Walnut Creek Skilled Nursing & Rehabilitation Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Walnut Creek, California.
- Location
- 1224 Rossmoor Parkway, Walnut Creek, California 94595
- CMS Provider Number
- 056327
- Inspections on file
- 36
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Walnut Creek Skilled Nursing & Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with quadriplegia, moderate cognitive impairment, and complete dependence on staff for feeding had a visible timer placed on the overbed table to track the duration of feeding and repositioning care. The DON reported that, after IDT discussion about the time staff spent providing care, the team decided to use the timer so the resident could see how long CNAs were with him. The resident stated that no one asked for permission or consent before placing the timer, that it made him feel rushed, and that he worried about choking if he ate too fast. A UM reported obtaining verbal permission before placing the timer but could not produce any documentation of the resident’s agreement, despite a facility policy requiring residents be treated with dignity, respect, and self-determination.
A dependent resident with traumatic brain injury, dysphagia, and moderate cognitive impairment, receiving GT feeding and fully dependent on staff for ADLs, was observed with an oily face, visible dry white matter in the mouth and on the teeth, and crust-like material between the eyelids. An LVN acknowledged the need for suction-based oral care, and a CNA noted the need for face washing and shaving, while the Infection Preventionist stated the eyes required cleaning. The UM reported that oral and personal hygiene should be provided at least twice daily and as needed, consistent with facility policy requiring assistance to maintain grooming and personal and oral hygiene for dependent residents.
A resident with CKD stage 3, gait and mobility issues, depression, and prior TIA, admitted under Kaiser Medicare coverage, had an unsigned NOMNC indicating an end to covered services and a planned discharge. After the resident experienced oxygen desaturation, was sent to the ED, and returned for further observation and treatment, the facility placed the discharge on hold but changed the payer status to private pay based on the unsigned NOMNC, without obtaining updated authorization from Kaiser or a new NOMNC. The Business Office did not secure required authorization or a Financial Responsibility Form and instead billed the resident’s representative for several days of room and board and sent multiple collection letters, despite remaining Medicare days and facility policies and contract terms requiring proper notice and documentation for non-covered services.
A resident with CKD stage 3, gait and mobility issues, depression, and a history of TIA experienced a change in payer source from Medicare to private pay without proper financial notification. The facility relied on an unsigned NOMNC to end Medicare coverage and convert the stay to private pay, but there was no resident or representative signature, no attestation, and no documented notice of private pay costs. The business office manager confirmed that private payment was required from the effective date of the payer change until discharge based on this unsigned NOMNC. Review of the Kaiser contract and facility policy showed that residents must be notified in advance and sign appropriate financial responsibility documents for non-covered services, and must receive notices detailing covered and non-covered services and charges, which did not occur in this case.
Several residents with complex medical needs were found to have mattresses with visible grime, stains, and dried matter, despite facility policies requiring daily cleaning and infection control. Staff interviews revealed inconsistent cleaning practices and discomfort cleaning around medical equipment, leading to unsanitary conditions that were noticed by at least one cognitively intact resident.
Two residents were routinely administered pain medications, including Norco and acetaminophen, without documented evidence of pain or clarification of physician orders. Nursing staff provided these medications on a scheduled basis even when pain assessments indicated no pain, and the DON confirmed that orders should have been clarified with the physician. This resulted in unnecessary drug administration without adequate clinical justification.
A staff member was observed handling ready-to-eat food with the same gloved hand used to touch oven and steamer handles, without changing gloves between tasks. This practice was inconsistent with the facility's policy, which requires gloves to be changed after each use and food to be handled with clean utensils to prevent manual contact.
Two residents who required staff assistance with ADLs, including nail care, were observed with long fingernails despite care plans and facility policies mandating regular grooming. Staff acknowledged the issue but did not ensure timely nail trimming, and both residents remained with untrimmed nails, contrary to established procedures for hygiene and infection prevention.
The facility did not consistently provide the ordered frequency of Restorative Nursing Assistant (RNA) services for range of motion (ROM) to three residents with significant mobility limitations, including those with hemiplegia, hemiparesis, and contractures. Despite physician orders and care plans specifying RNA interventions three times weekly, documentation and staff interviews confirmed that only one or two sessions were provided per week due to staffing reassignments.
Two residents with depression expressed suicidal ideation, but staff did not implement required safety measures such as one-on-one monitoring or removal of potentially harmful objects. One resident reported suicidal thoughts without subsequent care plan updates or increased supervision, while another was found with a wrist injury that was not investigated for self-harm. Both residents continued to have access to hazardous items in their rooms, and staff responses did not align with facility policy for managing suicide threats.
Staff failed to wear required PPE while providing care to two residents on Enhanced Barrier Precautions, including one resident with quadriplegia and ventilator dependence. Despite posted signage and facility policy, a respiratory therapist and a CNA did not use gowns or gloves during high-contact care activities, while the Infection Preventionist and DON confirmed this was a breach of infection control protocol.
A resident's personal belongings, including a transfer sling and orthopedic shoes, were repeatedly lost or mishandled by staff, causing distress to the resident's family and lack of reimbursement documentation. In a separate incident, another resident with incontinence and chronic health conditions was found to have wet towels placed inside their disposable brief by a CNA, leading to emotional distress and a violation of care protocols.
A resident's representative was not promptly notified when the resident experienced vomiting, despite being listed as the emergency contact and representative. The representative only learned of the situation after the resident's condition worsened and required hospital transfer for fever and weakness. Facility records confirmed the lack of timely notification.
A resident dependent on staff for all care, with multiple medical conditions including dementia and Tourette syndrome, was transferred from a shower chair to their room using a mechanical lift. During the transfer, the resident's genitals were exposed and visible from the hallway, as staff were unable to fully cover them with linens and did not use a privacy curtain. The transfer was performed in the hallway due to space constraints in the room, and the resident was loudly vocalizing, drawing attention from others.
A resident with multiple complex conditions, including hypotension and quadriplegia, did not receive prescribed doses of Midodrine HCL on several occasions when nursing staff incorrectly held the medication at a systolic blood pressure of 140, despite physician orders to hold only for SBP greater than 140. Staff did not notify the physician or document the reason for withholding the medication as required.
A resident with quadriplegia and hypotension did not receive prescribed Midodrine HCL on several occasions when their systolic blood pressure was at the threshold specified in the physician's order. Nursing staff held the medication without proper notification or documentation, and the medication was not administered as required, contrary to facility policy.
A resident experienced emotional distress when an RN administered medications despite the resident's refusal to receive care from that nurse. The resident, with a history of refusing new staff due to ALS and anxiety, requested a different nurse, but the RN proceeded, citing other nurses were busy. The facility lacked a specific policy on residents' rights to refuse staff, relying on standard healthcare principles.
A resident with multiple sclerosis was confined to bed for two days due to the unavailability of a Mechanical Lifting Device (MLD) sling needed for transfers. Interviews with CNAs and the administrator confirmed a shortage of slings, affecting multiple residents. The facility's policy on safe lifting and movement was not followed, compromising the resident's ability to leave her bed.
A resident admitted with thoracic fusion and chronic pain did not receive prescribed Oxycodone for 13 hours, leading to severe pain and feelings of neglect. Staff interviews revealed medication was unavailable due to prescription issues, and alternative pain management measures were not documented. The facility's policy on pain management was not followed.
A resident with a FULL CODE status did not receive immediate chest compressions when found unresponsive, leading to a delay in emergency basic life support. Despite the presence of multiple staff members, chest compressions were not initiated until additional staff arrived. The resident was pronounced deceased 42 minutes after being found with no pulse.
The facility failed to re-train a CNA accused of abuse before allowing her to return to work, as required by their policy. The CNA, who had an incident with a resident with multiple diagnoses, returned to work without completing the necessary abuse training, potentially exposing residents to harm.
The facility failed to protect a resident from potential abuse when a CNA, who was the alleged abuser, continued to work in resident care areas after an abuse allegation was reported. Despite the resident's request for another CNA, the alleged abuser continued to care for other residents until the end of the shift, contrary to the facility's policy.
Use of Timer During Care Undermining Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to honor a resident’s right to dignity and respect when staff placed a visible timer on the resident’s overbed table to indicate the duration of feeding and repositioning care. The resident, who had quadriplegia and was completely dependent on staff for meals, had a BIMS score of 12, indicating moderate cognitive impairment. During observation, a small white rectangular timer with visible red markings was seen on the resident’s overbed table. The resident reported that the DON had put the timer there about two months earlier, that no one had asked for his permission or consent before placing it in front of him, and that staff last used the timer about a month prior. The resident stated that the timer made him feel rushed and worried that eating too fast could cause choking. In interviews, CNA 1 confirmed awareness of the timer in the resident’s room. The DON stated that the resident required two CNAs for one to two hours or longer to provide care and had complained that CNAs did not spend enough time with him. The DON reported that, after discussion with the IDT, the team decided to place a timer in the resident’s room to make the resident aware of the amount of time CNAs were spending with him. The Unit Manager stated he placed the timer in the room after speaking with the resident and obtaining verbal permission, but he was unable to locate any documentation of the resident’s agreement or consent. The facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity, and that residents have rights to a dignified existence, to be treated with respect, kindness, and dignity, and to self-determination.
Failure to Provide Adequate ADL and Oral Hygiene Care for a Dependent Resident
Penalty
Summary
The facility failed to provide necessary ADL care, including grooming and personal and oral hygiene, for a dependent resident who required staff assistance. The resident had a traumatic brain injury, dysphagia, and a BIMS score of 8 indicating moderate cognitive impairment, and was dependent on staff for ADLs such as oral and personal hygiene per the MDS. During observation, the resident was in bed receiving GT feeding with an oily-appearing face and pale, white dry matter noted between the upper roof of the mouth and tongue and between the upper and lower teeth. The LVN present acknowledged that the resident required oral care and stated that the resident’s oral care involved suctioning, which was the responsibility of licensed nursing staff. Additional observations throughout the same day showed that the resident’s basic hygiene needs remained unmet. A CNA stated that the resident’s face needed to be washed and shaved, and later, in the presence of the Infection Preventionist, crust-like matter was observed stuck between the resident’s left upper and lower eyelids, and the Infection Preventionist stated the resident’s eyes needed to be cleaned. The Unit Manager later stated that oral and personal hygiene should be provided at least twice daily and as needed, and that both licensed staff and CNAs were responsible for ensuring residents received proper ADL care. The facility’s policy on ADL care for dependent residents indicated that residents unable to carry out ADLs should receive necessary services to maintain grooming and personal and oral hygiene.
Improper Private-Pay Billing for Medicare-Covered Stay Extension
Penalty
Summary
The deficiency involves the facility’s failure to limit charges against a resident’s personal funds for services covered by Medicare. A resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and had full Medicare coverage for 100 days through Kaiser upon admission. A NOMNC dated 3/17/23 indicated Medicare-covered services would end on 3/20/23 with discharge planned for 3/21/23, but this NOMNC was unsigned and lacked attestation. Despite this, the facility treated the NOMNC as effective and changed the resident’s payer status to private pay effective 3/21/23, based on the unsigned NOMNC and without providing the resident or resident representative with a notice of private pay costs. On 3/20/23, the resident experienced oxygen desaturation, was transferred to the hospital, and then returned to the facility early on 3/21/23. Progress notes showed that the discharge to a board and care was placed on hold for observation after the emergency room visit, and the attending physician ordered STAT labs and a chest x-ray, followed by continued monitoring and a later plan for discharge with home health and PCP follow-up. The resident ultimately remained in the facility and was discharged to a board and care on 3/24/23. During this extended stay, the Admissions Coordinator stated that if a resident returns from the hospital with remaining Medicare days, coverage should continue automatically, and acknowledged uncertainty about what happened with this resident’s coverage, as Medicare days were still remaining when the NOMNC was issued. The Business Office Manager and Traveling Business Office Manager reported that the facility did not request authorization from Kaiser for the resident’s continued stay after the hospital return and did not obtain an updated NOMNC with a new discharge date. Kaiser’s referral message on 3/21/23 documented a discharge date of 3/21/23 with 3/20/23 as the last covered day, and there was no documented authorization request by the facility. Relying on the unsigned NOMNC and without a Financial Responsibility Form or prior notification of non-covered services as required by the facility’s contract with Kaiser and its own policy on notice of covered and non-covered services, the facility billed the resident’s representative for three days of room and board and generated multiple collection letters before Kaiser ultimately paid the facility. This resulted in unnecessary billing, inconvenience, and potential emotional distress to the resident’s representative.
Failure to Provide Required Financial Liability Notice When Payer Source Changed
Penalty
Summary
The facility failed to notify a resident and/or the resident’s representative of potential financial liability when the payer source changed from Medicare to private pay. The resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and the admission record identified the resident’s representative as the guarantor. The case manager stated the resident had full Medicare coverage for 100 days upon admission and that a Notice of Medicare Non-Coverage (NOMNC) dated 3/17/23 indicated Medicare-covered services would end on 3/20/23, with discharge scheduled for 3/21/23. However, the NOMNC was unsigned and lacked attestation. A plan of care note documented that the Kaiser case manager emailed the NOMNC to the facility case manager, stating the resident was to be discharged to a board and care, and that the facility case manager would follow up the next day. The business office manager reported that the resident’s payer changed effective 3/21/23, requiring private payment from that date until discharge due to lack of secondary insurance, and that this change was based on the unsigned NOMNC. The business office manager acknowledged that the NOMNC should have been signed by the resident and that a notice of private pay costs should have been provided, but neither occurred. The medical records assistant confirmed there was no signed NOMNC in the chart and no documentation that a private pay cost notice was issued. Review of the facility’s contract with Kaiser showed that residents may be billed for non-covered or unauthorized services only if notified beforehand and if a Financial Responsibility Form is signed, and otherwise the facility cannot charge more than the resident’s cost share. The facility’s policy on Notice of Covered and Non-Covered Services required that residents receive a notice detailing covered and non-covered services and associated charges upon admission and periodically throughout their stay, but this was not documented for this resident at the time of the payer change.
Failure to Maintain Clean and Sanitary Mattresses for Multiple Residents
Penalty
Summary
The facility failed to provide a clean, sanitary, and homelike environment for five residents, as evidenced by the presence of whitish grime, stains, and dried matter on their mattresses. Observations revealed that mattresses used by residents with significant medical needs, such as tracheostomies, tube feedings, and ventilator support, were visibly soiled. For example, one resident's mattress had whitish grime on the bottom left portion, while another's had whitish stains and dust-like powder on multiple areas. Additional mattresses were noted to have yellowish dried matter, brownish drip-like stains, and powder-like grime. Interviews with staff, including a CNA and the housekeeping supervisor, confirmed that both nursing and housekeeping staff were responsible for cleaning and sanitizing mattresses after care or spills. However, there was a lack of immediate cleaning following spills, and some staff expressed discomfort cleaning around medical equipment, leading to unaddressed stains and grime. One resident, who was cognitively intact, reported that her mattress was dirty and that no one had come to clean it, expressing a preference for a clean mattress. Record reviews indicated that the facility had policies in place requiring daily cleaning of patient rooms and emphasized the importance of infection control and maintaining a homelike environment. Despite these policies, the observed conditions and staff interviews demonstrated that cleaning and sanitizing practices were not consistently followed, resulting in unsanitary mattresses for multiple residents with complex medical conditions.
Routine Administration of Pain Medications Without Indication or Physician Clarification
Penalty
Summary
The facility failed to ensure that two residents' drug regimens were free from unnecessary medications, specifically pain medications, which were administered routinely without adequate indications or clarification of physician orders. For one resident with end stage renal disease and a BIMS score indicating cognitive intactness, Norco (hydrocodone-acetaminophen) and Tylenol Extra Strength were ordered and administered on a scheduled basis for pain, despite the resident consistently reporting a pain level of 0. Nursing staff confirmed that these medications were given as scheduled, regardless of the resident's reported pain level, and acknowledged that the resident did not have a chronic pain diagnosis. The Director of Nursing stated that nurses should have assessed for pain before administering these medications and should have clarified the orders with the physician. Another resident, diagnosed with a persistent vegetative state and non-verbal, was also administered acetaminophen routinely via g-tube for pain management, with scheduled doses given twice daily. The medication administration records showed that the pain level was documented as 0 most of the time. Nursing staff confirmed that the medication was given routinely, and the Director of Nursing again stated that the orders should have been clarified with the physician. In both cases, the facility's practice resulted in the regular administration of pain medications without documented evidence of pain or appropriate clinical justification, and without clarification of the physician's intent for routine versus as-needed administration. This practice was observed through medication administration records, staff interviews, and direct observation, and was acknowledged by both nursing staff and facility leadership as not aligned with proper medication management protocols.
Improper Glove Use During Food Preparation
Penalty
Summary
A facility staff member was observed preparing and serving food while wearing disposable gloves that were used to both handle ready-to-eat food and touch oven and steamer handles without changing gloves. The staff member scooped food from trays, placed items on plates, and at times pushed food toward the center of the plate with the same gloved hand that had been used to open and close kitchen equipment. This practice was witnessed during a trayline observation and confirmed by the kitchen manager, who acknowledged the issue. The facility's policy and procedure on food preparation and handling, last updated in 2023, specifies that bare hands should never touch ready-to-eat food and that disposable gloves are single-use items to be discarded after each use, with food to be handled using clean utensils to avoid manual contact.
Failure to Provide Necessary Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents who were unable to perform self-care, specifically in the area of grooming and personal hygiene related to fingernail care. Both residents had documented needs for staff assistance with ADLs, including nail care, as outlined in their care plans. Despite these interventions, observations revealed that both residents had long fingernails, and staff acknowledged the issue but did not ensure the nails were trimmed in a timely manner. Resident 60 was admitted with hemiplegia and hemiparesis following a cerebral infarction, resulting in dependence on staff for self-care. The care plan for this resident included checking and trimming nails on bath days as necessary. However, during observations, Resident 60 was found with long fingernails while being dependent on a ventilator and feeding tube. Staff interviews confirmed awareness of the long nails but cited the absence of nail clippers as a reason for not addressing the issue. Resident 142, admitted with diagnoses including malignant neoplasm of the tongue and systemic lupus erythematosus, also required assistance with personal care and had moderate cognitive impairment. Observations and interviews indicated that this resident had long fingernails and expressed a preference for shorter nails, but staff had not offered to trim them. Facility policies and procedures reviewed emphasized the importance of regular nail care for hygiene and infection prevention, and staff interviews confirmed their responsibility for maintaining residents' fingernails, yet the necessary care was not provided.
Failure to Provide Ordered Range of Motion Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decline in range of motion for three residents who required Restorative Nursing Assistant (RNA) services as indicated in their physician orders and care plans. Specifically, one resident with hemiplegia and hemiparesis following a cerebral infarction, and another resident in a persistent vegetative state with contractures, both had active physician orders and care plans for RNA programs three times a week for upper and lower extremities. However, documentation and staff interviews revealed that these residents only received one or two sessions per week instead of the prescribed three sessions. Observations confirmed that both residents were dependent on ventilators and feeding tubes, with one resident exhibiting stiffness in the upper extremities. The RNA responsible for providing these services stated that she was unable to consistently deliver the RNA program due to being reassigned as a CNA during staff shortages. Facility policy required verification of physician orders and review of care plans for range of motion exercises, but these were not consistently followed, resulting in a failure to provide the ordered frequency of care.
Failure to Provide Immediate Behavioral Health Interventions for Residents Expressing Suicidal Ideation
Penalty
Summary
The facility failed to provide immediate and necessary behavioral health care and services for two residents who expressed suicidal ideation. One resident, with a diagnosis of depression and a recent significant weight loss, reported feeling suicidal to a nurse, but there was no evidence of one-on-one monitoring, removal of potentially harmful objects, or an updated care plan addressing suicidal ideation. Staff interviews revealed that after the resident expressed suicidal thoughts, the information was reported to the unit manager, but no further immediate safety measures were implemented, and the care plan did not reflect the resident's current mental health needs. Another resident, also diagnosed with depression and previously observed holding scissors to his wrist while expressing a desire to die, was later found with a skin tear on his wrist. Although the physician was notified and treatment was provided, there was no documentation that staff investigated the cause of the injury. The resident continued to express emotional instability and thoughts of self-harm, and staff responses were limited to reassurance and email notifications, without evidence of increased monitoring or environmental safety checks. The social services team was not consistently informed of the resident's behaviors, and the director of nursing was unaware of the ongoing issues. Observations showed that both residents had access to potentially harmful items in their rooms, such as gait belts, electrical cords, and plastic bags, despite their expressed suicidal ideation. Facility policy required staff to take suicide threats seriously, remain with the resident, and notify appropriate personnel, but these procedures were not consistently followed. The lack of immediate action and investigation into self-harm incidents demonstrated a failure to ensure resident safety and provide necessary behavioral health interventions.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program for two of three sampled residents when staff did not wear appropriate Personal Protective Equipment (PPE) while providing care to residents on Enhanced Barrier Precautions (EBP). Specifically, one respiratory therapist did not wear a gown while performing oral suctioning for a resident with quadriplegia and ventilator dependence, despite an EBP sign posted on the door. The therapist initially stated that PPE was not necessary for this care, but later acknowledged that proper PPE should have been used to prevent contamination and transmission of secretions and bodily fluids. In another instance, a certified nursing assistant provided care to a resident under EBP without wearing any PPE, while the resident's family member did wear PPE. The CNA confirmed awareness that PPE was required in EBP rooms but did not comply during the observed care activity. Both residents were located in the subacute unit, where all residents were reportedly under EBP due to the risk of multidrug-resistant organisms (MDROs). Interviews with the Infection Preventionist and the Director of Nursing confirmed that EBP signage was posted for staff compliance and that not wearing PPE in these rooms posed a risk of spreading infection. Facility policy required the use of gown and gloves during high-contact resident care activities, such as device care or use, which includes tracheostomy and ventilator care. The observed failures represented a break in the facility's infection control protocol.
Failure to Safeguard Resident Belongings and Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to respect and safeguard the personal belongings of a resident with a history of intracranial injury. The resident's family reported that a personally purchased and labeled transfer sling had been missing for over two months, and a wheelchair, also labeled, had previously gone missing but was later found in another unit. Additionally, a pair of black orthopedic shoes intended to prevent foot deformities was lost for about three months, requiring the family to purchase a replacement. Despite the family providing receipts for reimbursement, there was no documentation that reimbursement occurred, and the family expressed emotional distress and frustration over the repeated loss and mishandling of the resident's belongings. Another deficiency involved the failure to treat a resident with respect and dignity during incontinence care. A resident with chronic kidney disease, heart failure, and incontinence, who was cognitively intact and dependent on staff for personal care, reported that a CNA placed two rolled towels inside their disposable brief. The resident and their representative both stated this caused significant emotional distress. Upon investigation, another CNA confirmed finding the wet towels during a shift change after the resident complained of discomfort. The CNA responsible admitted to placing towels and sometimes paper towels in the resident's brief in an attempt to keep the resident dry, as the resident frequently requested to be kept dry. The care plan for the resident indicated a risk for incontinence-associated dermatitis and directed staff to provide perineal care and regular toileting, but did not include the use of towels or other absorbent materials inside briefs. The unit manager confirmed that such practices were inappropriate and not permitted.
Failure to Timely Notify Resident Representative of Change in Condition
Penalty
Summary
Facility staff failed to notify the resident's representative (RR 2) when the resident experienced vomiting early in the morning. The resident, who had a history of senile degeneration of the brain and major depressive disorder, was later transferred to the hospital the same day after developing a high fever and weakness. Documentation showed that the physician was notified of the vomiting, but there was no record that RR 2 was informed at that time. Notification to RR 2 only occurred later in the day when the resident's condition had worsened. Interviews with RR 2 confirmed that she was not made aware of the vomiting episode until after the resident's condition had deteriorated. Facility staff, including the Assistant Director of Nursing and Unit Manager, acknowledged that RR 2 was listed as the resident's representative and emergency contact and should have been notified of the change in condition. Clinical records and interviews confirmed the lack of timely notification to the resident's representative regarding the initial change in condition.
Failure to Maintain Resident Privacy During Transfer
Penalty
Summary
Staff failed to ensure privacy for a resident with vascular dementia, Tourette syndrome, seizures, and an intracranial injury, who was dependent on staff for all care needs. During a transfer from a shower chair to the resident's room using a mechanical lift, the resident was covered with linens but did not have clothes underneath. Despite attempts to cover the resident, the scrotum remained visible, and the resident's genitals were exposed and viewable from the hallway. The transfer was conducted without the use of a privacy curtain, and the resident was loudly and repeatedly yelling an expletive, which drew additional attention from others in the hallway. Staff interviews revealed that the transfer could not be performed inside the resident's room due to space limitations, requiring all transfers to be conducted in the hallway. The care plan indicated the need for a mechanical lift with two-person assistance for transfers. Facility policy stated that residents have the right to privacy and confidentiality, and the DON confirmed that it was not acceptable for a resident's genitals to be visible in the hallway.
Failure to Administer Medication as Ordered for Resident with Hypotension
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. Specifically, the resident, who had diagnoses including cervical spinal cord injury, quadriplegia, hypotension, autonomic nervous system disorder, generalized muscle weakness, and depression, did not receive prescribed doses of Midodrine HCL on three occasions. The physician's order specified that Midodrine should be held only if the resident's systolic blood pressure (SBP) was greater than 140. However, the medication was held and not administered when the SBP was exactly 140, which did not meet the criteria for withholding the medication according to the order. Record reviews and staff interviews confirmed that the medication was not given on these occasions, and the staff used a code indicating 'No Med Required - Outside of Parameter' on the Medication Administration Record (MAR). The unit supervisor and administrator both stated that the physician's order was to hold the medication only for SBP greater than 140, and that the nurse should have administered the medication when the SBP was 140. The nurse involved acknowledged that the process required physician notification if the medication was held, but this was not documented in the resident's progress notes.
Failure to Administer Ordered Medication for Hypotension
Penalty
Summary
A deficiency occurred when a resident with a history of cervical spinal cord injury, quadriplegia, hypotension, autonomic nervous system disorder, muscle weakness, and depression did not receive Midodrine HCL as ordered by the physician on multiple occasions. The medication, prescribed to manage low blood pressure, was scheduled to be administered via G-tube every 8 hours and held only if the resident's systolic blood pressure (SBP) was greater than 140. On three separate dates, the medication was not given when the resident's SBP was exactly 140, which did not meet the physician's criteria for holding the medication. The Medication Administration Record (MAR) documented that the medication was held due to being 'outside of parameter,' and the code used indicated 'No Med Required.' Interviews with facility staff revealed that the expectation was to administer the medication unless the SBP exceeded 140, and that the nurse should have notified the physician and documented the reason if the medication was held. The resident and responsible party confirmed that the medication was not administered as scheduled, and that a different nurse, not the primary charge nurse, was involved in medication administration on at least one occasion. The facility's policy required medications to be administered as prescribed, but this was not followed, resulting in the resident not receiving the ordered treatment for hypotension.
Resident's Right to Choose Healthcare Provider Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose their healthcare provider, resulting in emotional distress for the resident. The incident involved a registered nurse (RN1) who administered medications to a resident despite the resident's explicit refusal to receive care from RN1. The resident, who had a history of refusing care from new staff due to multiple medical issues including ALS and anxiety, expressed a preference for another nurse. Despite this, RN1 proceeded with the medication administration, citing that other nurses were busy and did not inform the Sub-Acute Manager (SAM) to switch the assignment. The resident, who had an intact cognitive status as indicated by a BIMS score of 15, reported feeling distressed and unable to sleep following the incident. The resident described RN1 as rude and unprofessional and had requested SAM to be called to switch the assignment. However, RN1 did not comply with this request, leading to the resident's emotional distress. The facility's administrator acknowledged that RN1 should have respected the resident's choice and noted that there were enough nurses available to accommodate the resident's request. The facility lacked a specific policy regarding a resident's right to refuse a staff member, relying instead on the basic healthcare principle that residents have the right to refuse care from specific staff.
Resident Confined to Bed Due to Lack of MLD Sling
Penalty
Summary
The facility failed to meet the needs of a resident who required a Mechanical Lifting Device (MLD) sling for transfers, resulting in the resident being confined to bed for two days. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have enough slings available. The resident, who has multiple sclerosis and impairments in both upper and lower extremities, expressed dissatisfaction with being unable to leave her bed due to the lack of a sling. Interviews with Certified Nurse Assistants (CNAs) confirmed the shortage of slings, which affected multiple residents, including the one in question. The facility's administrator acknowledged the issue, stating that all residents needing slings should have access to them. The facility's policy on safe lifting and movement, revised in July 2017, emphasizes the use of appropriate techniques and devices to ensure resident safety, dignity, and comfort, which was not adhered to in this instance.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to manage pain for a resident who was admitted with a diagnosis of thoracic fusion and chronic pain. Upon admission, the resident was cognitively intact and had a physician's order for Oxycodone 5 mg every 6 hours as needed for moderate to severe pain. Despite this, the resident did not receive the prescribed pain medication for 13 hours after admission, resulting in severe pain and feelings of neglect. The resident's pain was initially assessed at a level of four, but no further pain management was documented that night. Interviews with staff revealed that the medication was unavailable due to prescription issues, and alternative pain management measures such as Tylenol and ice packs were reportedly given but not documented. The charge nurse could not recall administering any pain medication, and the Director of Nursing confirmed the lack of documentation and stated that the resident's pain should have been addressed. The facility's policy on pain assessment and management emphasizes the importance of recognizing and managing pain, which was not adhered to in this case.
Failure to Provide Timely CPR
Penalty
Summary
The facility failed to provide emergency basic life support, including CPR, to a resident who was found with no pulse and no spontaneous respiration. The resident, who had diagnoses including anoxic brain damage, dependence on respirator status, and chronic respiratory failure, was admitted with a Physician Orders for Life Sustaining Treatment (POLST) form indicating to attempt resuscitation/CPR and a code status of FULL CODE. Despite these directives, the resident did not receive immediate chest compressions when found unresponsive, leading to a delay in the provision of emergency basic life support. On the morning of the incident, a Licensed Vocational Nurse (LVN) was called to the resident's room by a Certified Nursing Assistant (CNA) and found a Respiratory Therapist (RT) bagging the resident, who had already turned blue. The LVN called a code and instructed another staff member to call 911 while grabbing the crash cart. Despite the presence of multiple staff members, including two RTs, chest compressions were not immediately initiated. It was only after additional staff arrived that chest compressions were started. The resident was pronounced deceased by emergency personnel 42 minutes after being found with no pulse. Interviews with the involved staff revealed confusion and a lack of immediate action in initiating CPR. The RTs and LVN provided inconsistent accounts of the sequence of events and the actions taken. Documentation in the resident's clinical record was found to be incomplete and did not include all important details about the incident. The facility's policy and procedure for CPR and Basic Life Support were not followed, contributing to the delay in providing life-saving measures to the resident.
Failure to Re-train Staff Accused of Abuse Before Returning to Work
Penalty
Summary
The facility failed to develop and implement written policies and procedures that included re-training and re-education of staff accused of abuse before returning to work with residents. This deficiency was identified during a review of Resident 8's case, who had multiple diagnoses including Alzheimer's disease, depressive disorder, type 2 diabetes mellitus, hemiplegia, and hemiparesis following a stroke. On a specific date, a CNA entered Resident 8's room and found feces on the floor, which led to an interaction where the resident felt the CNA was upset. The CNA was given in-service training and a suspension letter but refused to sign them and later returned to work without completing the required abuse training. Interviews with the DON, Administrator, CNA, LVN, and DSD revealed that the CNA did not receive the mandated one-on-one abuse training before returning to work. The facility's policy required all employees to attend resident rights and abuse prevention program in-service training sessions before having any resident contact. However, the policy did not explicitly state the need for re-training staff before returning to work after an alleged abuse incident. This oversight led to the CNA being scheduled to work without the necessary re-training, potentially exposing vulnerable residents to abuse.
Failure to Protect Resident from Alleged Abuser
Penalty
Summary
The facility failed to ensure Resident 8 was protected from further potential abuse when CNA 7, who was the alleged abuser, continued to work in resident care areas after an abuse allegation was reported. Resident 8, who has Alzheimer's disease, depressive disorder, type 2 diabetes mellitus, and hemiplegia and hemiparesis following a stroke, was very upset that CNA 7 was yelling and not very nice. Despite Resident 8's request for another CNA, CNA 7 continued to work in the same assignment and had access to Resident 8 and other residents. Interviews and record reviews revealed that CNA 7 was not immediately reassigned to duties that did not involve resident contact, as per the facility's policy and procedure. CNA 7 continued to care for nine other residents and answered their call lights until the end of the shift. The facility managers did not send CNA 7 home before the shift ended because they wanted to talk to her. This failure had the potential to result in retaliation and further occurrences of abuse.
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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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