Parkway Hills Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in La Mesa, California.
- Location
- 7760 Parkway Drive, La Mesa, California 91942
- CMS Provider Number
- 055078
- Inspections on file
- 42
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at Parkway Hills Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident was admitted with surgically repaired ankle and foot fractures and documented surgical wounds with staples, but no physician orders for wound care were obtained or documented for most of the month following admission, and the TAR showed no wound treatments during that time. Later, a wound care physician was consulted, orders were written, and treatments were documented, with subsequent notes indicating staple removal and resolution of most wounds. The wound care nurse stated it was her responsibility to assess new wounds and contact the physician for orders, acknowledged she did not recall obtaining orders for this resident, and stated she should have done so. The DON confirmed the expectation that the wound care nurse obtain and document physician orders for wound monitoring and treatment, in line with the facility’s clinical protocol requiring documentation of current treatments.
A resident with paraplegia was transferred to a GACH and, shortly after admission, was documented as calm, cooperative, medically cleared to return, and expressing a desire to go back to the original SNF, where an active bed-hold was in place. Despite this, the facility declined to readmit the resident when the hospital attempted to discharge him back, and instead the resident was later discharged to another SNF. In interviews, the AD and Administrator confirmed the decision not to readmit, which conflicted with the facility’s bed-hold and return policy requiring residents seeking to return within the bed-hold period to be allowed back to their previous room and evaluated based on their current condition.
The facility failed to maintain a safe and homelike environment, with hallway floors taped and missing sections creating tripping hazards, and a wobbly handrail posing risks to residents and staff. Two residents, one using a cane and another with a history of falls, expressed concerns about these conditions. The maintenance director acknowledged the issues, which predated his employment, and admitted to lacking a routine schedule for checking handrails.
The facility failed to staff an RN for at least 8 hours a day for 18 days between January and March 2024. Despite having sufficient LNs and CNAs, the facility could not retain RN services and had no staffing waivers. The DON highlighted the importance of an RN for managing staff and resident care. The absence of an RN had the potential to compromise resident care quality.
A long-term care facility experienced a 50% medication error rate during a medication pass observation. Errors included a nurse failing to administer full doses to a resident via a G-tube, another nurse delaying a resident's morning medications by over three hours, and a third nurse unable to administer a diabetes medication due to unavailability. The errors involved medications critical for managing conditions like seizures, hypertension, and diabetes.
Three residents in a LTC facility experienced significant medication errors. A resident did not receive the full dosage of medications through a G-tube due to improper administration. Another resident's morning medications were administered over three hours late, including critical medications for diabetes and hypertension. A third resident did not receive a diabetes medication because it was unavailable in the medication cart. These errors highlight issues in medication administration and availability.
The facility failed to ensure kitchen staff were competent in operating and documenting the use of low-temperature dishwashers. Observations revealed dishwashers were unsure of proper procedures for taking temperature and chlorine samples, leading to inaccurate logs and potential risks of foodborne illness. The Dietary Manager acknowledged the need for accurate documentation to ensure proper machine functioning.
The facility failed to provide palatable and flavorful meals, potentially affecting residents' meal intake and health. Residents reported issues such as bland, cold, and repetitive food, with some dietary needs not being met. A test tray observation confirmed the lack of seasoning and unsatisfactory texture in meals, highlighting a deficiency in food quality.
The facility failed to store soy sauce and teriyaki glaze as per manufacturer's instructions, requiring refrigeration after opening. Additionally, the low-temperature dishwasher did not reach the necessary rinsing temperature for sanitization, with staff unsure of proper temperature recording procedures. These issues could increase the risk of foodborne illness.
A resident's MDS was inaccurately coded regarding their pneumococcal vaccination status, leading to incorrect data submission to the federal database. Despite consenting to vaccines, the resident did not receive an updated pneumonia vaccine, as confirmed by the IP nurse and the resident. The DON acknowledged the error, stating the MDS should reflect accurate assessment per the RAI manual.
A resident with obstructive sleep apnea had a care plan that was not updated to include specific details about their CPAP machine's settings and cleaning procedures. Observations showed the CPAP machine was present but not in use, and staff interviews confirmed the resident used the machine at night. The facility's policy required detailed care plans, but this was not reflected in the resident's documentation, leading to a deficiency.
Two residents in the facility did not receive necessary assistance with nail care, despite facility policies requiring weekly trimming during showers. One resident, with hemiplegia and hemiparesis, had long, untrimmed nails with debris, while another resident with dementia had long, jagged nails. Staff interviews revealed a lack of action due to uncertainty and fear of causing harm, leading to a deficiency in care.
A resident with obstructive sleep apnea used a CPAP machine without a documented physician's order for its settings, leading to potential inappropriate care. The resident brought her own CPAP machine, and staff were unaware of the preprogrammed settings. The facility's policy required documentation of CPAP settings but lacked guidance on obtaining a physician's order.
A resident with a history of epilepsy and moderate cognitive deficits had an unlabeled medication cup left unattended on their bedside table. A nurse admitted to leaving the medications, which included Clonazepam and Depakote, because the resident did not want to take them immediately. Facility staff acknowledged that medications should not be left unattended due to risks of divergence and choking hazards.
The facility failed to maintain infection control procedures for three residents, including not changing oxygen tubing weekly for two residents and improper storage of a CPAP mask for another. The respiratory therapist was on emergency leave, leading to lapses in changing and labeling oxygen tubing. Additionally, a CPAP mask was not stored in a plastic bag as required, and there was no documentation of its cleaning. These deficiencies increased the risk of infection transmission.
The facility failed to offer and administer updated pneumococcal vaccines to two residents, despite having consent forms and CDC recommendations. One resident, cognitively intact with a history of pneumonia, was not offered the vaccine, while another resident with a G-tube and high-risk status had an incomplete consent form. The DON acknowledged the importance of vaccine administration, but the facility did not follow its policy, leading to the deficiency.
The facility did not meet the minimum square footage requirements for resident rooms, with some rooms providing less than the required 80 square feet per resident. Despite this, there was no observed adverse effect on residents' health or quality of life, and a waiver for the room size variance was recommended.
A resident with functional quadriplegia lacked adequate visual privacy during personal care due to insufficient curtain placement, allowing a roommate to view her when accessing the shared bathroom. The Maintenance Director acknowledged the issue and noted that adding a curtain would be a simple fix.
Failure to Obtain and Document Physician Orders for Surgical Wound Care
Penalty
Summary
The facility failed to obtain and follow treatment orders for a resident’s surgical foot and ankle wounds. The resident was admitted with a lateral malleolus fracture that had been surgically repaired, and nursing documentation on the day after admission noted surgical wounds with staples on the right foot and ankle. The physician’s History and Physical confirmed admission following a fall and ankle fracture with surgical repair. However, review of the physician’s orders from admission through late in the month showed no treatment orders for the surgical wounds during that period, and the Treatment Administration Record (TAR) documented that no wound treatments were performed for the surgical sites during most of the month. A wound care physician was consulted by the primary care physician later in the month to evaluate and treat the surgical wounds, and wound care orders were then written and carried out as documented on the TAR for the remaining days of the month. A subsequent wound care physician note indicated that surgical staples had been removed and most of the wounds had resolved, with instructions to continue wound care. The wound care nurse reported that she had assessed the resident’s skin and wounds at admission and five days a week thereafter, acknowledged that it was her responsibility to contact the physician for treatment orders, and stated she did not remember calling for such orders. She further stated that she should have obtained treatment orders so nurses would know to monitor for signs of infection or other problems. The DON stated her expectation that the wound care nurse obtain physician orders to monitor and treat wounds and that written physician orders should have been present in the medical record as evidence that treatments were provided, consistent with the facility’s clinical protocol requiring documentation of current treatments.
Failure to Readmit Hospitalized Resident Despite Active Bed-Hold and Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization despite an active bed-hold and the resident’s expressed desire to return, resulting in a deficiency related to transfer/discharge practices. The resident, who had paraplegia and was originally admitted to the facility on an unspecified date, was transferred to a general acute care hospital (GACH) on 3/28/26. According to the GACH Case Manager Interdisciplinary Note dated 3/30/26, the resident was calm, cooperative, medically cleared for discharge back to the skilled nursing facility, and stated that he wanted to return there. The resident had an active bed-hold at the facility at that time. Despite this, the facility did not accept the resident back. The GACH Nursing Note dated 4/3/26 documented that the resident was instead discharged to a different skilled nursing facility four days after being initially cleared for discharge back to the original facility. In an interview on 4/9/26, the Admissions Director stated that the GACH attempted to send the resident back, but the facility decided not to readmit him. In a subsequent telephone interview on 4/14/26, the Administrator confirmed that the facility decided not to readmit the resident from the GACH. This decision was inconsistent with the facility’s “Bed-Holds and Returns” policy, revised October 2022, which states that residents with a bed-hold who seek to return within the bed-hold period are allowed to return to their previous room and that post-hospitalization return decisions for residents with clinical or behavioral concerns are to be based on their current condition at the time of transfer.
Unsafe and Unhomelike Environment Due to Poor Flooring and Handrail Conditions
Penalty
Summary
The facility failed to provide a safe and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The hallway floors were found to be in poor condition, with gray duct tape used to secure the flooring and missing sections creating uneven surfaces. This was particularly concerning for residents with mobility issues, such as one resident who used a cane and expressed concern about the potential for injury due to the unstable flooring. Another resident, with a history of falling, also expressed fear about the missing flooring near their room. The maintenance director acknowledged the taped flooring and missing sections, noting that these issues predated his employment. Additionally, a handrail outside a resident's room was observed to be wobbly and secured with a loose screw, posing a risk to residents and staff. A CNA confirmed the handrail's instability and the danger posed by the uneven flooring. The maintenance director admitted to not having a routine schedule for checking handrails and was unaware of the issue until it was pointed out. The facility's policy on providing a safe and homelike environment was not adhered to, as evidenced by these observations.
Failure to Staff RN for Required Hours
Penalty
Summary
The facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days between January 1, 2024, and March 31, 2024. This deficiency was identified through a review of the PBJ Staffing Data Report and CASPER Report 1705, which indicated that no RN hours were recorded for 19 days within the specified period. The Staffing Coordinator confirmed that on specific dates in January, February, and March, there was no RN scheduled for at least 8 hours. Despite having sufficient Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) on those days, the facility was unable to retain RN services and had no waivers for staffing. Attempts to use registry RNs were made, but the registry was found to be undependable. The Director of Nursing (DON) emphasized the necessity of having an RN on duty for at least 8 hours daily to manage staff, oversee resident care, and administer intravenous medications. The facility's policy on staffing mandates providing a sufficient number of skilled staff to meet resident care plans and facility assessments. The absence of an RN for the required hours had the potential to result in inadequate supervision and compromised quality of care for residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent medication errors of less than 5% during a medication pass observation involving three licensed nurses and three residents. Licensed Nurse 1 (LN 1) administered medications to Resident 37 via a gastronomy tube but omitted one medication and failed to administer the full dose of several medications. The medications were not fully dissolved, leaving remnants in the medication cups, which resulted in Resident 37 not receiving the complete dosage necessary for managing health complications such as seizures, hypertension, and anxiety. Licensed Nurse 2 (LN 2) did not administer Resident 31's morning medications as scheduled, resulting in a delay of over three hours. This included medications for diabetes, high blood pressure, depression, and nutritional supplements. The delay was attributed to LN 2's incorrect assumption that Resident 31 was with the rehabilitation therapy team, which was not the case. The delay in medication administration was highlighted by the electronic medication administration record, which indicated the medications were late. Licensed Nurse 3 (LN 3) was unable to administer Resident 33's Januvia, a medication for diabetes management, because it was not available in the medication cart. LN 3 was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The Director of Nursing emphasized the importance of administering medications according to the facility's policy to prevent complications and ensure resident safety. The facility's medication error rate was calculated at 50%, significantly exceeding the acceptable threshold.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors. For Resident 37, a Licensed Nurse (LN) administered medications through a gastronomy tube but omitted one medication and did not ensure the full dose of medications was administered. The nurse was unsure of the medication being administered due to similar unlabeled medication cups and mixed all medications with the same syringe, leading to undissolved medication remnants. This resulted in Resident 37 not receiving the full dosage of medications necessary for managing epilepsy, hypertension, and mood stability. Resident 31 did not receive morning medications as scheduled because the nurse missed administering them, believing the resident was with the rehabilitation therapy team. The medications were administered more than three hours late, which included critical medications for diabetes, high blood pressure, and depression. The delay in administration was not acceptable, as it could lead to complications such as a hypertensive crisis or uncontrolled blood sugar levels. For Resident 33, the nurse was unable to administer Januvia, a medication for diabetes management, because it was not available in the medication cart. The nurse was unaware if the medication had been ordered and needed to notify the pharmacy for delivery. The absence of this medication could lead to hyperglycemia, highlighting the importance of ensuring medication availability and adherence to the facility's medication administration policy.
Incompetency in Dishwasher Operation and Documentation
Penalty
Summary
The facility failed to ensure that kitchen staff, specifically dishwashers, were competent in operating, documenting, and checking the water temperatures of two low-temperature dishwashers. This deficiency was identified through observations, interviews, and record reviews. During an observation, a dishwasher was seen taking a chlorine sample from the water exit site instead of directly from the dishes, and was unsure of where to take the temperature reading for the log. The temperature logged was 120 degrees Fahrenheit, but upon demonstration, the machine's thermometer showed 115 degrees Fahrenheit, and an independent reading showed 110 degrees Fahrenheit. The dishwasher was unaware of the appropriate temperature required. Further observations with the Dietary Manager revealed that the dishwashers were likely not taking accurate temperature readings, as the log showed consistent numbers despite different measurements. The Dietary Manager acknowledged that the machine was not reaching the appropriate temperature for rinsing and that manual washing would be necessary. Another dishwasher was also observed taking a chlorine sample incorrectly and was unaware of the proper procedure. The Dietary Manager admitted that the dishwashers should understand the importance of taking accurate temperatures and chlorine samples to ensure the machine's proper functioning and prevent foodborne illness.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and flavorful, which could potentially decrease meal intake and contribute to weight loss among residents. During a dining observation and interviews with residents, several concerns were raised about the quality of the food. Residents reported issues such as grilled cheese sandwiches not being cooked properly, dry macaroni and cheese, bland meat, cold food, and repetitive menu items like broccoli. Additionally, a vegetarian resident was served fish, and another resident on a renal diet received salty food. The facility's menu for the day included roast turkey with gravy and other items, but residents expressed dissatisfaction with the taste and temperature of the meals. A test tray observation conducted with the Dietary Manager (DM) and Registered Dietician (RD) revealed that the food served was bland and lacked seasoning. The temperatures of the dishes were taken, and while they were within safe ranges, the taste and texture were not satisfactory. The pureed diet meals had more seasoning compared to the regular diet meals. The DM acknowledged the importance of residents enjoying their meals to prevent weight loss and negative health impacts. The facility's policy on resident food preferences indicated that a variety of foods should be offered at each meal, but the observations and resident feedback suggested that this was not being effectively implemented.
Improper Food Storage and Dishwasher Temperature Issues
Penalty
Summary
The facility failed to store soy sauce and teriyaki glaze according to the manufacturer's recommendations, which required refrigeration after opening. During an observation and interview with the Dietary Manager (DM), it was found that opened containers of these sauces were stored in the dry storeroom, contrary to the instructions on the labels. The DM admitted to being unaware of the need for refrigeration for soy-based sauces and disposed of the sauces upon realizing the mistake. The facility's policy on food storage emphasized the importance of checking food labels to prevent serving spoiled or contaminated food, which could lead to foodborne illness. Additionally, the facility did not ensure that the low-temperature dishwasher reached the appropriate rinsing temperature for sanitization. An observation and interview with Dishwasher (DW) 11 revealed confusion about where to take temperature readings, with the DW incorrectly using a chlorine test strip for this purpose. The recorded temperature was below the required 120 degrees Fahrenheit, with independent measurements confirming this discrepancy. The DM acknowledged that the dishwashers might not have been taking accurate temperature readings and were likely recording incorrect data. The facility's policy required maintaining a temperature log to ensure the dishwashing machine operated within the manufacturer's guidelines to prevent the spread of foodborne illness through contaminated dishes.
Inaccurate MDS Coding for Resident's Vaccination Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident's vaccination status, leading to the submission of incorrect information to the federal database. Resident 31, who was readmitted to the facility with a history of congestive heart failure, was found to have an inaccurately coded MDS regarding their pneumococcal vaccination status. The resident's MDS indicated that their pneumococcal vaccination was up to date, despite the fact that an updated pneumonia vaccine had not been administered, as confirmed by the Infection Prevention (IP) nurse during a record review. Interviews and record reviews revealed that Resident 31 had consented to receive vaccines during the 2023-2024 vaccine season but was not offered or given an updated pneumonia vaccine. The resident confirmed receiving COVID-19 and flu vaccines but not the pneumonia vaccine. The Director of Nursing (DON) acknowledged the error, stating that the MDS should reflect an accurate assessment per the Resident Assessment Instrument (RAI) manual, which specifies coding the pneumococcal vaccination status as not up to date if the vaccine was not administered.
Failure to Update CPAP Care Plan for Resident with Sleep Apnea
Penalty
Summary
The facility failed to update a resident-centered care plan for a resident with obstructive sleep apnea who required the use of a CPAP machine. The resident was admitted with a diagnosis of obstructive sleep apnea, and during an observation, the CPAP machine was noted to be present but not in use, with the mask placed on the bed. Interviews with staff revealed that the resident applied the CPAP mask at night and removed it in the morning. A review of the care plan by the Minimum Data Set Nurse revealed that it lacked specific details regarding the CPAP machine's settings and the cleaning procedures for the tubing and mask. The facility's policy on comprehensive person-centered care plans emphasized the need for detailed interventions derived from thorough assessments, but this was not reflected in the resident's care plan. The absence of documentation for these critical aspects of care indicated that they were not being addressed, leading to a deficiency in providing appropriate care and treatment for the resident.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with nail care for two residents, Resident 43 and Resident 30, which was identified during a survey. Resident 43, who was admitted with hemiplegia and hemiparesis, had intact cognition but required substantial assistance with personal hygiene due to functional limitations in the upper extremity. Observations revealed that Resident 43 had long, untrimmed fingernails with debris underneath, and the resident reported that no one had cut his nails for a long time. Despite the facility's policy requiring weekly nail care, staff interviews indicated a lack of action due to uncertainty about the resident's health condition and fear of causing harm. Resident 30, diagnosed with dementia and muscle weakness, also had long and jagged fingernails. The resident expressed a desire for assistance with nail trimming, but observations over several days showed no change in the condition of the nails. Interviews with staff revealed that nail care was expected to be provided during shower days, but this was not done for Resident 30. The facility's policy allowed CNAs to trim fingernails unless the resident had diabetes, yet the necessary care was not provided. The facility's policy and procedure documents indicated that nail care should be performed weekly with showers and as needed. However, the failure to adhere to these guidelines resulted in the deficiency, as both residents did not receive the required assistance with nail care, potentially affecting their dignity and increasing the risk of infection and injury.
Lack of Physician's Order for CPAP Settings
Penalty
Summary
The facility failed to ensure a physician's order for the settings of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with obstructive sleep apnea. The resident, who brought her own CPAP machine from home, did not have a documented physician's order specifying the CPAP settings. During an observation, the CPAP machine was seen on a plastic container beside the resident's bed, with the mask placed on the bed. Interviews with the licensed nurse and respiratory therapist revealed that the CPAP was used during sleep hours at preprogrammed settings, but there was no knowledge of what those settings were, nor was there an order to verify them. The resident expressed concern that staff might alter the CPAP settings, as they were not documented in the physician's order. The Director of Nurses confirmed that CPAP settings should be included in the physician's order to ensure staff are aware of the correct settings. A review of the facility's policy and procedure on CPAP/BIPAP support indicated the need to document mode and settings in the resident's medical record, but it did not provide guidance on obtaining a physician's order for the CPAP machine prior to its use.
Unsecured Medication at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications for a resident were secured and locked during a medication storage inspection. During an observation, a clear medication cup containing six medications was found unlabeled and unattended on the bedside table of a resident who had been readmitted to the facility with a history of epilepsy and moderate cognitive deficits. The resident stated that a licensed nurse had left the medication cup on the table for later consumption. A certified nursing assistant confirmed witnessing the medication cup on the table and noted that medications should not be left unattended for safety reasons. The licensed nurse admitted to leaving the medications at the resident's bedside because the resident did not want to take them at that time, and the nurse did not want to delay administering medications to other residents. The medications included Clonazepam, fenofibrate, fish oil, a multivitamin, vitamin D, and Depakote. Another licensed nurse and the Director of Nursing both stated that medications should not be left unattended due to the risk of medication divergence, potential medication errors, and the possibility of causing a choking hazard. The facility's policy on medication storage requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Infection Control Deficiencies in Oxygen Tubing and CPAP Mask Management
Penalty
Summary
The facility failed to implement and maintain infection control procedures for three residents, leading to potential risks of infection. For Residents 27 and 34, the facility did not adhere to its policy of changing oxygen tubing weekly. Resident 27, who has chronic respiratory failure, COPD, and congestive heart failure, was observed with oxygen tubing labeled from two weeks prior, and there was no consistent labeling or changing of the tubing. Similarly, Resident 34, with diagnoses including congestive heart failure and chronic respiratory failure, had oxygen tubing that was not changed weekly as required. The respiratory therapist, who was responsible for changing the tubing, was on emergency leave, and the task was not adequately covered by other staff, leading to lapses in the procedure. Resident 6, diagnosed with obstructive sleep apnea, had issues with the storage and maintenance of their CPAP mask. The mask was observed on the floor and not stored in a plastic bag as per infection control guidelines. The licensed nurse stated that the mask should be stored in a plastic bag when not in use, but the resident reportedly refused this practice, although the resident later denied such a refusal. The respiratory therapist did not document the cleaning of the CPAP mask and tubing, which was supposed to occur weekly, further contributing to the deficiency. The facility's policies and procedures, including those for infection control and CPAP/BIPAP support, were not adequately followed, leading to these deficiencies. The lack of proper labeling, changing, and storage of medical equipment increased the risk of infection transmission among residents and staff. Interviews with staff, including the respiratory therapist, licensed nurse, and director of nursing, confirmed the expectations and importance of these procedures, highlighting the lapses in adherence to the facility's infection control policies.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and administer an updated pneumococcal vaccine to two residents, Resident 31 and Resident 37, as per the Centers for Disease Control (CDC) recommendations. Resident 31, who was cognitively intact and had a history of congestive heart failure and pneumonia, was readmitted to the facility and had a consent form dated for the vaccine season. However, the vaccine was not administered, and the resident confirmed that he was not offered the updated pneumonia vaccine, although he would have consented if it had been offered. Resident 37, who had a history of epilepsy and required nutritional and medication administration through a G-tube, was also not offered the updated pneumonia vaccine. The consent form for Resident 37 was incomplete, with no indication of consent or refusal for the pneumonia vaccine. The Infection Prevention (IP) nurse acknowledged that the vaccine was not offered due to the incomplete consent form, despite the resident's high-risk status for pneumonia infections due to his health condition. The Director of Nursing (DON) confirmed the importance of offering and administering vaccines to all residents if consented. The facility's policy, revised in October 2023, stated that pneumococcal vaccines should be administered unless medically contraindicated, already given, or refused, in accordance with CDC recommendations. However, the failure to adhere to this policy resulted in the deficiency noted in the report.
Room Size Deficiency in Resident Accommodations
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in four of its 28 resident rooms. Specifically, rooms designated for two residents only provided 71.5 square feet per resident, falling short of the 80 square feet requirement. Additionally, a room accommodating three residents offered only 73.66 square feet per resident, and a room with four residents provided 76 square feet per resident. Despite these deficiencies, the variations in room size were not observed to adversely affect the residents' health, safety, quality of care, or quality of life during the survey. The Department recommended the continuance of the room size variance/waiver for the affected rooms.
Inadequate Privacy Curtains Compromise Resident Privacy
Penalty
Summary
The facility failed to provide adequate visual privacy for a resident, identified as Resident 1, who was admitted with conditions including heart failure and functional quadriplegia, necessitating assistance with personal care. During an observation and interview, it was noted that the privacy curtain for Resident 1's bed did not extend to separate the walkway to the shared bathroom, allowing other residents to potentially view Resident 1 during personal care activities. Resident 1 expressed concerns about the lack of privacy, stating that if her roommate needed to use the bathroom while she was receiving care, the roommate would have a full view of her body due to the inadequate curtain placement. The roommate, identified as Resident 2, confirmed that accessing the bathroom required entering Resident 1's privacy curtain area, which would result in a clear view of Resident 1 during personal care. The Maintenance Director acknowledged the issue, stating that the current curtain setup did not prevent other residents from accessing the shared bathroom without breaching Resident 1's privacy. The director also mentioned that adding a curtain between Resident 1's bed and the walkway to the bathroom would be a simple solution. The facility's policy on confidentiality and personal privacy, revised in October 2017, emphasizes the importance of protecting residents' privacy during personal care, which was not upheld in this instance.
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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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