Skyline Healthcare Center - San Jose
Inspection history, citations, penalties and survey trends for this long-term care facility in San Jose, California.
- Location
- 2065 Forest Avenue, San Jose, California 95128
- CMS Provider Number
- 055318
- Inspections on file
- 63
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Skyline Healthcare Center - San Jose during CMS and state inspections, most recent first.
A resident with vertebral osteomyelitis and coccyx/left buttock wounds, cognitively intact per BIMS, reported that an LVN repeatedly punched, slapped, and squeezed his wound during ordered dressing changes, once captured on video showing the LVN making a fist and striking the wound through the dressing, causing the resident to cry out in pain. The resident also stated the LVN sometimes left him with pants down, curtain and door open, causing humiliation. Another resident corroborated witnessing the LVN hit, squeeze, or slap the wound and strike him across the backside. These actions occurred despite a facility abuse prevention policy stating residents have the right to be free from abuse and that administration will protect residents from abuse by anyone.
Surveyors found that food items, including cottage cheese past their use-by dates and unlabeled beverages, were improperly stored in facility refrigerators, some of which were operating at temperatures above the required range. Staff confirmed that these practices did not meet facility policies for food safety, labeling, and timely disposal.
Two dumpsters were found overfilled with garbage and their lids not fully closed, with additional trash bags left outside the covered dumpsters. Both the maintenance assistant and maintenance director confirmed that dumpsters should not be overfilled and all trash should be placed inside covered units, in accordance with facility policy and FDA Food Code requirements.
Staff were observed standing while feeding a resident instead of sitting at eye level, and two residents waited for their meal trays while another at the same table was already eating, contrary to facility policy. Additionally, a resident's urinary drainage bag was left uncovered and visible. These actions did not uphold resident dignity and comfort as required.
Several residents who were alert and cognitively intact reported not knowing the results of previous state surveys or the location of the survey binder. Key staff, including the Activity Director, were also unaware of the binder's location. Facility policy required survey results to be accessible and communicated to residents, but this was not done, as confirmed by interviews and record review.
Two LVNs did not wear gloves while handling a hazardous medication, despite clear labeling and facility policy requiring PPE use. Additionally, a resident with paraplegia did not have weekly weight monitoring as ordered by the physician, with the last weight recorded more than a month prior. Both deficiencies were confirmed by supervisory staff and were not in accordance with facility policies.
A review of medication records revealed that staff failed to accurately document the administration and removal of controlled medications for several residents. In some cases, medications were recorded as given in the MAR but not signed out in the CDR, while in other cases, medications were signed out in the CDR but not documented in the MAR. These discrepancies were confirmed by staff interviews and record reviews, resulting in inaccurate accountability of controlled substances.
Surveyors found that medications and biologicals were improperly stored, with different routes of administration and both active and discontinued drugs kept together in a medication room bin, and opened bottles of normal saline left unattended at the bedside tables of two residents. Staff confirmed these practices were not in line with facility policy, which requires proper storage and restricted access to medications.
Surveyors identified multiple infection control lapses, including used urinals and soiled linens improperly stored, medical equipment covered with used items, and improper storage of suction devices. A resident with a biliary catheter did not have required enhanced barrier precaution signage or PPE at the room entrance. Staff, including a treatment nurse and two kitchen employees, were observed not wearing face masks properly during wound care and food preparation. These deficiencies were confirmed by staff and were not in accordance with facility policy.
Surveyors observed that the dishwashing area floor was very wet and lacked a caution sign to warn staff or others entering the kitchen. Both the dietary manager and registered dietitian confirmed that safety signage should have been present, and facility policy requires prompt use of wet floor signs to maintain a safe environment.
The facility did not ensure that laundry staff consistently documented the cleaning of dryer lint as required by facility policy, with logs left blank for several hours on multiple days. The housekeeping supervisor and infection preventionist confirmed the expectation for hourly documentation, but records showed noncompliance.
A resident with epilepsy and developmental disorders was found asleep with her call light button on the floor, making it inaccessible. An LVN confirmed the inaccessibility and acknowledged the need for a more appropriate device, as required by facility policy for residents unable to use the standard call system.
Two residents were not given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when Medicare Part A services were discontinued, despite having benefit days remaining and continuing to reside in the facility. Facility records and staff confirmed that the required notice was not provided, as mandated by CMS guidelines.
A resident did not have an annual MDS assessment completed within the required timeframe. Review of the medical record and confirmation by the MDS Coordinator showed that the assessment was missed, in violation of CMS requirements for annual comprehensive assessments.
Two residents' MDS assessments were inaccurately coded: one resident's multiple falls were not recorded, and another resident's tobacco use was omitted, despite documentation in their medical records and assessments. MDS Coordinators confirmed these errors during record review.
Two residents were admitted without timely development of required baseline care plans. One resident with significant communication deficits did not have a communication care plan initiated, and another resident with a cancer diagnosis was not assessed for activities and lacked an activity care plan. Staff interviews and record reviews confirmed that these baseline care plans were not created within 48 hours of admission, as required by facility policy.
Two residents did not have their care plans properly updated: one resident's care plan was not revised after multiple falls and changes in cognitive status, and another resident's care plan for an antibiotic remained active after the medication was completed. These lapses were confirmed by the ADON and DON, and were not in accordance with facility policy requiring timely care plan updates.
A resident with a diagnosis of malignant neoplasm was found using bilateral half side rails without a physician's order, as required by facility policy. The resident was confused and unable to answer questions, and review of medical records confirmed the absence of an order authorizing side rail use.
Two residents consistently received their lunch meals late and at a cold temperature, as confirmed by both resident interviews and direct observation. Lunch trays were delivered well after the facility's established meal service window, contrary to policy and staff confirmation of expected meal times.
A resident with Type 2 diabetes did not receive timely insulin and the correct dosage of Myfortic due to a nurse's failure to follow physician orders. Insulin was administered late, and blood sugar checks were delayed, while only one of three prescribed Myfortic tablets was given on time. The DON confirmed these lapses, which were against the facility's medication administration guidelines.
A registered nurse left medications unattended on a bedside table in a resident's room. The resident, diagnosed with dementia and anxiety disorder, was not present at the time. The medications, vitamin B-12 and gabapentin, were left without supervision, contrary to the facility's policy requiring controlled storage accessible only to authorized personnel.
Two residents with psychiatric conditions did not receive necessary follow-up psychiatric services as recommended in their care plans. Despite evaluations indicating the need for follow-up within two to four weeks, the facility failed to provide these services, as confirmed by the social service assistant and assistant director of nursing. This oversight was contrary to the facility's policy on maintaining residents' mental and psychosocial well-being.
The facility failed to maintain an effective pest control program, with ongoing cockroach sightings in residents' rooms, nursing stations, and the kitchen. Despite a plan of correction requiring immediate treatment upon sightings, only weekly treatments were documented. Staff and residents reported seeing cockroaches, and observations confirmed unclean conditions. The administrator acknowledged the issue as an ongoing project, but the facility's policy for immediate action was not effectively implemented.
The facility failed to properly dispose of kitchen refuse, as observed when a garbage disposal bin was found without its lid, leaving refuse exposed. This was confirmed by the RD, who stated the bin should have been closed. The facility's policy requires waste to be kept in a tightly closed container, aligning with the FDA's 2022 Food Code.
A facility failed to ensure a pest-free environment, as evidenced by fruit flies in a resident's room and hallway. A nurse and CNA observed flies due to old food, but the maintenance supervisor confirmed no reports were made, contrary to the facility's pest control policy.
The facility failed to ensure proper pain management for a resident by not following physician orders for PRN medications, not updating the care plan, and using an incomplete pain scale. The resident had multiple diagnoses, including spinal stenosis and schizoaffective disorder, and experienced various levels of pain that were not adequately managed.
Failure to Prevent Physical Abuse During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse during wound care. The resident had osteomyelitis of the vertebra and physician’s orders for treatment of a coccyx pressure injury and a left buttocks open wound, including cleansing with normal saline or Dakin’s solution, application of Santyl ointment, collagen, calcium alginate, and foam dressings twice daily or as needed. During wound treatment, a licensed vocational nurse (LVN A) was observed on a video recording provided by the resident standing on the left side of the bed while the resident lay face down. After pressing down the tape around the wound dressing with his gloved fingers, LVN A made a fist with his right hand and punched the resident’s wound on top of the dressing, causing the resident to scream in pain and shout obscenities. In interviews, the resident reported that prior to setting up the video recording, LVN A had punched his wound three or four times and, on other occasions, slapped the wound. The resident stated he was afraid to report LVN A and described that sometimes LVN A would perform the wound treatment, then leave the room with the resident’s pants down, the curtain open, and the door open, which the resident found humiliating. Another resident corroborated the abuse, stating he witnessed LVN A hitting, squeezing, or slapping the resident’s wound multiple times and also hitting him across the backside. The facility’s abuse prevention policy states that residents have the right to be free from abuse and that administration will protect residents from abuse by anyone, but the described actions of LVN A toward the resident’s wound and exposure during care constituted abuse that was not prevented.
Improper Food Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility. During inspections of medication rooms and the kitchen, refrigerators designated for resident food storage were found to be operating at temperatures significantly above the required range, with one refrigerator consistently reading 60 degrees Fahrenheit despite being closed for extended periods. Additionally, food items such as a pitcher of pinkish-red fluid and an unopened container of applesauce were stored in these refrigerators. The nurse supervisor confirmed that the refrigerator temperature should be maintained between 35 and 41 degrees Fahrenheit, as per facility policy. Furthermore, ten cups of cottage cheese past their use-by dates were found in the kitchen refrigerator, and both the dietary manager and registered dietitian verified that these items should have been discarded according to policy. Further observations revealed improper labeling and dating of food and beverages. In medication storage rooms, surveyors found a pitcher with brown-colored fluid with no label and an open container of thickened water that had exceeded the 24-hour discard guideline. Another refrigerator contained a pitcher of pinkish-red fluid that was not labeled. Facility policies require all food and beverages in refrigerators to be clearly labeled and dated, and to be discarded within specified timeframes. These deficiencies were confirmed by staff during interviews and were documented as not being in accordance with professional standards for food safety.
Improper Storage and Disposal of Garbage in Dumpsters
Penalty
Summary
Two out of four outside dumpsters at the facility were observed to be overfilled with garbage, with their lids not fully closed. Additionally, plastic bags containing trash were found outside the covered dumpsters rather than being placed inside. These conditions were confirmed during an observation and interviews with the maintenance assistant and maintenance director, both of whom acknowledged that dumpsters should not be overfilled and should remain properly covered, and that all trash should be placed inside the covered dumpsters. The facility's policy on pest control requires that the dumpster area be kept clean and lids remain closed. The United States Food and Drug Administration's 2022 Food Code also mandates that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The observed failure to comply with these requirements had the potential to attract pests, which could affect the 238 residents residing in the facility.
Failure to Maintain Resident Dignity During Meals and Personal Care
Penalty
Summary
Multiple deficiencies were identified related to the failure to maintain resident dignity and respect during mealtimes and personal care. Certified nursing assistant C was observed feeding a resident while standing over her, rather than sitting at eye level as required by facility policy. This was confirmed by both the nurse supervisor and the director of staff development, who stated that staff should sit at eye level to maintain resident comfort and dignity. The facility's policy on assisting residents to eat also specifies that staff should sit at eye level in front of the resident. In the dining room, two residents were observed waiting for their meal trays while another resident at the same table had already begun eating. Both residents confirmed they were hungry and had to wait while watching another resident eat. The activity director and assistant director of nursing acknowledged that meal trays should be served to all residents at the same table at the same time or in immediate succession, in accordance with the facility's policy to promote dignity and timely service. Additionally, a resident with an indwelling Foley catheter was observed with an uncovered drainage bag, making the contents visible. The infection preventionist confirmed that the drainage bag should have been covered for privacy. The facility's policy on dignity specifies that urinary catheter bags should be kept covered to promote resident well-being and self-esteem. These failures were observed to have the potential to affect the emotional and psychosocial well-being of the residents involved.
Failure to Inform Residents of Survey Results and Binder Location
Penalty
Summary
The facility failed to ensure that residents were aware of and reminded about the results of previous state recertification surveys, as well as the location of the binder containing these results. During a resident council meeting, five residents who were alert, oriented, and had intact cognition scores (BIMS scores ranging from 14 to 15) stated they did not know the results of the previous surveys or where the survey binder was located. These residents had various medical conditions, including acute respiratory disease, chronic pulmonary edema, atrial fibrillation, diabetes mellitus, peripheral vascular disease, cellulitis, hyperlipidemia, osteoarthritis, congestive heart failure, hemiplegia, hypertension, and seizures. Interviews with facility staff revealed further gaps in communication and knowledge. The Activity Director, who had been employed at the facility for twenty-five years, was unaware of the survey results and the location of the survey binder, suggesting it might be in the administrator's office. The administrator confirmed that the Activity Director should know the binder's location to inform and remind residents. The Director of Nursing also verified that all staff should be aware of the binder's location. A review of the facility's policy and procedure on access to survey results indicated that survey results and approved plans of correction should be available in a readable form and accessible to residents without needing to ask staff. The policy also stated that residents should be notified at least annually during Resident Council meetings, and meeting minutes should reflect that survey results were communicated. However, the findings showed that these procedures were not followed, as neither residents nor key staff were aware of the survey results or the binder's location.
Failure to Follow PPE Protocols and Physician Orders
Penalty
Summary
Two Licensed Vocational Nurses (LVNs) failed to wear proper Personal Protective Equipment (PPE), specifically gloves, while handling a medication labeled as a hazardous drug (Divalproex Sodium) for two residents. Both LVNs acknowledged that the medication packaging was marked with a hazardous drug label and admitted they should have worn gloves during administration. The Director of Nursing and Consultant Pharmacist confirmed that gloves are required when handling such medications, and the facility's policy mandates the use of appropriate PPE to minimize exposure to hazardous drugs. Additionally, a resident with a primary diagnosis of unspecified paraplegia had a physician's order for weekly weight monitoring every Saturday at 9:00 a.m. However, the resident's weight was not monitored as ordered, with the last recorded weight taken over a month prior to the review. The nursing supervisor and Director of Nursing both verified that the physician's order for weekly weight checks was not followed, and the facility's policy requires all physician orders to be carried out accurately and promptly.
Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for seven out of twelve residents reviewed during a random audit. Specifically, medications were documented as administered on the Medication Administration Record (MAR) for several residents, but the corresponding doses were not signed out on the Controlled Drug Record (CDR). For example, a resident with a physician's order for Methadone had three tablets unaccounted for in the CDR, and the nurse confirmed that while the medication was documented in the MAR, it was not signed out in the CDR. Similar discrepancies were found for residents receiving Lorazepam and Hydrocodone-Acetaminophen, where the medications were recorded as given in the MAR but not reflected in the CDR. Conversely, there were instances where medications were signed out of the CDR but not documented as administered in the MAR. This occurred with residents prescribed Oxycodone, Tramadol, and other controlled substances. In these cases, nursing staff removed the medications from the locked controlled medication compartment, signed them out in the CDR, but failed to document the administration in the MAR. The Director of Nursing (DON) acknowledged that these controlled medications were not accounted for in the MAR during concurrent interviews and record reviews. A review of the facility's policies and procedures confirmed that staff are required to document the administration of medications immediately in both the MAR and the CDR. The observed failures to follow these procedures resulted in inaccurate accountability of controlled medications, as confirmed by staff interviews and record reviews during the survey.
Improper Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store medications and biologicals in accordance with its own policies and accepted professional standards. In one medication room, a clear plastic bin was found containing medications with different routes of administration, including liquid Lithium, Atorvastatin tablets, and a Symbicort inhaler, as well as both active and discontinued medications. The bin also contained house stock normal saline and wound dressings. The nurse supervisor and DON confirmed that these items should not have been stored together, and that discontinued medications should have been removed and disposed of per policy. Additionally, opened bottles of 0.9% sodium chloride (normal saline) were found unattended at the bedside tables of two residents. One resident had both a large and small bottle of normal saline at their bedside, and another had a used bottle of normal saline left at their bedside. The MDS Coordinator confirmed that these items were used for wound treatment and should have been stored in the treatment cart, not left unattended. Facility policy requires that medications and biologicals be stored properly and only accessible to authorized personnel.
Infection Control Lapses in Resident Care and Food Preparation
Penalty
Summary
Multiple infection control deficiencies were identified during observations, interviews, and record reviews within the facility. Used and uncovered urinals were found on bedside tables next to medical equipment such as spirometers, and suction devices were improperly stored, including a yankauer suction tube placed inside an open clean gloves box and a suction machine and nebulizer covered by a used wash basin. Soiled linens were observed on the floor, and urinals were left full and not emptied in resident rooms. These practices were confirmed by staff, including the assistant director of nursing and certified nursing assistants, who acknowledged that these items should have been stored or disposed of according to facility policy to prevent contamination and cross-infection. Further deficiencies included the lack of enhanced barrier precaution (EBP) signage and personal protective equipment (PPE) outside the room of a resident with a biliary catheter, despite facility policy requiring such measures for residents with indwelling devices. Staff interviews confirmed that EBP signage and PPE should have been present. Additionally, a treatment nurse was observed wearing a surgical mask below the nose during wound care, and two kitchen staff were not wearing their face masks properly while preparing food for the tray line. These lapses were acknowledged by the staff involved and by supervisory personnel, who confirmed that masks should cover both the nose and mouth during resident care and food preparation. Review of facility policies indicated requirements for proper storage and handling of soiled linens, urinals, and PPE use, as well as the need for EBP for residents with wounds or indwelling devices. The observed failures to follow these policies were confirmed by staff during interviews and were directly linked to the deficiencies cited in the report.
Failure to Provide Wet Floor Warning in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen's dishwashing area, as observed during an initial tour with the dietary manager. The floors in the dishwashing area were found to be very wet, and there was no caution or warning sign present to alert staff or individuals entering the area about the wet floor. This condition was directly observed by surveyors and acknowledged by the dietary manager during the tour. Further confirmation was provided during an interview with the registered dietitian, who verified that kitchen areas, including dishwashing areas, should always be kept safe and that signage for wet floors is necessary to warn staff. A review of the facility's undated Kitchen Safety policy indicated that all dietary and kitchen staff must follow established safety guidelines, including keeping walkways clear and promptly cleaning spills using wet floor signs. The lack of a warning sign and the presence of a wet floor constituted a failure to adhere to these established safety procedures.
Failure to Ensure Laundry Staff Compliance with Dryer Lint Cleaning Documentation
Penalty
Summary
The facility failed to maintain an effective infection control training program for laundry staff, specifically regarding the routine cleaning of dryer lint. Record review showed that the laundry lint cleaning log was left blank for several hours on multiple days, indicating that staff did not document or possibly did not perform the required cleaning during those times. The housekeeping supervisor confirmed the gaps in documentation and stated that the log served as proof of lint cleaning. The infection preventionist stated that laundry staff were required to check and document lint cleaning every hour. The facility's policy required lint traps to be cleaned after each load and for staff to document this action, but the logs did not reflect compliance with this policy on several occasions. No specific residents or their medical histories were mentioned in relation to this deficiency.
Call Light Inaccessibility for Resident with Special Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light button for one resident was within reach and appropriate for her condition. The resident, who had a history of epilepsy, lack of coordination, psychological development disorder, and delayed childhood milestones, was observed asleep with her call light button on the floor. During a subsequent observation and interview, an LVN confirmed that the call light was not accessible and acknowledged that the resident should have had a device suitable for her needs. Review of the facility's policy indicated that residents unable to use the standard call system should be provided with an alternative means of communication, documented in the care plan.
Failure to Provide SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents who were discharged from Medicare Part A services while still having benefit days remaining and continued to reside in the facility. For one resident, the medical record showed admission under Medicare Part A, with a planned discharge from these services while the resident remained in the facility. The facility's own documentation confirmed that the SNF ABN was not provided to this resident. Similarly, another resident was admitted under Medicare Part A, later discharged from these services with benefit days remaining, and continued to live in the facility without receiving the required SNF ABN. The interim social services director confirmed during an interview that the SNF ABN was not given to either resident. Facility records and CMS guidelines require that a SNF ABN be provided in such circumstances to inform residents of their financial liability and appeal rights when Medicare Part A services are discontinued. The failure to provide this notice was documented in the facility's records and confirmed by staff during the survey.
Failure to Complete Required Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment for one resident as required. Review of the resident's medical record showed that while an annual MDS assessment was completed in May of the previous year, there was no evidence of a completed annual MDS assessment for the following year. During an interview and concurrent record review, the MDS Coordinator confirmed that the annual assessment had not been completed within the required timeframe. According to the CMS RAI Manual, the annual MDS assessment must be completed at least every 366 days, and this requirement was not met for the resident in question.
Inaccurate MDS Coding for Falls and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of falls, medical records and progress notes documented two separate incidents where the resident was found on the floor in her room. However, the MDS for this resident was coded to indicate that no falls had occurred during the specified time frame. The MDS Coordinator confirmed during record review that these falls should have been coded as 'Yes' in section J1800, in accordance with the RAI Manual instructions. For another resident with diagnoses including osteomyelitis and vertebral fractures, a Safe Smoking Assessment Evaluation documented that the resident smoked cigarettes. Despite this, the MDS was coded to indicate that the resident did not use tobacco. The MDS Coordinator confirmed that section J1300 should have been coded 'Yes' to reflect current tobacco use, as supported by the resident's assessment and the RAI Manual guidelines.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop resident-centered baseline care plans within 48 hours of admission for two residents. For one resident with a history of cerebral infarction, aphasia, gait abnormalities, and dysphagia, there was no communication problem care plan initiated upon admission or up to the time of the survey. Clinical records and interviews with the ADON and MDS Coordinator confirmed that the resident's MDS indicated significant communication deficits, yet no baseline care plan addressing these needs was created within the required timeframe. For another resident admitted with a primary diagnosis of malignant neoplasm of the breast, there was no baseline activity care plan developed, and no activity care plan was present at all. The resident's physician order allowed participation in activities as tolerated, but the activity director confirmed that the resident had not been assessed for activities and no baseline activity care plan was created within 48 hours of admission, as required by facility policy. These findings were verified through record review and staff interviews.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident with diagnoses including schizophrenia, cerebral infarction, hemiplegia, and impaired cognition, the care plan interventions related to falls and cognitive function were not revised or modified after multiple falls and changes in cognitive status. The assistant Director of Nursing confirmed that the care plan had not been updated to reflect these changes, despite facility policy requiring care plans to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. For another resident with a history of intracerebral hemorrhage, kidney contusion, and sepsis, the care plan for an antibiotic remained active even after the antibiotic course was completed. The Director of Nursing confirmed that the care plan should have been resolved but was not. These failures were identified through interviews, medical record reviews, and review of facility policies and procedures, and placed the residents at risk of not receiving appropriate, consistent, and individualized care.
Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was observed using bilateral half side rails without a physician's order authorizing their use. The resident, who was admitted with a primary diagnosis of malignant neoplasm of the breast, was found lying in bed with the side rails up. The resident was confused and unable to answer questions at the time of observation. Review of the resident's medical records, including the physician order report covering the relevant period, confirmed that there was no documented physician's order for the use of side rails for this resident. Further review and interview with the nurse supervisor verified the absence of a physician's order for the side rails, despite facility policy requiring such an order, including documentation of diagnosis and medical necessity. The facility's policy treats side rails as physical restraints, necessitating a physician's order prior to use, which was not obtained in this case.
Delayed Meal Service Resulting in Cold Food
Penalty
Summary
The facility failed to ensure that two residents received their lunch meals in accordance with the scheduled meal times, as required by facility policy. Both residents reported that their food consistently arrived late and was cold. Observations confirmed that lunch trays for these residents were delivered significantly after the designated meal service window, with one tray arriving at 1:34 p.m. and another at 1:50 p.m., despite the policy stating that lunch should be served between 11:30 a.m. and 1:00 p.m. The dietary manager confirmed that the last lunch tray should be delivered by 1:00 p.m., and documentation supported the established meal times. These delays resulted in the residents receiving meals outside the scheduled period, with food that was not at an appetizing temperature.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Type 2 diabetes and other conditions, leading to a deficiency in care. The resident had specific orders for insulin administration and medication dosage, which were not followed correctly. On one occasion, insulin lispro was administered late, and the resident's blood sugar was not checked before lunch as required, resulting in delayed insulin administration. Additionally, the resident was prescribed Myfortic, a medication to prevent organ transplant rejection, to be taken in a specific dosage twice daily. However, the charge nurse administered only one out of the three prescribed tablets at a scheduled time, leading to a delay in the complete dosage being given. This deviation from the prescribed medication schedule was noted in the resident's progress notes and risk meeting notes. The Director of Nursing confirmed these lapses during an interview, acknowledging that the nurse responsible did not follow the physician's orders as documented. The facility's guidelines stipulate that medications should be administered within a specific timeframe relative to meal times, which was not adhered to in this case. These failures in following physician orders had the potential to impact the resident's health adversely.
Unattended Medications in Resident's Room
Penalty
Summary
The facility failed to store medications safely when a registered nurse left medications unattended on a bedside table in a resident's room. The resident, who was not present in the room at the time, had been admitted with diagnoses including dementia and anxiety disorder. The medications left unattended were vitamin B-12 and gabapentin, which were prescribed to the resident. During an observation, it was noted that the medications were left in a medication cup on the bedside table without supervision. The registered nurse responsible for the resident's care confirmed that she left the medications unattended while she was at the nurse's station preparing documents for another resident. The facility's policy on medication storage requires that medications be stored in a controlled environment accessible only to authorized personnel, which was not adhered to in this instance.
Failure to Provide Follow-Up Psychiatric Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable mental and psychosocial well-being for two residents. Resident 1, diagnosed with obsessive-compulsive personality disorder, bipolar disorder, and major depressive disorder, was admitted to the facility and had a psychiatric evaluation on 6/22/23. The psychiatrist recommended a follow-up within two to four weeks, but no follow-up services were provided. Similarly, Resident 2, who was readmitted with a diagnosis of dementia, had an initial psychiatric evaluation on 4/7/22, which also recommended a follow-up within two to four weeks. However, no follow-up psychiatric services were provided for Resident 2 either. Interviews with the social service assistant and the assistant director of nursing confirmed that both residents should have continued receiving psychiatric services as per their psychiatric visit progress reports. The facility's policy and procedure on psychosocial well-being and behavioral health services stated that residents would receive necessary services to maintain their well-being in accordance with their comprehensive assessment and plan of care. The failure to follow up on the psychiatric services for these residents was acknowledged by the facility staff, indicating a lapse in adhering to the established care plans.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing sightings of cockroaches in various areas, including residents' rooms, nursing stations, the kitchen, and activity rooms. Despite having a plan of correction from a previous survey, which included immediate pest treatment upon sightings, the facility did not follow through with these actions. Weekly pest treatments were documented, but there were no records of immediate treatments following the identification of cockroaches. Staff and residents reported seeing cockroaches, and environmental observations confirmed the presence of pests and unclean conditions, such as food residuals and trash on the floors. Interviews with staff, including a licensed vocational nurse, registered nurse, housekeeping supervisor, dietary manager, and certified nursing assistants, revealed that cockroaches were a recurring issue. The administrator acknowledged that addressing the pest problem, particularly with German cockroaches, was an ongoing project. The facility's policy required routine inspections and immediate action upon pest sightings, but these procedures were not effectively implemented, leading to a failure in providing a sanitary environment for residents.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of refuse in the kitchen, as observed during a survey. At 10:55 a.m. on June 6, 2024, three garbage disposal bins were noted in the kitchen, with one bin having a folded box, a cup, two plastic food containers, and a metal food container placed on top of it. Another bin was found without its lid, leaving the refuse exposed to the air. This observation was confirmed by the registered dietitian (RD) during an interview at 11:13 a.m., who acknowledged that the garbage disposal bin should have been closed with its lid. The facility's policy and procedure on Sanitation and Infection Control, dated 2023, requires that kitchen waste not disposed of by mechanical means be kept in a clean, leak-proof, nonabsorbent, tightly closed metal or plastic container with a plastic liner. Additionally, the 2022 Food Code from the Food and Drug Administration specifies that waste handling for refuse should be kept covered. The failure to adhere to these guidelines had the potential to attract pests and affect the 238 residents in the facility.
Pest Control Deficiency Due to Unreported Fruit Flies
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of multiple flying insects in a resident's room and the hallway. On May 1st, a licensed vocational nurse reported numerous flies in a resident's room due to old food. Concurrently, a certified nurse assistant observed more than ten fruit flies in the same room, confirming the nurse's observation. On June 6th, two fruit flies were seen near bananas on the resident's over-the-bed table, and another fly was observed near the resident in the hallway. The maintenance supervisor confirmed that there were no reports of fruit flies in the resident's room from May 1st to June 6th, despite the facility's policy requiring insect sightings to be reported to the housekeeping/maintenance supervisor.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to pain management for one resident. The licensed nurses did not follow the physician's order to administer PRN pain medications based on the pain assessment documented. Additionally, the licensed nurses did not update the resident's care plan for pain management and administered the wrong medication for severe pain. The pain scale used did not include all pain levels, which could have contributed to improper pain assessment and management. The resident was admitted with diagnoses including generalized muscle weakness, cervical region spinal stenosis, major depressive disorder, and schizoaffective disorder. Despite having physician orders for Morphine and Tylenol for pain management, the licensed nurses failed to administer these medications as prescribed. The ADON confirmed that there was no documented evidence that the resident had refused the PRN pain medication. The care plan was not updated to include the PRN medication, and the pain scale used was incomplete, lacking levels 1, 3, 5, and 7.
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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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