Westgate Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Visalia, California.
- Location
- 4525 W. Tulare Ave., Visalia, California 93277
- CMS Provider Number
- 555208
- Inspections on file
- 43
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westgate Gardens Care Center during CMS and state inspections, most recent first.
A confidentiality breach occurred when staff provided EMS with the wrong POLST containing another resident’s full name, birthdate, and treatment preferences. During a hospital transfer, an LVN requested a POLST from the medical records assistant, who mistakenly printed the form for a different resident with the same last name. The LVN did not verify the resident identifiers on the document before giving it to EMS, resulting in disclosure of the wrong resident’s confidential medical information in violation of the facility’s confidentiality policy.
A resident was found to be sleeping on a low air flow therapeutic mattress with a dark brown circular stain. An LVN reported that the stain did not look appealing and that the mattress should have been changed. The DON and DOH later reviewed a photograph of the mattress and confirmed the dark brown stain, acknowledging it should have been removed and replaced. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
A resident with Parkinson's Disease, panic disorder, and severe cognitive impairment (BIMS score of 3) did not have a comprehensive, person-centered care plan addressing cognition. The DON confirmed that such a care plan was required but had not been developed, contrary to facility policy.
A resident with end stage renal disease missed a scheduled dialysis session due to transportation issues, and staff did not notify the attending physician as required by facility policy. Multiple staff interviews confirmed the lack of notification, despite established procedures for reporting missed treatments.
A resident with End Stage Renal Disease missed a scheduled hemodialysis treatment because transportation was not provided, and staff did not notify the transportation company as required by facility policy. Nursing staff either did not realize the resident was not picked up or failed to follow the expected procedure to address the missed transport.
A resident who required partial assistance for transfers was moved from a wheelchair to bed by a CNA and LVN without the use of a gait belt, contrary to facility policy. The improper transfer resulted in the resident landing face down on the bed. Staff interviews and documentation confirmed that the required gait belt was not used during the transfer.
A resident with dementia and hemiplegia reported being struck on the head by a CNA, an incident witnessed by a family member during a phone call. Although the CNA was removed from care and an internal investigation was started, facility staff did not report the abuse allegation to the Ombudsman, law enforcement, or state licensing agency as required by policy.
Staff did not follow the care plan for a resident with a history of verbally abusive behavior, resulting in the resident verbally and physically abusing another resident. Despite observing aggressive behavior, staff failed to intervene, allowing the situation to escalate and leading to physical harm and distress for the affected resident.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident was discharged home without home health services being arranged in advance, despite physician orders and discharge documentation specifying the need for physical therapy, occupational therapy, nursing, and durable medical equipment. The referral to home health was not sent until several days after discharge, and there was no evidence that the required services were coordinated prior to the resident leaving the facility.
A resident was found with lidocaine at the bedside without having been evaluated for self-administration, as required by facility policy. Nursing staff confirmed the medication was left accessible and that no physician orders or lock box were in place. The facility's policy mandates an interdisciplinary assessment before allowing self-administration, which was not completed in this instance.
A resident was issued a 30-day discharge notice for non-payment, but the facility did not notify the Ombudsman as required. The administrator stated notification was not needed since the resident did not dispute the discharge, and the Ombudsman confirmed they were unaware of the notice. Facility policy requires simultaneous notification to the Ombudsman when a discharge notice is given.
The facility failed to ensure Advance Directives (ADs) were offered and completed for two residents, potentially leading to their healthcare wishes not being honored. Resident 19 had no AD on file, and there was no documentation of it being offered or discussed. Resident 103 expressed interest in an AD, but no follow-up was documented. The facility's policy requires providing information about ADs, which was not followed in these cases.
The facility's arbitration agreement failed to explicitly state that residents or their representatives had the right to rescind the agreement within 30 days of signing. This was discovered during a review with the Admissions Director, revealing that 92 out of 138 residents had signed such agreements. The Administrator confirmed the omission, despite the facility's policy indicating a 30-day rescission period.
The facility did not document attendance for ten out of twelve QAPI meetings in 2024, as required. While meetings were held monthly, attendance records were only available for November and December. The facility's policy assigns the responsibility of maintaining meeting documentation to the QAPI Administrator, but this was not followed for most of the year.
Three residents experienced significant delays in having their call light requests answered, leading to discomfort and emotional distress. One resident waited up to two hours for assistance with changing a soiled brief, while two others waited over 15 minutes for toileting help. The facility's policies on prompt response and dignity were not adhered to, as indicated by ongoing issues noted in Resident Council Minutes.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their ability to call for assistance. Observations revealed that one resident's call light was tied to the bed rail, and another's was attached to the bed but not reachable. CNAs confirmed the call lights should be within reach, as per facility policy.
A facility failed to provide a functioning overhead light for a resident, compromising their right to a safe and comfortable environment. The resident, with moderate cognitive impairment, was unable to use the light due to a detached string. Despite being reported and marked as corrected in the maintenance log, the issue persisted, as confirmed by staff interviews.
A resident with mobility issues was not assisted by CNAs to attend scheduled smoking breaks, as outlined in their care plan. Despite being ready, the resident remained in bed without receiving the necessary help to reach the designated smoking area, contrary to facility policy.
A facility failed to properly label medications for a resident, leading to potential medication errors. A resident prescribed two types of insulin had mislabeled insulin pens, with one pen labeled with another resident's name. The DON confirmed that labels should match to prevent errors. The facility's policy requires correct labeling and contacting the pharmacy for mislabeled items.
The facility failed to accurately document meal consumption for two residents, leading to potential weight changes. One resident expressed dissatisfaction with the food and left most of the meal uneaten, yet it was recorded as 76-100% consumed. Another resident also left parts of the meal uneaten, but the consumption was similarly overestimated. The DSD and IPC confirmed the inaccuracies, noting only 25% was consumed in both cases.
The facility failed to report an allegation of sexual abuse between two residents to the proper authorities. A CNA observed inappropriate touching, but the required SOC 341 form was not sent to the Ombudsman. The DON admitted to not completing the form, and the Administrator could not provide evidence of notification. The facility's policy required immediate reporting, which was not followed.
A facility failed to implement a care plan intervention for a resident who had fallen in the restroom. The care plan required non-skid strips on the restroom floor, but they were not present during an observation. A CNA confirmed their absence, and the Maintenance Director, responsible for placing them, was unaware of the requirement. The ADON acknowledged the strips should have been placed. The facility's policy emphasizes ongoing assessments and revisions to care plans, which was not followed.
A resident with moderate cognitive impairment expressed discomfort with a specific CNA and requested that the CNA not return to his room. This request was reported to the LVN on duty but was not communicated to the oncoming staff, resulting in the CNA being reassigned to the resident. The facility's policy required immediate reassignment of staff in such cases, which was not followed.
A facility failed to notify a physician of a change in a resident's discharge plan, resulting in the physician being unaware of the resident's transfer to a hospital. The resident was initially planned for discharge with home health services, but the plan changed to a hospital transfer after a Medicare appeal was denied. The facility's policy required physician notification, but no documentation was found. Both the Administrator and DON acknowledged the oversight.
A resident with a history of falls and cognitive impairment experienced a fall resulting in a head injury and spinal fracture. Despite multiple falls, the facility failed to adequately revise the care plan, relying on insufficient interventions like bed positioning and call light accessibility. The only new measure added was placing mattresses beside the bed, which did not prevent further incidents.
The facility failed to implement a care plan for a resident at risk for falls by not ensuring the call light was within reach. The call light was found clipped to the wall, out of the resident's reach, contrary to the care plan and facility policies.
Confidentiality Breach When Wrong POLST Given to EMS
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s personal and medical records when the wrong Physician Orders for Life-Sustaining Treatment (POLST), which contained a resident’s full name, birthdate, and treatment preferences, was printed and provided to Emergency Medical Services (EMS). During transfer of Resident 2 to an acute hospital, the Licensed Vocational Nurse (LVN) requested a copy of Resident 2’s POLST from the Medical Records Assistant (MRA). The MRA, noting that Resident 1 and Resident 2 shared the same last name, mistakenly provided Resident 1’s POLST instead of Resident 2’s and acknowledged that the wrong POLST was given. The LVN then failed to verify that the POLST received from MRA belonged to Resident 2 before handing it to EMS, and was unaware that the document actually pertained to Resident 1. Resident 2’s responsible party later reported that EMS had been given the POLST for Resident 1 rather than for Resident 2. This sequence of actions and inactions violated the facility’s policy and procedure on Confidentiality of Information and Personal Privacy, which requires safeguarding the confidentiality of all residents’ personal and medical records.
Failure to Provide a Clean Therapeutic Mattress
Penalty
Summary
Surveyors identified that the facility failed to provide a clean mattress for one of six sampled residents. On 2/8/26, a Licensed Vocational Nurse (LVN) observed that this resident’s low air flow therapeutic mattress had a dark brown circular stain and stated the stain did not look appealing and the mattress should have been changed. During a subsequent interview, the Director of Nursing (DON) and Director of Housekeeping (DOH) reviewed a photograph of the mattress taken on 2/8/26 and confirmed the presence of the dark brown stain, agreeing that the mattress should have been removed and replaced. As a result of this inaction, the resident slept on a stained mattress, with the report noting potential for skin irritation and respiratory issues. Review of the facility’s “Homelike Environment” policy dated 2001 indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance. The deficiency centers on the facility’s failure to ensure the resident’s mattress was clean and appropriately maintained in accordance with its own policy and procedure for providing a safe and clean environment.
Failure to Develop Care Plan for Cognition in Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing cognition for a resident with severe cognitive impairment. The resident had diagnoses of Parkinson's Disease and panic disorder, and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, a review of the resident's admission record and care plan revealed that no care plan had been created to address the resident's cognitive needs. During an interview and record review, the DON confirmed that a care plan should have been developed for the resident's cognitive impairment, but none was present. The facility's policy requires the interdisciplinary team to create and implement a comprehensive care plan with measurable objectives and timeframes for each resident, including those with cognitive issues. This process was not followed for the resident in question.
Failure to Notify Physician of Missed Dialysis Treatment
Penalty
Summary
The facility failed to notify the attending physician when a resident with end stage renal disease missed a scheduled dialysis treatment. The resident was scheduled for hemodialysis three times a week, and on one occasion, did not attend the treatment because transportation did not arrive. Review of the resident's clinical records confirmed the missed dialysis session, and interviews with nursing staff and the Director of Nursing revealed that the attending physician was not informed of the missed treatment, despite facility practice and policy requiring such notification. Interviews with multiple staff members, including two LVNs and an RN, confirmed that it was standard practice to notify the attending physician of any missed dialysis treatments. However, documentation and staff statements indicated that this notification did not occur. The facility's policy on changes in a resident's condition or status specifically required physician notification in the event of significant changes, such as missed treatments, but this protocol was not followed in this instance.
Failure to Ensure Transportation for Dialysis Appointment
Penalty
Summary
A resident with a diagnosis of End Stage Renal Disease, requiring hemodialysis three times weekly, missed a scheduled dialysis treatment due to a failure in transportation arrangements. The resident's clinical records and progress notes confirmed that the resident did not attend the scheduled dialysis session because the transportation service did not arrive to pick up the resident. Interviews with nursing staff revealed that the transportation company was not notified when the resident was not picked up, and staff were either unaware of the missed pickup or did not follow the facility's practice of contacting the transportation provider to determine the cause. The Director of Nursing confirmed that the expectation was for nurses to notify the transportation company in such situations, but this was not done. Review of the facility's policy indicated that the facility is responsible for helping arrange transportation for residents as needed. The failure to ensure transportation resulted in the resident missing a critical dialysis treatment.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of a gait belt during resident transfers for one of three sampled residents. According to the resident's Minimum Data Set, the individual required partial/moderate assistance for chair/bed-to-chair transfers. During a transfer from wheelchair to bed, the resident reported that the CNA and LVN did not transfer her correctly, resulting in her landing face down on the bed. Multiple interviews with facility staff, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that a gait belt was not used during the transfer, and the transfer was performed inappropriately. A review of the facility's policies indicated that a gait belt must always be used for any resident who is not completely independent, with no exceptions. The staff involved did not adhere to this policy, as confirmed by their own statements and the investigation findings. The incident was documented in the Facility Reported Event and progress notes, and the resident expressed that the staff were rough and did not transfer her correctly, leading to the incident.
Failure to Report Abuse Allegation to Required Agencies
Penalty
Summary
The facility failed to implement its own policy regarding the reporting of an abuse allegation involving a resident with multiple medical conditions, including metabolic encephalopathy, dementia, hemiplegia, and hemiparesis. The resident, who had moderate cognitive impairment, reported an incident where a CNA struck her on the head, causing her head to hit the bed's side rail. This incident was witnessed indirectly by a family member during a phone call and subsequently reported to facility staff. Upon learning of the allegation, facility staff, including the Director of Staff Development (DSD), Infection Preventionist (IP), Director of Nursing (DON), and the Administrator, were informed. The CNA involved was immediately removed from resident care, and an internal investigation was initiated. However, the staff did not report the allegation to any external agencies, such as the Ombudsman, law enforcement, or the state licensing agency, as required by the facility's policy and regulatory guidelines. The facility's policy clearly states that all allegations of abuse must be reported to the appropriate external agencies immediately, defined as within two hours for abuse allegations or those resulting in serious bodily injury. Despite this, the staff acknowledged during interviews that the required external reporting did not occur. The failure to follow the established reporting procedures constituted a deficiency in the facility's abuse prevention and response protocols.
Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
Staff failed to implement the care plan for a resident with a history of verbally abusive behaviors related to poor impulse control. The care plan included interventions such as gentle redirection when applicable. On the day of the incident, staff observed the resident invading another resident's personal space, appearing angry and aggressive, but did not intervene. This inaction allowed the resident to escalate, resulting in cussing at and physically hitting the other resident on the leg, as well as throwing the resident's belongings on the floor. Documentation and interviews confirmed that the resident had a moderately impaired cognitive status and had previously exhibited similar behaviors, including yelling and becoming upset with the roommate. Staff members present at the time either did not intervene or delayed intervention, despite being aware of the resident's behavioral history and the care plan interventions. The facility's policy required individualized behavioral interventions to address such behaviors, but these were not implemented during the incident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were arranged prior to the discharge of a resident. Physician orders indicated that the resident was to be discharged home with home health services, including physical therapy, occupational therapy, nursing, and durable medical equipment. The discharge summary also documented that these services and equipment were to be provided upon discharge. However, a review of the resident's progress notes revealed that the referral to home health was not sent until six days after the resident had already been discharged. During an interview and record review with the Social Service Director, it was confirmed that there was no evidence of home health being notified of the resident's discharge orders before the resident left the facility. The facility's policy required that discharge planning ensure the resident's health and safety needs were met and that arrangements for community care and support services were made prior to discharge. This process was not followed, resulting in the resident being discharged without the necessary home health services in place.
Medication Left at Bedside Without Self-Administration Evaluation
Penalty
Summary
A deficiency occurred when a resident was found with lidocaine, a medication used to relieve pain, left at the bedside without having been evaluated for self-administration. During observation, the resident was seen holding a washcloth to her mouth in apparent pain, with a medication cup containing a clear gel substance on her over-bed table. The resident reported that the nurse provided the lidocaine so she could use it when in pain. Licensed nursing staff confirmed that the medication was left at the bedside and acknowledged that an evaluation is required before a resident is permitted to self-administer medication. However, the resident had not been evaluated for this, nor were there physician orders or a lock box present as required by facility policy. Further interviews with nursing staff and the Director of Nursing confirmed that the resident did not have physician orders to self-administer medications and that the lidocaine should not have been left at the bedside. Review of the facility's policy indicated that an interdisciplinary team assessment is necessary to determine if self-administration is safe and appropriate, considering the resident's cognitive and physical abilities. In this case, the required assessment and procedures were not followed, resulting in the medication being accessible to the resident without proper authorization or safeguards.
Failure to Notify Ombudsman of Resident Discharge for Non-Payment
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when a resident was issued a 30-day notice of discharge for non-payment. The Notice of Proposed Transfer/Discharge (NPTD) was provided to the resident, citing non-payment of the share of cost assigned by Medi-Cal as the reason for discharge. The notice was signed by both the facility representative and the resident. However, the Ombudsman was not informed of the impending discharge, as required by facility policy and federal regulations. During interviews, the facility administrator stated that the Ombudsman was not notified because the resident did not dispute the discharge. The Ombudsman confirmed that their office was unaware of the discharge notice. Review of the facility's policy indicated that a copy of the discharge notice should be sent to the Ombudsman at the same time it is provided to the resident and their representative. This omission resulted in a failure to follow required notification procedures for resident discharge.
Failure to Ensure Advance Directives Offered and Completed
Penalty
Summary
The facility failed to ensure that Advance Directives (ADs) were offered and completed for two residents, which could potentially lead to their healthcare wishes not being honored. During an interview and record review, it was found that there was no documentation of an AD being offered or discussed with Resident 19 or their responsible party. The Nursing Consultant confirmed the absence of an AD on file for Resident 19. For Resident 103, the AD indicated interest in executing an AD, but there was no follow-up documentation. The Social Services staff acknowledged that Resident 103 had expressed interest in an AD, but no further action was documented. The facility's policy requires that residents or their representatives be provided with information about their rights to accept or refuse treatment and to formulate an AD, but this was not adhered to in these cases.
Arbitration Agreement Rescission Rights Not Explicitly Stated
Penalty
Summary
The facility failed to ensure its arbitration agreement explicitly stated that residents or their representatives had the right to rescind the agreement within 30 calendar days of signing. This oversight was identified during an interview and record review with the Admissions Director, where it was found that 92 out of 138 residents had signed arbitration agreements. The facility's Arbitration Agreement mentioned the possibility of rescission within 30 days but did not explicitly state the right to do so. The Administrator acknowledged that the agreement should have clearly indicated this right. Additionally, the facility's policy on Binding Arbitration Agreements, dated November 2023, stated that residents or their representatives are provided 30 days to review and rescind any agreement not understood at the time of admission.
Failure to Document QAPI Meeting Attendance
Penalty
Summary
The facility failed to document the attendance of required members at the Quality Assurance and Performance Improvement (QAPI) committee meetings for ten out of twelve meetings in 2024. During an interview and record review with the Administrator, it was revealed that while the facility held monthly QAPI meetings throughout 2024, attendance records were only available for the meetings in November and December. There was no documentation of attendance for meetings from January to October 2024. The facility's policy indicated that the QAPI Administrator is responsible for maintaining documentation of meeting minutes, but this was not adhered to for the majority of the year.
Delayed Response to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity, as they experienced significant delays in having their call light requests answered. Resident 97 reported waiting up to two hours for assistance with changing her soiled brief, which required the help of two staff members. This delay caused her discomfort and emotional distress. Resident 97 had a diagnosis of long-term complications from a stroke and required substantial assistance with hygiene. Similarly, Resident 34, who had Parkinson's Disease, reported waiting more than 15 minutes for assistance with toileting, which left him feeling upset. Resident 13, diagnosed with spinal stenosis, also experienced a delay of more than 15 minutes for help with changing her brief, resulting in discomfort and anger. The facility's Resident Council Minutes from the past few months indicated ongoing issues with CNAs not responding promptly to call lights, with residents expressing concerns about staff availability and willingness to assist. The facility's policy on answering call lights emphasized the importance of responding to residents' needs as soon as possible, and the dignity policy highlighted the prohibition of practices that compromise residents' dignity, including delays in toileting assistance. Despite these policies, the facility's failure to adhere to them resulted in residents experiencing discomfort and emotional distress.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could potentially result in their needs not being met. During an observation and interview, it was noted that Resident 42's call light was tied to the right side rail near the top of the bed, making it unreachable for the resident. Both Resident 42 and a Certified Nursing Assistant (CNA) confirmed that the call light was out of reach. Similarly, in Resident 101's room, the call light was attached to the bed but not within reach of the resident. CNA 2 also acknowledged that the call light should be within reach. The facility's policy, dated 2010, states that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Provide Functioning Overhead Light for Resident
Penalty
Summary
The facility failed to ensure a functioning overhead light was available for a resident, identified as Resident 37, which compromised the resident's right to a safe and comfortable environment. During an observation and interview, it was noted that the string to turn on the light above the resident's bed was detached, rendering the light unusable for personal use. The resident reported that the string had been broken for a couple of weeks, indicating a prolonged period without access to adequate lighting. The resident's Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment with a BIMS score of 11. Interviews with a Licensed Vocational Nurse and a Maintenance Assistant confirmed that the string should have been longer to allow the resident to operate the light. A review of the facility's Maintenance Log showed that the issue was reported by another LVN and was marked as corrected the day before the observation, suggesting a discrepancy between reported maintenance actions and the actual condition of the light.
Failure to Assist Resident with Scheduled Smoking Breaks
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as Resident 103, regarding smoking breaks. The care plan specified that Resident 103, who has muscle weakness and mobility issues, required assistance to and from the designated smoking area. However, on the day of observation, Resident 103 was not offered assistance to attend the scheduled smoking breaks. Despite being dressed and ready, the resident remained in bed and expressed that no staff had come to help him prepare for the smoke break. The facility's policy outlined specific smoking times and locations, and it was the responsibility of the CNAs to assist residents to these areas. During interviews, it was confirmed that the CNAs did not offer the smoking break to residents in the relevant hallway, including Resident 103. The facility's policy mandates that smoking is only permitted in designated areas outside the building, and the care plan emphasized the need for assistance, which was not provided, leading to a failure in meeting the resident's psychosocial needs.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medications for one of its residents, identified as Resident 83, which led to a potential risk of medication errors. During a review of Resident 83's records, it was found that the resident was prescribed two types of insulin: Insulin Lispro, a fast-acting insulin to be administered before meals, and Insulin NPH, an intermediate-acting insulin to be administered at bedtime. However, during an observation, a Licensed Vocational Nurse (LVN) discovered that the insulin pen intended for Resident 83 was mislabeled. The plastic bag containing the insulin pen was labeled with Resident 83's name but indicated Insulin NPH, while the pen inside was labeled as Insulin Lispro. Furthermore, a replacement insulin pen obtained from the medication room was also mislabeled, with the pen inside labeled with another resident's name. The Director of Nursing (DON) confirmed that the labels on insulin bags and pens should match to prevent residents from receiving the wrong type of insulin or another resident's medication. The facility's policy on medication labeling and storage requires that medications dispensed by the pharmacy be labeled in accordance with federal and state requirements and accepted pharmaceutical practices. The policy also states that if medication containers have incorrect labels, the dispensing pharmacy should be contacted for instructions on returning or destroying these items. This incident highlights a failure in the facility's medication management system, specifically in ensuring that medications are correctly labeled to prevent potential medication errors.
Inaccurate Meal Consumption Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document meal consumption percentages for two residents, Resident 93 and Resident 103, which could potentially lead to unplanned weight changes. During an observation and interview, Resident 93 expressed dissatisfaction with the food, stating she never ate 80% of her meals. Observations showed that Resident 93 left most of her meal uneaten, yet her meal consumption was inaccurately recorded as 76-100% consumed. The Director of Staff Development (DSD) and Infection Preventionist Consultant (IPC) reviewed the meal and agreed that only 25% was consumed. Similarly, Resident 103's meal consumption was inaccurately documented. Observations revealed that Resident 103 ate only a portion of the meal, leaving the salad and apple juice untouched. However, the meal consumption was recorded as 76-100% consumed. The DSD and IPC, upon reviewing the meal, concurred that only 25% was consumed. The facility's Dietary Intake Guide and policy on charting and documenting emphasize the need for accurate and complete documentation, which was not adhered to in these instances.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide a written report of an allegation of sexual abuse to the proper authorities for two residents. During an interview, the Ombudsman stated they did not receive the required SOC 341 form from the facility regarding the allegation of sexual abuse between the two residents. The incident was documented in Resident 2's Progress Notes, indicating that a CNA observed Resident 2 inappropriately touching Resident 1. The Licensed Vocational Nurse confirmed the observation, stating that the CNA saw Resident 2 with his hands on Resident 1's peri area. The Director of Nurses admitted to not filling out or sending the SOC 341 form to the Ombudsman. The Administrator, upon reviewing the mandated reporter pathway, acknowledged that law enforcement and the Ombudsman should have been notified immediately or as soon as practically possible by phone and with a written report within 24 hours of the alleged abuse. However, the Administrator could not provide documented evidence that the written SOC 341 was sent to the Ombudsman. The facility's policy and procedure required verbal and written notices to be submitted via special carrier, fax, email, or telephone, which was not adhered to in this case.
Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who had experienced a fall in the restroom. The care plan, dated January 11, 2024, specified that non-skid strips should be placed on the restroom floor to prevent further falls, with the intervention initiated on December 23, 2024. However, during an observation and interview on January 2, 2025, it was found that the non-skid strips were not present on the restroom floor. A Certified Nursing Assistant confirmed the absence of the strips, and the Maintenance Director, who was responsible for placing them, stated he was unaware of the requirement. The Assistant Director of Nursing acknowledged that the strips should have been placed following the care plan update. The facility's policy on comprehensive, person-centered care plans emphasizes the need for ongoing assessments and revisions to ensure residents' well-being, which was not adhered to in this instance.
Failure to Address Resident's Grievance Regarding CNA Assignment
Penalty
Summary
The facility failed to promptly address a grievance raised by a resident who expressed discomfort with a specific Certified Nursing Assistant (CNA). On August 26, 2024, after receiving care from CNA 1, the resident reported feeling uncomfortable and requested that CNA 1 not return to his room. This request was immediately communicated by CNA 2 to the Licensed Vocational Nurse (LVN) on duty. However, the LVN did not relay this information to the oncoming staff or take any action to ensure the resident's request was honored. As a result, when CNA 1 returned to work on August 30, 2024, he was again assigned to care for the resident, leading to the resident expressing his discomfort vocally. The Director of Staff Development (DSD) confirmed that the facility's policy required immediate reassignment of staff when a resident expressed discomfort, which was not followed in this case. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was entitled to have his grievances addressed promptly according to the facility's policy on resident rights.
Failure to Notify Physician of Change in Discharge Plan
Penalty
Summary
The facility failed to notify the physician when there was a change in the discharge plan for a resident, resulting in the physician being unaware of the resident's transfer to the hospital. The physician order dated two days prior to the discharge indicated that the resident was to be discharged with home health services, including physical therapy, occupational therapy, a registered nurse, a wound nurse, a home health aide, and a master of social work. However, the resident's responsible party was informed that the appeal for the Notice of Medicare Non-Coverage was denied, and the discharge plan was changed to transfer the resident to a hospital. The resident was transferred to the hospital via ambulance, and the responsible party signed the transfer discharge, discharge summary, and inventory of personal items. During interviews, both the Administrator and the Director of Nursing acknowledged that the physician should have been notified of the change in the discharge plan and that a new discharge order should have been written. The facility's policy and procedure for transfer or discharge indicated that the resident's attending physician should be notified in such cases, but there was no documentation of this notification in the resident's clinical record.
Failure to Revise Fall Care Plan for Resident
Penalty
Summary
The facility failed to revise and implement an appropriate plan of care for falls for a resident, which had the potential to cause serious harm. The resident, who had a history of falls and was generally confused, experienced a fall on 3/16/24, resulting in a head injury and a fracture of the L3 vertebra. Despite previous falls in the facility, the care plan was not adequately updated to address the resident's high risk of falling. The resident's medical records indicated a high fall risk score and cognitive impairment, as evidenced by an unassessable score on the Brief Interview for Mental Status. The resident required partial moderate assistance for various movements and had a history of attempting to get up independently, which was not effectively managed by the facility. The interventions in place, such as keeping the bed in the lowest position and ensuring the call light was within reach, were not sufficient to prevent further falls. The facility's Interdisciplinary Team (IDT) met multiple times to discuss the resident's falls but failed to implement new or effective interventions. The only new measure added to the care plan since January 2024 was placing mattresses on either side of the bed. The Director of Nursing acknowledged that the care plan should have been revised and suggested that moving the resident closer to the nurse's station could have been a more effective intervention.
Failure to Implement Care Plan for Call Light Accessibility
Penalty
Summary
The facility failed to ensure the care plan was implemented for a resident at risk for falls when the call light was not within reach. The care plan, dated 1/5/24, specified that the call light should be kept within reach of the resident. However, during an observation on 4/17/24, the call light was found clipped to the wall, out of the resident's reach. A Certified Nursing Assistant (CNA) had to unclip the call light and place it on the resident's abdomen for accessibility. The resident confirmed that the call light was used to call for help, and the CNA acknowledged that it should have been on the bed for easy access. The Director of Nursing (DON) also confirmed that the call light should have been close to the resident. A review of the facility's policy and procedure (P&P) on answering call lights, dated 10/10, indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. Additionally, the facility's P&P on comprehensive, person-centered care plans, dated 3/22, emphasized that care plans should describe services to help residents attain or maintain their desired level of wellbeing. The failure to follow these policies resulted in the resident's inability to call for assistance when needed.
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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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