Riverwood Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Stockton, California.
- Location
- 5320 Carrington Circle, Stockton, California 95210
- CMS Provider Number
- 555496
- Inspections on file
- 32
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 60
Citation history
Health deficiencies cited at Riverwood Health Care during CMS and state inspections, most recent first.
The facility failed to prevent resident-on-resident physical abuse when two roommates with a known history of arguments were left together without adequate interventions, resulting in one resident with severe cognitive impairment and multiple neurologic conditions being struck in the back of the head by the other resident. Staff had prior knowledge that one resident became easily agitated and that the pair had repeated disagreements over lights and TV volume, but these behaviors and conflicts were not documented or care planned. On the day of the incident, a CNA heard yelling, temporarily separated the residents and notified an LN that they should be kept apart, but after returning the cognitively impaired resident to the shared room, the other resident got up from bed and hit him from behind, leading to staff intervention and post-incident assessment.
Two residents with a history of disagreements were involved in an incident where one struck the other in the back of the head after staff had earlier observed and reported escalating verbal conflict and suggested the residents be separated. The subsequent abuse investigation was incomplete: only two staff were interviewed with no follow-up questions, prior arguments and behavioral concerns were not documented or reported, and the incident itself was not entered into the medical records. The DON, who had no prior training or experience in conducting abuse investigations, shared limited investigative duties with the ADON, resulting in a failure to uncover prior incidents or fully understand the events leading to the abuse, contrary to the facility’s abuse policy requiring thorough investigation and documentation.
The facility failed to timely notify the State Agency (SA) of a change in the DON position for a census of 85 residents. The DON began the role but the required change-of-DON application and written notice were not completed and mailed until weeks later, as confirmed by the DON’s and acting ADM’s interviews and the dated documents. The ADM reported being unaware of the required timeframe for notification, and SA records showed the DON application was received several days after it was mailed, delaying SA verification of the DON’s qualifications.
A resident with multiple comorbidities was admitted on oxygen and IV antibiotics with hospital discharge orders for oxygen at 2 L/min for SOB or low O2 saturation with immediate MD notification, and weekly CBC and Chem 7 labs. The weekly CBC order was never transcribed into facility orders, and there was no evidence that CBCs were drawn. One morning, the resident complained of SOB and had an O2 saturation of 88%; an LVN administered ordered albuterol and independently increased oxygen from 2 L/min to 4 L/min, despite regulations prohibiting LVNs from adjusting oxygen flow and facility policy requiring prompt MD notification for significant changes in condition. The LVN did not notify an RN or the MD/NP of the change in condition, and there was no oxygen therapy care plan in place. Later that morning, the NP found the resident unresponsive with CPAP still on, initiated a code, and EMS pronounced the resident deceased, with the MD and NP confirming they had not been notified earlier of the resident’s SOB and low O2 saturation.
A resident admitted with multiple complex conditions, including sepsis, sleep apnea, and morbid obesity, arrived with hospital discharge instructions and MD orders for continuous O2 at 2 L/min via nasal cannula and specific parameters for use and physician notification. Although the facility noted and carried out the hospital discharge orders and had a policy requiring a baseline care plan within 48 hours that includes necessary healthcare information, the baseline care plan summary did not include O2-related interventions or instructions. The DON confirmed that no specific O2 care plan was developed for this resident, resulting in a failure to create a person-centered baseline care plan for oxygen therapy.
Staff, including CNAs and LNs, used a group messaging app on personal smartphones to communicate resident names, room numbers, and medical information, despite the app not being HIPAA-compliant. The DON and ADM acknowledged that the app lacked necessary security controls, and staff were not required to report lost or stolen phones, increasing the risk of unauthorized access to PHI. Facility policy required protection of resident information, but the use of this app directly contradicted those requirements.
Two residents at risk for elopement were not adequately protected due to the facility's failure to implement necessary prevention measures. A resident with dementia exhibited exit-seeking behavior, but the facility did not initiate orders for a wander guard or conduct an elopement risk assessment. The resident's wander guard was not functioning, leading to an elopement and injury. Another resident was found with an expired wander guard, highlighting lapses in monitoring and maintenance of safety devices.
The facility failed to follow safe injection practices by storing pre-drawn, unlabeled flu vaccine syringes in a staff food refrigerator. Additionally, pneumonia vaccines for three residents were documented as administered but were found in the refrigerator intended for medication destruction. The facility did not adhere to its policies on vaccine documentation and storage, leading to these deficiencies.
The facility failed to ensure safe medication use and destruction practices, including undated and unsigned medication destruction logs, improper storage of discontinued medications, and discrepancies in vaccine administration records. These issues could lead to drug diversion and unsafe drug use.
The facility failed to ensure safe medication storage, with prescription medications and vaccines improperly stored in a dorm-style refrigerator alongside personal food items, without temperature monitoring or proper labeling. Additionally, discontinued medications were found in an active storage area in the main medication room. The DON and ADON were unaware of these practices, which violated the facility's policies on medication storage and disposal.
A facility failed to provide a written discharge notice to a resident's responsible party, resulting in a deficiency. The RP was verbally informed of the discharge when the resident was sent to the hospital, but no written notice or information on appeal rights was provided. The facility administrator confirmed the lack of documentation in the resident's medical record.
A resident with multiple diagnoses was sent to a hospital on a 5150 hold due to aggressive behavior. The facility failed to reassess the resident's condition or communicate with the hospital about the resident's needs for returning. Interviews and hospital notes revealed a lack of documentation and communication, potentially impacting the resident's psychosocial well-being.
The facility exceeded the acceptable medication error rate, with two residents receiving plain multivitamins instead of the prescribed multivitamins with minerals. The errors were made by an LVN who was unclear about the different types of multivitamins, despite clear physician orders. The DON and Administrator emphasized the need for staff to accurately follow medication orders.
A facility failed to follow physician's orders for a resident's medication administration, leading to carvedilol being given when the resident's SBP was below 130 mmHg and midodrine when SBP was above 120 mmHg. Nursing staff misunderstood the parameters, resulting in multiple instances of incorrect medication administration.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. Despite training and posted signage, a CNA entered the resident's room wearing only gloves and a mask, omitting the required gown. The Director of Nursing and Administrator confirmed that staff had been trained on EBP and expected to follow the PPE guidelines.
A facility failed to carry out a physician's order to reduce a resident's gabapentin dosage, resulting in the resident refusing several doses and leaving the facility against medical advice. The ADON and DON confirmed that the order was communicated but not executed, and the nurse should have checked the physician's note and clarified the order.
Failure to Prevent Resident-on-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. Resident 2, who had epilepsy, depression, muscle weakness, unsteadiness on feet, and a traumatic brain injury, and who was assessed with a BIMS score of 7 indicating severe cognitive impairment, was sharing a room with Resident 1. Staff were aware that Resident 1 could become easily agitated, upset, and rude, and that the two residents had a history of disagreements and arguments about lights and television volume at night. These prior conflicts were not documented or reported in the medical record, and no behavior concerns for Resident 1 were care planned or communicated to leadership. On the day of the incident, CNA 1 was preparing Resident 2 for a shower when Resident 1 began yelling at Resident 2. CNA 1 moved Resident 2 into the hallway to prevent escalation and notified Resident 1’s nurse that Resident 1 was upset and yelling, and that the residents should be separated. CNA 1 then escorted Resident 2 to the shower and returned with him about 15 minutes later. She positioned Resident 2 in his wheelchair in front of his bed toward the back of the room, with his back to the door and to Resident 1’s bed, while she stood along the back wall at Resident 2’s nightstand. While CNA 1 was at the nightstand, she observed Resident 1 get up from his bed, approach Resident 2 from behind, and hit him in the back of the head with a fist. CNA 1 called for help, and staff responded and separated the residents. LN 1 arrived and saw Resident 1 standing between the two beds; both residents were yelling, and Resident 2 reported he had been “sucker punched” in the back of the head and was upset. LN 2, the nurse assigned to both residents that day, later assessed Resident 2 for injuries; Resident 2 stated that Resident 1 came over and hit him in the back of the head and appeared surprised, scared, and startled. The DON and Social Services Director confirmed there was no documentation of prior disagreements or behavior issues in either resident’s record, despite staff knowledge of previous arguments and Resident 1’s tendency to become easily agitated.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of resident-to-resident abuse following an incident in which one resident hit another. On the day of the incident, a CNA reported that while preparing one resident for a shower, she heard the roommate yelling and upset, moved the resident into the hallway to prevent escalation, and notified the assigned nurse that the residents should be separated. After completing the shower and returning the resident to the room, the CNA observed the roommate get up from his bed and strike the resident in the back of the head with a closed fist, then called for help and staff separated the residents. The assigned nurse later confirmed he was told the residents were fighting and that the struck resident reported being hit in the back of the head, but he did not document the incident in either resident’s medical record because the ADON and DON were already present taking statements. The facility’s investigation was limited and did not capture key information about prior behaviors and conflicts between the two residents. The ADON confirmed that only two staff members were interviewed and that he asked the CNA only what happened and what she witnessed, without follow-up or clarifying questions, and he could not recall receiving formal training on taking statements or investigating abuse. Another CNA reported she had been told in morning report that the resident who later hit his roommate could become easily agitated, upset, and rude. A nurse reported that the two residents had a history of disagreements and arguments about lights and television volume at night, occurring a few times after they were roomed together, and that the resident who later hit his roommate was known to yell out for staff and be impatient; however, she did not document or report these prior arguments because she felt she had resolved them. The DON stated that when a nurse is notified of residents arguing, she expected the nurse to address it immediately to prevent escalation, and that it was her expectation that staff document and share all incidents between residents that could lead to abuse. Upon review of both residents’ medical records, the DON confirmed there was no documentation of previous disagreements between the two residents and no documented concerns with the aggressor’s behaviors, and she had no knowledge of any prior incidents between them. The DON was assigned by the previous Administrator to complete the abuse investigation and the five-day follow-up report to the State Agency, confirmed it was her first time fully completing an investigation, shared investigative duties with the ADON, and reported she had not been trained in how to complete an abuse investigation. The facility’s abuse policy required that suspected or alleged abuse be immediately reported, thoroughly investigated, and completely documented, with a verification of incident investigation report completed within five working days, but the investigation did not meet these standards and did not reveal several past incidents or provide a full picture of events leading to the abuse.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to provide timely written notice to the State Agency (SA) of a change in the Director of Nursing (DON) position for a census of 85 residents. The current DON reported in an interview that she began her role on 12/10/25 and that corporate staff requested her licensing information, but she did not know when the leadership change notification was sent to the SA. During a concurrent interview and record review, the acting Administrator (ADM) confirmed that the change-of-DON documents were dated and mailed on 1/7/26, rather than at the time the change occurred, and stated he was not aware of the time requirement for notification. A facility letter to the SA dated 1/7/26, signed by the DON the same day, referenced a “CHANGE OF DIRECTOR OF NURSING Application,” and SA database records showed the DON application was received on 1/13/26. This delay in notification postponed the SA’s verification that the DON was qualified to lead clinical services, which the report states had the potential to compromise resident safety and regulatory compliance for all 85 residents. The deficiency centers on the facility’s inaction in promptly notifying the SA of the DON change at the time it occurred, as required by rules on disclosure of ownership and administrative personnel changes. The DON’s start date, the later date of the application and mailing, and the ADM’s lack of awareness of the time requirement are specifically documented as the factors leading to the late reporting.
Failure to Provide Timely Respiratory Assessment, Physician Notification, and Lab Follow-Through After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate respiratory care, timely clinical assessment, and appropriate physician notification for a resident with complex medical conditions, including sepsis, facial cellulitis, type 2 diabetes, hypertension, morbid obesity, sleep apnea, and blindness. The resident was admitted from the hospital with discharge instructions that included oxygen at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification, and weekly CBC and Chem 7 labs after SNF admission. The facility signed that these hospital discharge orders were noted and would be carried out, but the weekly CBC order was never transcribed into the facility’s physician orders, and there was no evidence that CBC labs were ever drawn. The DON confirmed that the CBC order was not transcribed or completed, despite the resident being on IV antibiotics for infection. On the morning of the incident, the resident was in bed with CPAP and oxygen at 2 L/min via nasal cannula. Around change of shift, a CNA informed LVN 1 that the resident was complaining of shortness of breath and had an oxygen saturation of 88%. LVN 1 assessed the resident, confirmed shortness of breath and low oxygen saturation, administered two puffs of albuterol as ordered, and increased the resident’s oxygen from 2 L/min to 3 L/min and then to 4 L/min via nasal cannula, using her own nursing judgment. LVN 1 documented that the oxygen saturation improved to 94–95% by 8:15 a.m. and stated she remained in the room monitoring the resident until that time. LVN 1 acknowledged that this was a change in condition and that she did not notify the physician, explaining that she was passing medications and did not get the chance to call. The SBAR and progress notes showed that the physician was not notified of the change in condition until after the resident was found unresponsive. The facility’s DON stated that it was not within an LVN’s scope of practice to perform a full clinical assessment for a change in condition or to adjust oxygen flow rates under the updated respiratory care regulations. The DON confirmed that LVN 1 did not escalate the resident’s care to an RN for a full assessment and that LVN 1 should not have titrated the oxygen without a physician’s order. The DON also confirmed that there was no oxygen therapy care plan developed for the resident, despite the resident being on oxygen therapy. Later that morning, at approximately 10:10 a.m., the NP found the resident in bed unresponsive, with no pulse and no respirations, and the CPAP still in place even though the order specified CPAP off at 7 a.m. A code was called, CPR was initiated, and 911 was contacted, but paramedics pronounced the resident deceased at 10:26 a.m. The NP and Medical Director both stated that staff should not have titrated oxygen without an order and that they were not notified of the resident’s earlier change in condition involving shortness of breath and low oxygen saturation. The facility’s written policy on change in resident condition required prompt notification of the attending physician when there is a significant change in the resident’s physical condition, including specific instructions to notify the physician of changes in condition. The facility’s in-service education and regulatory guidance from the Respiratory Care Board and the Board of Vocational Nursing and Psychiatric Technicians specified that LVNs may not initiate or adjust oxygen liter flow or concentration and must work under the supervision of an RCP, RN, or physician. Despite these policies and regulations, LVN 1 independently adjusted the resident’s oxygen flow, did not notify an RN or physician of the change in condition, and the facility did not ensure transcription and implementation of the hospital’s weekly CBC orders. These combined failures resulted in the physician not being aware of the resident’s change in condition, a delay in adequate assessment and potential identification of the need for a higher level of care, and delay in adequate care and treatment, and the resident died within two hours of the documented change in condition.
Failure to Develop Baseline Oxygen Care Plan on Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the interventions and instructions needed to provide effective and person-centered oxygen therapy for a newly admitted resident. The resident was admitted with multiple diagnoses, including acute osteomyelitis, sepsis, cellulitis and abscess of the mouth, type 2 diabetes, essential hypertension, bilateral blindness, depression, sleep apnea, morbid obesity, and anxiety. Hospital inpatient discharge instructions directed that oxygen be started at 2 L/min for shortness of breath, chest pain, or oxygen saturation less than 90%, with immediate physician notification for specified respiratory changes and abnormal findings. The facility signed the hospital discharge orders as noted and carried out, and the physician’s orders dated shortly after admission included continuous oxygen at 2 L/min via nasal cannula every shift. Despite these orders, review of the resident’s care plans showed that no oxygen care plan was developed. The DON confirmed during interview and concurrent record review that the resident was admitted with oxygen therapy and that the baseline care plan summary, which the facility used as the resident’s baseline care plan, did not include specific interventions and instructions for oxygen therapy. The DON acknowledged that a specific oxygen care plan was not developed for this resident. Review of the facility’s “Baseline Care Plan Summary” policy, revised in October 2025, indicated that the facility was required to develop and implement a baseline care plan within 48 hours of admission that includes the minimum healthcare information necessary to properly care for a resident, but this was not done for the resident’s oxygen needs.
Unauthorized Disclosure of PHI via Non-Compliant Messaging App
Penalty
Summary
Facility staff failed to ensure the privacy and confidentiality of residents' personal and medical records by communicating protected health information (PHI) through a group messaging platform (GMP) installed on staff members' personal smartphones. Multiple interviews and observations confirmed that both licensed nurses and certified nursing assistants routinely used this application to share resident names, room numbers, medical updates, and care needs. The GMP was not password-protected once the phone was unlocked, and staff were not required to report if their phones were lost or stolen, increasing the risk of unauthorized access to PHI. The Director of Nursing (DON), Administrator (ADM), and other staff acknowledged that resident identifiers and medical information were shared through the GMP, and that the application was not HIPAA-compliant. The DON admitted that there was no way to control or monitor who could access the information if a staff member's phone was compromised. Staff interviews revealed that the expectation was to use the GMP for communication about resident care, and some staff expressed concerns about the privacy implications, with at least one nurse refusing to install the app due to HIPAA concerns. Facility policies reviewed indicated that PHI should only be disclosed as permitted by law and that employees are responsible for protecting resident information from unauthorized release. However, the use of the GMP, which lacks necessary security features and is not HIPAA-compliant, directly contradicted these policies. The facility's own leadership acknowledged the risks and lack of control over PHI once it was shared via staff personal devices.
Failure to Implement Elopement Prevention Measures
Penalty
Summary
The facility failed to implement adequate elopement prevention measures for two residents at risk for elopement. Resident 1 exhibited exit-seeking behaviors, but the facility did not initiate orders for a wander guard device or conduct an elopement risk assessment as outlined in the resident's care plan. Additionally, Resident 1's wander guard was not functioning at the time of elopement, and there was inconsistent documentation of the device's placement in the resident's chart. These oversights led to Resident 1's elopement, resulting in a head injury, hospital visit, and stitches. Resident 1, who had a history of dementia and wandering behavior, was not adequately monitored or protected despite having a care plan in place. The care plan included interventions such as frequent monitoring and the use of a wander guard device, but these were not effectively implemented. The facility's staff, including licensed nurses and the Director of Nursing, acknowledged the lack of necessary orders and assessments, which contributed to the resident's ability to leave the facility unsupervised. Furthermore, Resident 3 was found wearing an expired wander guard, indicating a lapse in the facility's monitoring and maintenance of safety devices. The Maintenance Assistant and a licensed nurse confirmed the expiration, and the Director of Nursing acknowledged the risk of elopement due to non-functional devices. The facility's failure to ensure the functionality and timely replacement of wander guards posed a significant risk to residents' safety.
Improper Vaccine Storage and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for safe injection practices, as evidenced by the improper storage and handling of vaccines. The Infection Preventionist (IP) stored pre-drawn, unlabeled, and undated flu vaccine syringes in a staff food refrigerator, which also contained personal food items. The IP admitted to preparing these syringes without labeling them, as she intended them for staff use, and acknowledged that the refrigerator's temperature was not monitored. This practice was deemed unsafe by the Director of Nursing (DON), who was unaware of the situation until it was brought to her attention. Additionally, pneumonia vaccines for three residents were documented as administered, yet the actual vaccines were found in the same refrigerator, intended for medication destruction. The Assistant Director of Nursing (ADON) could not explain how these vaccines, documented as given nearly a year prior, were still present in the refrigerator. The facility's policy required documentation of vaccine lot numbers and expiration dates in residents' medical records, which was not adhered to in these cases. The facility's policies on administering medications and vaccinations were not followed, as evidenced by the improper storage and lack of documentation. The DON and Administrator could not provide a reason for storing discontinued medications in a refrigerator instead of a designated medication cabinet. The facility's failure to comply with its policies and CDC guidelines for vaccine administration and storage contributed to the deficiencies identified during the survey.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure safe medication use and destruction practices, as evidenced by several deficiencies. Firstly, the prescription medication destruction and disposition logs were not properly dated, witnessed, or co-signed by licensed staff. During an inspection of the main medication room, it was found that the binder for medication destruction was overfilled with pages lacking dates and co-signatures. The Director of Nursing (DON) was unsure about the need for a witness co-signature and when the last medication destruction occurred. The facility's Consultant Pharmacist confirmed that all prescription destructions should be documented and witnessed by two licensed nurses. Additionally, a discontinued medication, semaglutide, prescribed to a resident who had been discharged, was improperly stored in an active storage area. The medication was never used, as the resident's treatment was changed to insulin. Despite the facility's policy requiring discontinued medications to be stored in a locked cabinet until destruction, the semaglutide was found in the medication refrigerator. The Assistant Director of Nursing (ADON) acknowledged that the resident's discontinued medications should have been stored securely until destruction. Furthermore, three pneumonia vaccines belonging to different residents were found in a staff food refrigerator, despite being documented as administered in the Medication Administration Record (MAR). The ADON could not explain how these vaccines were found in the refrigerator or why they were documented as administered. The facility's policy requires proper documentation of vaccine administration, including lot numbers and expiration dates, but this was not adhered to. These failures could contribute to the risk of drug diversion and unsafe drug use.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices, as observed in a dorm-style refrigerator located in an office shared by the Director of Staff Development (DSD), Infection Preventionist (IP), and the staffing coordinator. This refrigerator contained personal food items alongside a drawer full of prescription injectable medications, including vaccines and unlabeled pre-drawn syringes of a flu vaccine. There was no temperature monitoring performed for this refrigerator, and the DSD was unaware of how long the medications had been stored there. The DSD acknowledged the improper storage of medications with personal food and indicated that the medications might belong to facility staff. The IP admitted to preparing the pre-drawn syringes for staff administration and acknowledged the lack of labeling and temperature monitoring. In the main medication room, the refrigerator stored opened vials of flu vaccine and Tuberculosis testing agent without any marking for a beyond-use date. Additionally, discontinued medications belonging to a discharged resident were found in an active storage area in the refrigerator. The Director of Nursing (DON) was unaware of these storage issues and expressed concern over the unsafe practices, including the presence of pre-drawn flu vaccine syringes without labels. The Assistant Director of Nursing (ADON) confirmed that discontinued medications should not have been stored in the unsecured office refrigerator and should have been kept in a locked cabinet in the medication room. The facility's policies on medication labeling and storage, as well as discarding and destroying medications, were not adhered to. The policies require that all medications and biologicals be stored in locked compartments under proper conditions and that discontinued medications be stored in a locked cabinet until destruction. The failure to follow these policies resulted in unsafe medication storage practices, posing a risk to the safety of the residents and the potential for drug diversion.
Failure to Provide Written Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of a facility-initiated discharge for a resident, resulting in a deficiency. The resident's responsible party (RP) was verbally informed of the discharge when the resident was sent to the hospital, but no written notice was provided. This omission meant that the RP was not informed of the appeal rights or the process to contest the discharge decision, nor was contact information for the appeal unit and the ombudsman provided. The RP only became aware of these rights through a hospital social worker. The facility administrator acknowledged that a written 30-day notice of discharge was not sent to the RP and confirmed the absence of documentation in the resident's electronic medical record. The discharge was due to the resident's psychotic episodes, and the verbal notice was given to the RP because the resident was developmentally delayed. The facility's policy requires documentation of appropriate notice in the medical record, which was not adhered to in this case.
Failure to Reassess Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to determine if a resident could return to the facility after being transferred to an acute care hospital. The resident, who had been admitted with diagnoses including heart failure, bipolar disorder, schizophrenia, depression, and anxiety disorder, was sent to the hospital on a 5150 hold due to aggressive behavior. There was no documented evidence that the facility communicated with the hospital to assess the resident's condition or to determine if the facility could meet the resident's needs upon discharge from the hospital. Interviews with the resident's responsible party and facility staff revealed that the facility did not attempt to reassess the resident's readiness to return. The facility's Social Services Director and Case Manager were unsure if anyone from the facility had visited the hospital to evaluate the resident. The resident's primary physician confirmed that neither he nor anyone from the facility had assessed the resident at the hospital. Hospital notes indicated that the facility had communicated with the hospital, stating that the resident was discharged and would not be accepted back. The facility's policy requires documentation and communication of the resident's needs and the facility's inability to meet those needs, but there was no evidence of such documentation. This lack of communication and documentation had the potential to negatively impact the resident's psychosocial well-being.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate during a medication administration observation. Two errors were identified out of 26 opportunities, involving two residents. Resident #23, who has a medical history of multiple sclerosis and intact cognition, was prescribed a multivitamin with minerals but was administered a plain multivitamin instead. Similarly, Resident #82, with severe cognitive impairment and a history of anemia and moderate protein-calorie malnutrition, was also prescribed a multivitamin with minerals but received a plain multivitamin. The errors were attributed to Licensed Vocational Nurse (LVN) #5, who admitted to administering the incorrect medication due to confusion over the different types of multivitamins. Interviews with the Nurse Practitioner and Director of Nursing (DON) confirmed that the physician's orders were not followed, as the residents were supposed to receive multivitamins with minerals. The DON and Administrator both expressed expectations that staff should review and follow medication orders accurately, highlighting the importance of adhering to the specific details of physician prescriptions.
Failure to Follow Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to physician's orders regarding the administration of medications for a resident with a history of end-stage renal disease, hypertensive heart, and chronic kidney disease with heart failure. Specifically, the facility did not follow the order to hold carvedilol when the resident's systolic blood pressure (SBP) was below 130 mmHg and to refrain from administering midodrine when the SBP was above 120 mmHg. This oversight was identified for one resident among five sampled for unnecessary medications. The Medication Administration Record (MAR) showed that carvedilol was administered on multiple occasions when the resident's SBP was below the specified threshold, and midodrine was given when the SBP exceeded the prescribed limit. Interviews with nursing staff revealed a misunderstanding of the parameters, with one nurse mistakenly believing the hold parameter for carvedilol was an SBP below 100 mmHg instead of 130 mmHg. The Director of Nursing and the Administrator both expressed that they expected nurses to follow medication orders and parameters as prescribed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a gastrostomy tube, as required by their policy. The policy, dated April 5, 2024, mandates that staff perform hand hygiene and don a gown and gloves before engaging in high-contact resident care activities, such as dressing. Resident #196, admitted on July 17, 2024, had a medical history that included a gastrostomy tube and was at risk for aspiration. An order for enhanced standard precautions related to the gastrostomy tube was in place for every shift. On July 22, 2024, a Certified Nursing Assistant (CNA) entered the resident's room wearing only gloves and a mask, despite signage indicating the need for a gown, gloves, and mask. The CNA acknowledged that she had been trained on EBP and was aware of the requirement to wear a gown when providing care to residents with a gastrostomy tube. The Director of Nursing confirmed that staff had been in-serviced on EBP and that signage was posted to guide staff on the necessary personal protective equipment (PPE). The Administrator also expected staff to adhere to the training and signage instructions.
Failure to Carry Out Physician's Order for Medication Adjustment
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality when a physician's order to reduce gabapentin for a resident was not carried out. The resident, who had multiple diagnoses including surgical aftercare following surgery on the nervous system and diabetes mellitus, had an active order for gabapentin 400 mg every eight hours. On 4/6/24, the physician ordered to taper the gabapentin to 300 mg daily, but this order was not executed. The resident subsequently refused several doses of the medication, citing that the current dosage was too high and caused trouble for her legs. The resident left the facility against medical advice on 4/8/24. During interviews and record reviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the physician's order to reduce the gabapentin dosage was communicated but not carried out. The ADON and DON both stated that the nurse should have checked the physician's note for new orders and clarified the order when the resident refused the medication. The facility's policies on medication orders and administering medications were reviewed, indicating that medications should be administered as prescribed and that a current list of orders must be maintained in the clinical record of each resident.
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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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