Alameda Healthcare & Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Alameda, California.
- Location
- 430 Willow Street, Alameda, California 94501
- CMS Provider Number
- 555486
- Inspections on file
- 51
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Alameda Healthcare & Wellness Center during CMS and state inspections, most recent first.
During a COVID-19 outbreak, the facility did not notify the state health department or post required signage at the entrance. Staff, including a receptionist, CNA, and RNA, were observed wearing N95 masks incorrectly, and others wore surgical masks instead of N95s in hallways. Residents with cognitive and immune vulnerabilities were present, and one resident reported inconsistent mask use by staff. Facility leadership confirmed the outbreak and acknowledged lapses in reporting and signage.
Multiple residents did not receive medications according to physician orders and care plans due to insufficient nursing staff, resulting in late administration of critical medications and a significant medication error involving a narcotic overdose. Nurses were assigned to pass medications to over 25 residents per shift, leading to delays, errors, and inaccurate documentation, with staff reporting frequent interruptions and lack of support.
Multiple residents did not receive medications as ordered, including late administration of seizure, blood pressure, anticoagulant, and pain medications, and one resident received a fivefold overdose of methadone due to staff distraction and workload. Nursing staff cited high resident loads and lack of assistance as reasons for delays, and medication records did not always accurately reflect administration times.
A resident with a history of heart failure and dementia received five times the prescribed dose of methadone when an RN, distracted during medication preparation, administered 25 mg instead of 5 mg. The error was discovered during a narcotics count the following day, after the resident had also received hydromorphone and subsequently experienced vomiting and over-sedation.
Surveyors found that a medication room with a number-coded lock could be opened without a code, and a refrigerator inside containing an e-kit with lorazepam was left unlocked. A nurse supervisor confirmed the storage should have been locked, and the DON stated all medication storage must be secured at all times. Facility policy requires controlled medications to be double-locked and accessible only to authorized personnel.
The facility's QAPI committee did not fully implement or monitor its program to reduce medication errors and late medication administration, resulting in multiple instances where residents received medications late or in incorrect doses. These included late administration of seizure, blood pressure, anticoagulant, and pain medications, as well as a significant dosing error with methadone. Nurses cited high workloads, lack of support, and distractions as contributing factors, while audits and oversight were inconsistently performed.
A facility failed to ensure that a staff member alleged of abuse completed required abuse prevention re-training before returning to work with a resident who had complex medical needs, including cognitive and respiratory deficits. The staff member resumed duties without completing or acknowledging the mandated training, contrary to facility policy.
A resident with significant medical needs did not receive timely podiatry care after a toenail avulsion and fungal infection, despite physician orders and nursing staff requests. The Social Services Coordinator was unaware of the order for an outpatient podiatry referral, and no appointment was arranged, resulting in the resident not being seen by a podiatrist until the next scheduled in-house visit several months later.
A long-term care facility failed to maintain proper infection control practices, affecting nine residents. Staff did not adhere to hand hygiene protocols during incontinent care and failed to follow PPE protocols for residents on enhanced barrier precautions. Additionally, a resident's urinal was found unclean and not replaced, indicating lapses in sanitation practices.
The facility failed to ensure appropriate use of bed rails for three non-ambulatory residents, increasing the risk of entrapment or injury. Despite facility policy, bed rails were used for residents who could not benefit from them due to their medical conditions, as confirmed by the DON.
A long-term care facility failed to administer medications according to physician orders for multiple residents, resulting in improper documentation, missed doses, and late administration. Staff cited heavy workloads as a reason for delays, and interviews revealed inconsistencies in adherence to facility policies on medication timing and error reporting.
The facility failed to manage waste disposal properly, with trash bags on the ground, overfilled dumpsters, and lids propped open. The Dietary Supervisor confirmed the area was not well maintained and acknowledged the improper state of the dumpster lids.
The facility failed to maintain the dignity and privacy of three residents by displaying signs with personal medical information above their beds. One resident, who was cognitively intact, had a sign with dietary needs and feeding instructions. Another resident, severely impaired, had signs for feeding and seizure precautions. A third resident, also cognitively intact, had signs for feeding status, fall risk, and aspiration precautions. The DON confirmed that this information should not be publicly displayed.
Two residents were found with medications at their bedside without the necessary assessments, physician's orders, or care plans. One resident with COPD had an inhaler without documentation, while another with end-stage renal disease had tablets left by an LVN. Both cases lacked the required self-administration assessments and approvals.
A resident with dementia and Alzheimer's disease was observed receiving peri care with the door open, compromising privacy. Despite the privacy curtain being drawn, the resident's legs were visible from outside the room. Staff interviews revealed differing understandings of privacy protocols, with some believing curtain use was sufficient, while others emphasized the need to close the door. The facility's policy mandates privacy and confidentiality, which was not maintained in this case.
The facility failed to maintain air conditioning filters in the subacute unit, affecting 21 residents, including 11 on ventilators. Observations revealed thick, gray film on the filters, and the Maintenance Supervisor admitted they were last cleaned in July 2024. No system was in place to track regular maintenance.
A resident, cognitively intact with a BIMS score of 14, reported rough treatment by a CNA during care. The facility's policy requires abuse allegations to be reported within two hours, but the report to the SSA was delayed, as confirmed by the Administrator.
A facility failed to provide timely written notification to a resident, their representative, and the Ombudsman regarding a hospital transfer. A resident was transferred due to gastrointestinal bleeding, but the required notification to the Ombudsman was not documented. The Social Services staff responsible for notifications could not locate the necessary documentation, leading to a deficiency in communication as per facility policy.
The facility failed to provide bed hold notifications to two residents within 24 hours of their hospital transfers, as required by policy. Despite claims from Social Services that notifications were given, the Administrator confirmed the Admissions Coordinator did not provide them. This oversight was identified through EMR reviews, which showed no notifications for residents with chronic conditions transferred for medical emergencies.
A facility failed to transmit a resident's MDS assessment in a timely manner. The resident, admitted with a femur fracture, spinal stenosis, and chronic kidney disease, had their discharge assessment completed but not transmitted as required by CMS guidelines. An interview confirmed the oversight.
The facility failed to maintain accurate care plans for two residents and did not invite a cognitively intact resident to care conferences. One resident's care plan incorrectly included splint usage, while another's included smoking cessation resources despite being in a vegetative state. Additionally, a resident was not invited to care conferences, contrary to facility policy.
A facility failed to create a person-centered discharge plan for a resident who expressed a desire to return home. Despite being cognitively intact, the resident was not involved in discharge planning discussions. Social services staff did not engage with the resident regarding discharge preferences, and the Social Services Director was unaware of this oversight.
A resident requiring cataract surgery did not receive an ophthalmologist referral order due to the facility's failure to follow up on a referral sent nearly a year prior. The resident's appointments were repeatedly canceled, and staff interviews revealed a lack of awareness about the referral. The facility's policy on coordinating medical services was not followed.
A resident with chronic respiratory failure did not receive prescribed enteral feeding due to staff oversight, missing 15% of their daily nutritional intake. The feeding pump was not turned on at the scheduled time, as confirmed by the resident's spouse and a nurse, who cited time constraints as the reason for the delay.
A facility failed to complete dialysis communication sheets for a resident with end-stage renal disease, missing documentation on 17 occasions over 94 days. The facility's policy requires nursing staff to communicate vital signs, weight, and condition changes to the dialysis provider, and for the provider to report back any issues. Interviews confirmed the deficiency, with the DON expecting nurses to complete pre- and post-dialysis documentation, which was not done.
A resident with a traumatic brain injury and schizophrenia expressed suicidal thoughts during an assessment, prompting a referral to a psychiatrist. However, the facility failed to follow up on the referral, and the resident was not seen by a psychologist. Interviews revealed a lack of a system to ensure psychiatric consultations were completed, leading to the resident being severely depressed.
Expired medications and supplies were found in the Sub-Acute Medication Room, including Erythromycin, Famotidine, and Oseltamivir Phosphate, as well as Calamine Lotion, Silver Nitrate Applicators, and a Dextrose IV bag. The DON acknowledged the issue and mentioned previous efforts to remove expired items.
A facility failed to establish a contract with a dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy requires maintaining signed service agreements with all providers, but a review revealed the absence of such a contract with the dialysis center. This was confirmed by the Administrator, placing residents receiving dialysis at potential risk.
A resident with complex medical needs did not receive podiatry services for a year, leading to excessive toenail growth and a wound on the right great toe. The wound became severely infected, resulting in osteomyelitis and requiring hospitalization and antibiotic treatment. The facility's failure to ensure timely podiatry care contributed to the resident's deteriorating foot health and subsequent medical complications.
A resident with significant medical conditions was vaccinated for COVID-19 without consent from their responsible party, despite prior instructions not to vaccinate due to a compromised immune system. This resulted in swelling and probable pain in the resident's arm. The facility's policy required obtaining consent, which was not adhered to in this case.
Failure to Report COVID-19 Outbreak and Enforce Proper Mask Use
Penalty
Summary
The facility failed to follow infection control practices during a COVID-19 outbreak. Specifically, the facility did not notify the California Department of Public Health about the outbreak and did not post signs at the front entrance to inform visitors, residents, or staff of the outbreak. Observations revealed that staff, including a receptionist, a CNA, and a Restorative Nursing Assistant, were not wearing their N95 masks correctly, with masks worn below the nose. Additionally, a Certified Nursing Assistant and a Laundry Aid were observed wearing surgical masks instead of N95 respirators in resident hallways, contrary to facility policy during the outbreak. Interviews confirmed that staff were aware of the requirement to wear N95 masks and the importance of proper mask usage, but these protocols were not consistently followed. Resident records reviewed included individuals with significant medical vulnerabilities, such as cognitive communication deficits and immunodeficiency, as well as a resident admitted for COVID-19 screening. One resident reported that staff did not always wear their masks correctly. Facility leadership, including the DON and Administrator, acknowledged the outbreak and the need for N95 masks and signage, but confirmed that the outbreak had not been reported to the state health department and that required signage was not in place at the time of the survey.
Insufficient Nursing Staff Leads to Delayed and Incorrect Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely and accurate medication administration for multiple residents, as evidenced by direct observations, interviews, and record reviews. Several licensed nurses were responsible for administering medications to a high number of residents per shift, resulting in significant delays and errors. For example, one nurse was observed administering 12 medications late to a resident with epilepsy, including a seizure medication, and left the medications unattended on the bedside table for several hours. The resident was not capable of self-administering medications, and the medication administration record did not accurately reflect the times medications were given. Another incident involved a registered nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. The nurse attributed the error to being distracted by the needs of another resident and rushing through the medication pass. The error was only discovered during a subsequent narcotics count. Additional residents experienced late administration of critical medications, such as blood pressure medications and anticoagulants, with documentation and interviews confirming that these medications were often given hours after their scheduled times. Staff interviews revealed that nurses were frequently assigned to pass medications to 25 or more residents per shift, leading to delays and increased risk of errors. Nurses reported difficulty finding assistance and being interrupted by other resident care needs, which further contributed to late medication passes. The facility's own policy required medications to be administered within one hour of the scheduled time, but this standard was not met. The Director of Nursing acknowledged that current staffing levels were insufficient to allow for safe and timely medication administration.
Failure to Administer Medications According to Physician Orders and Care Plans
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and resident care plans for five of eight sampled residents. Staff did not administer medications as prescribed, resulting in late administration of critical medications and, in one case, a significant medication error involving a narcotic overdose. For example, one resident with epilepsy and supraventricular tachycardia did not receive seizure medication on time, as the nurse left the medications at the bedside for several hours before administration, despite the resident not being capable of self-administration and having no such order. The medication administration record did not accurately reflect the timing of administration. Another resident received a fivefold overdose of methadone when a registered nurse, distracted by another resident's needs, mistakenly administered five tablets instead of one. The error was only discovered during a subsequent narcotics count, and the nurse acknowledged the mistake. Additional residents experienced late administration of medications for blood pressure, anticoagulation, and pain management, with staff citing high resident loads, frequent interruptions, and lack of available assistance as reasons for the delays. Medication administration records showed that medications were often given hours after their scheduled times. Interviews with nursing staff and leadership confirmed that medication passes were frequently delayed due to staffing shortages and competing resident care demands. Staff reported that they were unable to administer medications within the facility's policy timeframe, and some residents noted that their medications were routinely given late, with documentation not always reflecting the actual time of administration. The facility's policy required medications to be administered within one hour of the scheduled time, but this standard was not met in multiple observed instances.
Significant Medication Error: Overdose of Methadone Administered
Penalty
Summary
A registered nurse (RN) administered a significant medication error to a resident who had been admitted with acute heart failure, dementia, and failure to thrive. The resident had physician orders for methadone 5 mg orally twice daily and hydromorphone as needed for pain. On one occasion, the RN, while distracted and rushing due to the needs of another resident, mistakenly administered five tablets of methadone 5 mg (totaling 25 mg) instead of the prescribed single 5 mg tablet. The error was not immediately recognized and was only discovered the following day during a narcotics count. Following the administration of the incorrect methadone dose, the resident received additional doses of hydromorphone both before and after the error. The resident subsequently experienced vomiting and was observed to be over-sedated. Facility documentation and interviews confirmed the medication error, the circumstances leading to it, and the resident's adverse reaction. The facility's policy required nursing staff to adhere to the seven rights of medication administration, including the right amount and right time, which was not followed in this instance.
Failure to Secure Medication Room and Controlled Substances
Penalty
Summary
A deficiency was identified when the medication room in the sub-acute area was found to be unsecured during an observation. The door to the medication room, which was supposed to be secured with a number-coded lock, could be opened without entering a code. Inside the medication room, a refrigerator containing an emergency kit (e-kit) with a vial of lorazepam, a controlled medication, was also found to be unlocked, with the keyed padlock hanging on a hinge. These observations were made in the presence of a nurse supervisor, who confirmed that the e-kits were supposed to be stored in a locked refrigerator and acknowledged that a mechanism keeping the door unlocked had been engaged. Further interviews with facility staff, including the DON, confirmed that all medication rooms and medication storage areas were required to be locked at all times to prevent unauthorized access. A review of the facility's policy indicated that medication supplies should only be accessible to authorized personnel and that controlled medications must be stored in a double-locked compartment. The failure to secure both the medication room and the refrigerator containing controlled substances constituted a breach of these policies.
Failure to Implement Effective QAPI Program for Medication Administration
Penalty
Summary
The facility's quality assurance committee failed to effectively implement its QAPI program aimed at reducing medication errors and preventing late medication administration. Despite having a QAPI project in place, the committee did not fully implement the interventions, did not adequately investigate the causes of late medication administration and errors, and failed to monitor or reassess the program when issues persisted. This resulted in continued medication errors and late administration for five of eight sampled residents, with the potential to affect all residents in the facility. Specific incidents included a nurse administering 12 medications late to a resident with epilepsy, including a seizure medication, and another nurse administering a dose of methadone five times higher than ordered to a resident with acute heart failure and dementia. Additional cases involved late administration of blood pressure and anticoagulant medications to residents with significant cardiovascular and neurological conditions, as well as late administration of pain medications to a resident with chronic pain syndrome. Observations and interviews revealed that nurses were often delayed due to high workloads, lack of assistance, and frequent distractions, with some nurses admitting to documenting medications as given on time even when they were late. Record reviews showed that the facility's QAPI program relied on self-reporting of errors by nursing staff and limited audits by the DON, which were not consistently performed as outlined in the program. The pharmacy consultant was not fully integrated into the QAPI process and was unaware of recent medication errors or related QAPI plans. The facility's policy required ongoing evaluation and monitoring of the QAPI program, but these steps were not adequately carried out, contributing to the persistence of medication administration issues.
Failure to Ensure Abuse Prevention Re-Training for Staff After Allegation
Penalty
Summary
The facility failed to develop and implement written policies and procedures that ensured re-training and re-education of staff alleged of abuse or mistreatment before allowing them to return to work with residents. Specifically, after an allegation of mistreatment involving a registered nurse, the nurse was suspended pending investigation but was permitted to resume resident care duties without completing required abuse prevention re-training or signing an acknowledgment of training completion. The facility's policy required such re-training after suspension for abuse allegations, but this was not followed in this instance. The resident involved was admitted with significant medical needs, including bed confinement, cognitive communication deficits, sepsis, dependence on a respirator, and acute and chronic respiratory failure. Interviews with facility leadership confirmed that, contrary to policy, the only education provided to the nurse was to have another staff member present during certain care activities, and this education was not focused on the nature of the abuse allegation. The required abuse prevention training was not completed prior to the nurse's return to resident care.
Failure to Provide Timely Podiatry Services for Resident with Fungal Toenail Infection
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including bed confinement, cognitive communication deficit, sepsis, and respiratory failure, did not receive timely podiatry services after experiencing toenail avulsion and fungal infection. The resident had a physician's order for podiatry services as clinically indicated, and specific orders were in place to monitor and care for avulsed toenails. Despite these orders, after the resident's left great toenail came off due to fungal infection, there was no documentation that an outpatient podiatry appointment was arranged as ordered by the physician. The in-house podiatrist, who visits every 61 days, did not return to the facility until several months later, and the resident was not seen by a podiatrist in the interim. Interviews with staff revealed that the Social Services Coordinator was unaware of the physician's order for an outpatient podiatry referral and did not arrange for the service, instead waiting for the next scheduled in-house podiatry visit. Documentation showed that the need for podiatry care was recognized by nursing staff and communicated to Social Services, but the referral process was not completed. The facility's policy required coordination between nursing and social services to ensure physician orders for outside referrals were documented and acted upon, but this did not occur, resulting in a lack of timely podiatry care for the resident.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices for nine residents, leading to potential risks of infection and spread. Observations revealed that staff did not adhere to hand hygiene protocols during incontinent care for several residents, including not washing hands between glove changes and failing to clean between the labia. This was confirmed by staff interviews, where they acknowledged the lapses in hand hygiene and the need for glove changes during care. Additionally, the facility did not follow proper personal protective equipment (PPE) protocols for residents on enhanced barrier precautions (EBP). Staff were observed wearing gowns outside of resident rooms and not changing them between different residents, which is against the facility's policy. In some cases, staff were unaware of the EBP status of certain rooms and did not don the necessary PPE, further compromising infection control measures. The facility also failed to maintain sanitary conditions for resident equipment, as evidenced by a resident's urinal that was found to be unclean and not replaced as required. Interviews with staff confirmed that the urinal should have been cleaned or replaced, highlighting a lack of adherence to the facility's sanitation policies. These deficiencies indicate a systemic issue with infection prevention and control practices within the facility.
Improper Use of Bed Rails for Non-Ambulatory Residents
Penalty
Summary
The facility failed to ensure the appropriate use of bed rails for three residents, increasing the risk of entrapment or injury. The facility's policy on bed rails, revised in November 2022, states that bed rails should only be used to treat a resident's medical symptoms and not for staff convenience or as a form of discipline. Despite this, observations and interviews revealed that bed rails were improperly used for residents who could not benefit from them due to their medical conditions. Resident 30, who was non-ambulatory and had bilateral upper extremity contractures, was observed with bilateral half rails on her bed. Her care plan included the use of bedrails for bed mobility, but her bed rail assessment indicated that side rails were not necessary. The Director of Nursing (DON) confirmed that Resident 30 was unable to use the bed rails and that they should not have been present. Similarly, Resident 53, who was in a persistent vegetative state and had contractures, was observed with bilateral enabler bars. Although his care plan and order history included the use of these bars, his assessment showed that he could not use them independently. The DON confirmed the inappropriateness of the enabler bars. Resident 99, also non-ambulatory with contractures, was found with quarter side rails, despite her assessment indicating no need for them. The DON acknowledged that these side rails were unnecessary and should be removed.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for nine residents, leading to potential decreased therapeutic results. The deficiencies included improper documentation, failure to administer medications, and late administration of medications. For instance, Resident 16 did not receive several morning medications due to a heavy medication pass, as confirmed by a registered nurse. Resident 29's medication administration was documented as completed, despite the resident refusing the medications when they were offered late in the afternoon. Several residents experienced late medication administration, which was attributed to staff being busy or having a high number of residents to attend to. Resident 33 received albuterol sulfate late on multiple occasions, and Resident 38 did not receive lorazepam on time. Similarly, Resident 44's medications were administered late, and Resident 45 received critical medications, including insulin and clonidine, hours after the scheduled time. These delays were confirmed through interviews with nursing staff, who cited workload as a reason for the delays. The facility's policies on medication administration and error reporting were not adhered to, as evidenced by the lack of timely documentation and notification to physicians about late or missed medications. Interviews with the medical director, pharmacist, and nursing staff revealed discrepancies in expectations for medication administration timing, with some staff unaware of the ongoing issues. The facility's administrator and director of nursing acknowledged that medication reviews were part of quality assurance meetings, but did not indicate that late administration was a current concern.
Improper Waste Management in Dumpster Area
Penalty
Summary
The facility failed to properly manage waste disposal in the dumpster area located behind the building. Observations on two consecutive days revealed several deficiencies: bags of trash were found on the ground, a stack of wooden pallets and broken-down cardboard boxes were present, and the blue dumpster was overfilled, preventing its lid from closing properly. Additionally, the large green dumpster had its lid propped open by a white plastic pipe. These conditions were confirmed by the Dietary Supervisor, who acknowledged that the area was not well maintained during the initial days of the survey and that the dumpster lids should not be propped open.
Violation of Resident Dignity Due to Display of Medical Information
Penalty
Summary
The facility failed to uphold the dignity and privacy of three residents by displaying signs above their beds containing personal medical information. Resident 21, who was cognitively intact with a BIMS score of 15, had a sign indicating dietary needs and feeding instructions, which was visible during multiple observations. Despite being alert, the resident was noted to be disorganized, and the sign remained in place over several days. Similarly, Resident 77, who was severely impaired with a BIMS score of zero, had signs indicating feeding instructions and seizure precautions. These signs were observed on multiple occasions above the resident's bed and nightstand. Resident 89, who was cognitively intact with a BIMS score of 13, had three signs above the bed detailing feeding status, fall risk, and aspiration precautions. These signs were also observed over several days. The Director of Nursing confirmed that such information should not be publicly displayed and should instead be included in the Kardex.
Failure to Ensure Proper Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents who self-administered medications had the necessary assessments, physician's orders, and care plans in place. This deficiency was identified for two residents, R44 and R73, who were observed with medications at their bedside without the required documentation and approvals. The facility's policy mandates that residents must be assessed by the interdisciplinary team and have a physician's order before they can self-administer medications, which was not adhered to in these cases. Resident R73, who was admitted with a diagnosis of chronic obstructive pulmonary disease (COPD), was observed with an albuterol sulfate inhaler on her overbed table. Despite being cognitively intact, as indicated by a Brief Interview for Mental Status score of 15 out of 15, there was no evidence of a physician's order, self-administration assessment, or care plan for the inhaler in her electronic medical record. The Director of Nursing confirmed that R73 should not have had the inhaler at her bedside without the necessary documentation and approval. Resident R44, with a primary diagnosis of end-stage renal disease, was also found with medications at her bedside. She had a medication cup with sevelamer carbonate tablets, which were left by an LVN who stated that R44 preferred to take her pills with meals. However, R44 did not have a self-administration assessment, and her care plan did not include self-administration of medications. The Director of Nursing confirmed that R44 should have had an assessment if medications were to be left at her bedside.
Failure to Ensure Privacy During Resident Care
Penalty
Summary
The facility failed to ensure privacy during care for a resident, identified as R108, who was moderately impaired for decision-making with a BIMS score of eight out of 15. R108 was admitted with multiple diagnoses, including unspecified dementia and Alzheimer's disease. During an observation, a Certified Nurse Aide (CNA) was seen providing peri care to R108 with the door open, despite the resident being in a three-person room. Although the privacy curtain was drawn, R108's legs were visible from outside the room, compromising the resident's privacy. Interviews with staff revealed inconsistencies in understanding the facility's privacy policy. CNA5 believed that drawing the curtains was sufficient, while the Regional Quality Management Consultant and another CNA stated that best practice involves closing the door and drawing the curtains. The Director of Nurses expected either the curtains to be fully drawn or the door to be closed during such care. The facility's policy on Resident's Rights emphasized the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Maintain Air Conditioning Filters in Subacute Unit
Penalty
Summary
The facility failed to maintain air conditioning filters in one of its four residential units, specifically affecting the subacute unit where 21 residents reside, 11 of whom are on ventilators. During an observation, it was noted that the portable air conditioner at the end of the subacute resident hall had three filters with a thick, gray film caked on them. The facility's policy on Heating and Air Conditioning System Inspection, revised on 01/01/12, assigns the responsibility of inspections to the Maintenance Department to protect the health and safety of residents, visitors, and staff. However, during an interview, the Maintenance Supervisor admitted that the filters were last cleaned in July 2024 and acknowledged that they needed cleaning again. The Maintenance Supervisor also stated that there was no log or system in place to track items requiring regular maintenance.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident to the State survey agency (SSA) within the required timeframe. The facility's policy mandates that any allegations of abuse must be reported to law enforcement and relevant agencies within two hours. However, in this case, the report was not sent to the SSA until later in the evening, resulting in a delay. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident reported that a Certified Nursing Assistant (CNA) was rough during care, which was brought to the attention of the Director of Nursing by a surveyor. Despite the facility's policy, the report to the SSA was confirmed to be late by the Administrator, highlighting a failure in adhering to the established reporting procedures.
Failure to Notify Ombudsman and Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their representative, and the Ombudsman regarding a transfer to the hospital. Specifically, the facility did not ensure that a written notice was given to one of the three residents reviewed for hospitalization, identified as Resident 30, prior to or as soon as practical following their transfer to the hospital. The facility's policy requires that upon transfer to an acute hospital, the resident or their representative should be given an opportunity to execute a Bed Hold and be provided with a Notice of Proposed Transfer and Discharge document. However, there was no documentation indicating that the Ombudsman was notified of the transfer for Resident 30. Resident 30 was admitted to the facility and had a quarterly Minimum Data Set assessment that did not include a Brief Interview for Mental Status due to the resident's inability to participate. The resident was discharged to the hospital due to gastrointestinal bleeding and later returned to the facility. The Social Services staff member responsible for sending out transfer and discharge notifications acknowledged during an interview that she could not locate the Ombudsman notification for Resident 30's hospitalization. This oversight created the potential for residents or their responsible parties to lack the necessary information to understand the transfer to the hospital.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to two residents, R30 and R100, within 24 hours of their emergent transfers to the hospital. According to the facility's policy, residents or their representatives should be notified in writing about the bed hold option whenever a resident is transferred to an acute care hospital. However, upon review of the electronic medical records (EMR) for both residents, no bed hold notifications were found. R30, who was diagnosed with chronic respiratory failure with hypoxia, was transferred to the hospital due to gastrointestinal bleeding. Similarly, R100, with a primary diagnosis of type two diabetes mellitus with diabetic chronic kidney disease, was transferred due to fever, coughing, and wheezing. Interviews conducted during the investigation revealed that the Social Services staff member claimed to have provided bed hold notifications, but the Administrator confirmed that the Admissions Coordinator failed to do so for both residents. This oversight increased the potential for residents to be unaware of their right to request a bed hold, which could affect their ability to return to the facility. The absence of documented notifications in the EMR for both residents highlights a lapse in adherence to the facility's policy and regulatory requirements.
Failure to Transmit MDS Assessment Timely
Penalty
Summary
The facility failed to ensure timely transmission of a Minimum Data Set (MDS) assessment for one resident, identified as Resident 86, out of 47 sampled residents. According to the Center for Medicare and Medicaid Services (CMS) Long-term Care Facility Assessment Instrument 3.0 User's Manual, the MDS completion date should be no later than 14 calendar days after the discharge date, and the transmission date should be no later than 14 calendar days after the MDS completion date. Resident 86 was admitted to the facility with diagnoses including a fracture of the neck of the right femur, spinal stenosis, and chronic kidney disease. The discharge assessment for this resident, with an Assessment Reference Date (ARD) of March 1, 2024, was completed on March 9, 2024, but there was no evidence of it being transmitted. An interview with MDS1 confirmed that the assessment was not transmitted after completion.
Care Plan Inaccuracies and Resident Exclusion from Conferences
Penalty
Summary
The facility failed to ensure accurate and regularly updated care plans for two residents, R4 and R99, and did not invite resident R101 to participate in care conferences. For R4, the care plan inaccurately included the use of splints, despite no orders or observations supporting their use. The Director of Nurses confirmed that R4 did not wear splints and that the care plan was incorrect. Similarly, R99's care plan erroneously included smoking cessation resources, although R99 was in a vegetative state and not a smoker. The Director of Nursing acknowledged this error and the need for an update. Additionally, the facility did not invite R101, who was cognitively intact, to care conferences, despite the facility's policy requiring such invitations. R101 expressed a desire to attend these meetings, and the Social Services Director confirmed that all cognitively intact residents should be invited, regardless of their responsible party status. This oversight increased the risk of excluding residents' preferences and concerns from their care plans.
Failure to Develop Person-Centered Discharge Plan
Penalty
Summary
The facility failed to develop and implement a person-centered discharge plan for one resident, identified as R101, who was reviewed for discharge planning. According to the facility's policy, discharge planning should begin upon a resident's admission, with the attending physician reviewing the resident's progress to determine a possible discharge date. However, R101, who was cognitively intact with a BIMS score of 15 out of 15, expressed a desire to know the plan for returning home but had not attended any meetings to discuss discharge planning. Interviews revealed that the facility's social services staff did not engage with R101 regarding discharge preferences. Social Services (SS1) stated that R101 did not have a discharge plan because R101 was considered a long-term care resident, defined as anyone remaining in the facility past 90 days. The Social Services Director (SSD) confirmed that all residents should be asked about their discharge goals and desires but was unaware that SS1 had not spoken with R101 about discharge preferences. This lack of communication and planning led to the deficiency in discharge planning for R101.
Failure to Facilitate Ophthalmologist Referral for Cataract Surgery
Penalty
Summary
The facility failed to make an ophthalmologist referral order for a resident who required cataract surgery. The resident, who was admitted with diagnoses including diabetes mellitus with diabetic chronic kidney disease, had a Brief Interview for Mental Status (BIMS) score indicating moderate decision-making capacity. Despite a referral form dated nearly a year prior, there was no physician order for the resident to receive cataract surgery. The resident reported that her appointments were repeatedly canceled by the facility staff, and she felt that the staff did not want her to see an eye doctor, resulting in her vision remaining cloudy. Interviews with facility staff revealed a lack of awareness and follow-up regarding the ophthalmologist referral. The receptionist at the ophthalmologist's office confirmed that a referral was sent to the facility's social services department. However, the social services staff, including a new employee and the social services supervisor, did not recall receiving the referral. The facility's policy on referrals to social services indicated that staff should be aware of and coordinate services for residents' medical and psychosocial well-being, which was not adhered to in this case.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to adhere to physician orders for enteral feeding for a resident with chronic respiratory failure and hypoxia, increasing the risk of dehydration and weight loss. The resident, who was unable to participate in a BIMS assessment, had a physician order for enteral feeding with Jevity 1.5 at 60 ml/hr for 20 hours daily, starting at noon and stopping at 8 AM, to provide 1200 calories per day. However, on the specified date, the enteral feeding was not initiated at the scheduled time of 12:00 PM. Observations and interviews revealed that the resident's feeding pump was not turned on as ordered. The resident's spouse confirmed the pump had not been activated since their arrival at the facility at 12:50 PM. Further observation at 2:52 PM confirmed the pump remained off, and the registered nurse acknowledged the oversight, citing a lack of time to turn it on. This resulted in the resident missing three hours of feeding, equating to a 15% loss of the daily nutritional intake prescribed by the physician.
Incomplete Dialysis Communication Sheets for a Resident
Penalty
Summary
The facility failed to ensure that dialysis communication sheets were complete for a resident who required dialysis services. The facility's policy on dialysis care mandates that nursing staff communicate vital signs, weight, and any changes in the resident's condition to the dialysis provider in writing. Additionally, the dialysis provider is expected to communicate any problems encountered and ongoing monitoring requirements back to the facility. However, for one resident with end-stage renal disease, there were 17 instances over a period of 94 days where the dialysis communication sheets were missing, indicating a lapse in the required documentation and communication process. Interviews with the resident, the Administrator, and the Director of Nursing confirmed the deficiency. The resident, who attends dialysis three times a week, acknowledged taking her communication book to the dialysis center. Both the Administrator and the Director of Nursing confirmed that the communication sheets were not completed as expected. The Director of Nursing expressed an expectation that nurses complete the pre-dialysis sheet, send it to the dialysis center, and complete the post-dialysis portion upon the resident's return, which was not adhered to in this case.
Failure to Ensure Timely Mental Health Services for Resident with Suicidal Ideations
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with suicidal ideations, which could potentially contribute to continued suicidal thoughts and self-harm. The resident, who was readmitted with a traumatic brain injury and schizophrenia, expressed suicidal thoughts during a Minimum Data Set assessment in May 2024. Although a referral to a psychiatrist was made, there was no follow-up to ensure the consultation was completed. The resident later expressed feelings of loneliness and sadness, and it was noted that the resident had not been seen by a psychologist. Interviews with the social services staff revealed a lack of a check-and-balance system to ensure psychiatric consultations were completed. The Social Service Supervisor confirmed that a psychological referral was made in May 2024, but no follow-up was conducted. The resident was eventually seen and determined to be severely depressed, highlighting the facility's failure to ensure timely and appropriate mental health services for the resident.
Expired Medications and Supplies Found in Medication Room
Penalty
Summary
The facility failed to adhere to its policy on the storage of medications, resulting in the presence of expired medications, treatment supplies, and intravenous supplies in the Sub-Acute Medication Room. During an observation conducted with the Director of Nursing (DON), it was found that several medications, including Erythromycin, Famotidine, and Oseltamivir Phosphate, were expired. The Erythromycin bottle lacked an open or discard date, despite instructions to discard after 35 days of opening. Famotidine had been opened on 05/10/24 and should have been discarded by 06/10/24, but it remained in stock. Similarly, Oseltamivir Phosphate did not have an open or discard date, although it should have been discarded 17 days after opening. In addition to expired medications, the observation revealed expired treatment and intravenous supplies, such as Calamine Lotion, Grafco-Silver Nitrate Applicators, and a Dextrose 10% IV bag. The Calamine Lotion had an expiration date of 02/2024, the Silver Nitrate Applicators expired in April 2019, and the Dextrose IV bag expired in March 2024. During an interview, the DON acknowledged the issue of outdated medications and mentioned that a sweep had been conducted to remove expired items, with plans to implement a routine system for future removal of expired medications.
Failure to Establish Contract with Dialysis Center
Penalty
Summary
The facility failed to ensure a contract was completed with a dialysis center for a resident with end-stage renal disease (ESRD) who required dialysis services. The facility's policy titled 'Service Agreements' mandates that the Administrator must keep an original signed and dated copy of all service agreements with vendors, consultants, and providers. However, upon review, it was found that the facility did not have a contract with the dialysis center where the resident received treatment. This oversight was confirmed during an interview with the Administrator, who acknowledged the absence of a contract with the dialysis center, thereby placing all residents receiving dialysis at potential risk.
Failure to Provide Timely Podiatry Services Leads to Severe Infection
Penalty
Summary
The facility failed to provide adequate podiatry services for a resident, resulting in a significant health issue. The resident, who had been admitted in 2016 with multiple complex medical conditions including dependency on a ventilator, tracheostomy, and anoxic brain damage, did not receive podiatry services for a year. This neglect led to excessive toenail growth, which subsequently caused a wound on the resident's right great toe when the nails were eventually trimmed. The wound developed a severe infection, progressing to osteomyelitis, and required hospitalization and antibiotic treatments. The deficiency was identified through interviews and record reviews. A podiatrist noted severely thick toenails and trimmed them, but during a subsequent visit, observed bleeding from the resident's right big toe, which had developed into an ulcer. The podiatrist ordered wound care and antibiotics, but the resident was hospitalized due to the severity of the infection. The wound was later diagnosed as osteomyelitis, and the same organism, MRSA, was found to be the causative agent for both the toe wound and a bloodstream infection. The resident's condition required extensive medical intervention, including intravenous antibiotics and multiple hospital visits. Despite these efforts, the resident's right great toe continued to require treatment for infection and dry gangrene. The facility's failure to ensure timely podiatry services directly contributed to the resident's deteriorating foot health and subsequent medical complications.
Failure to Obtain Consent for COVID-19 Vaccination
Penalty
Summary
The facility failed to obtain consent from the responsible party (RP 1) before administering a COVID-19 vaccination to Resident 1, who had a history of significant medical conditions including ventilator dependency, tracheostomy, and anoxic brain damage. The responsible party had previously informed the facility in December 2021 not to vaccinate Resident 1 due to their compromised immune system. Despite this, the facility administered a COVID-19 vaccine to Resident 1 on 5/3/22 without obtaining the necessary consent from RP 1. This oversight resulted in Resident 1 experiencing swelling and probable pain in the vaccinated arm, which was noticed by RP 1 during a visit on 5/12/22. The facility's Director of Nursing confirmed awareness of the refusal to vaccinate Resident 1 due to their compromised immune system. The facility's policy required obtaining general consent for vaccinations, which could be given in various forms, but this procedure was not followed in this instance, leading to the deficiency.
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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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