that the purpose of a care plan is to ensure safety precautions are in place to prevent falls and injuries. During a review with the Assistant Director of Nursing (ADON), it was confirmed that the care plan interventions were necessary for the resident's safety. The ADON also noted that a bed rail assessment conducted on November 16, 2024, indicated that the resident did not need bed rails, and the care plan should have been updated to reflect this. The facility's policies and procedures emphasize the importance of developing and implementing comprehensive person-centered care plans to meet residents' needs. These care plans should be reviewed and revised as the resident's condition changes. The failure to implement and update the care plan interventions for Resident 1 posed a potential safety risk, as the resident's needs were not adequately addressed, increasing the likelihood of falls and injuries.
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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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