Brookside Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident’s right to a quiet environment when one resident was unable to rest due to continuous yelling from her roommate over several days. The affected resident had respiratory failure, heart failure, anxiety disorder, and takotsubo syndrome, and an MDS dated 2/19/26 showed a BIMS score of 12/15, indicating moderate cognitive impairment. During an interview, the resident reported that since her roommate’s admission about a week earlier, the roommate had been constantly yelling whenever awake, day or night, which caused migraine headaches and kept her from sleeping. Staff reportedly told the resident to use earphones, but she expressed concern that she would not be able to hear her TV or the fire alarm. She also stated she had been in the room first and did not want to move, and that when she reported her concerns to the Social Services Director, she was told there were no other rooms available and that the facility’s policy was to keep rooms filled. Observations on 3/5/26 confirmed that the roommate repeatedly yelled “help me” while awake, and her yelling could be heard from the nurses’ station and conference room. The roommate’s record showed a diagnosis of vascular dementia with agitation, a BIMS score of 8/15 indicating moderate cognitive impairment, and an admission nursing evaluation noting non-compliance, anxiety, psychosis, poor safety awareness, and that she kept yelling “help me” throughout the shift. A licensed nurse stated that the roommate yelled constantly and that the affected resident had complained of headaches, sleep deprivation, and anxiety, and that attempts to calm the roommate were only temporarily effective. The Social Services Director stated that his understanding of the process was that the resident with noise issues would be moved, regardless of who had been in the room longer, and could not describe the facility’s process for pairing roommates. The facility’s policy on room or roommate changes allowed changes for incompatibility and for the safety, health, and well-being of residents, but the resident’s complaints and the ongoing disruptive behavior were not effectively addressed, resulting in the resident’s sleepless nights, migraines, and emotional and psychological distress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect and account for a resident’s personal belongings, specifically a black safe box containing valuables and collectibles, following admission. The resident was admitted with diagnoses including respiratory failure, heart failure, and muscle weakness, and had a BIMS score of 12/15 indicating moderate cognitive impairment. Her personal belongings were transferred from another facility three days after admission. The resident reported that she did not receive her belongings in her room until days after delivery because staff could not locate them, and when the belongings were finally brought to her room, the black safe box was missing. A CNA confirmed that the resident reported the missing safe and that the CNA had never seen it in the room. The Social Service Director stated that the resident’s belongings were transported from another facility but there was no documentation that the belongings were received upon delivery, and it was unclear whether the black safe box was included. The Social Service Director also stated that a personal inventory was completed after admission but could not identify the date. A nurse reviewing the electronic record could not locate the resident’s personal inventory and explained that the facility no longer kept paper charts and the inventory should have been uploaded but likely was not. The DON stated that an inventory sheet should have been completed at the time the belongings were delivered and within 24 hours of admission. Review of the Resident Personal Belongings Inventory showed that the inventory was not completed until months after admission, and the black safe box was not listed. The facility’s Theft and Loss policy required that an inventory of resident belongings be completed on admission and that items brought in after admission be added to the inventory list, which was not followed in this case, resulting in the resident’s black safe box being unaccounted for and causing her emotional distress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident who was dependent on staff for activities of daily living received scheduled bathing to maintain personal hygiene. The resident had muscle weakness and moderate cognitive impairment, with an MDS indicating a need for substantial/maximal assistance with showering/bathing. The resident’s ADL care plan documented that she required substantial assistance by one to two staff for bathing/showering as needed. The resident reported that she did not receive showers and that she was supposed to receive bed baths every Tuesday and Friday, but there was a period when she only received one bed bath. CNAs interviewed stated that the resident was scheduled for showers or bed baths on Tuesdays and Fridays, but one CNA reported there were times the resident did not receive her bed bath as scheduled, and another CNA stated she had not seen the resident receive showers or bed baths. Record reviews showed multiple missed or undocumented bathing opportunities during the review period. The facility’s shower schedule listed the resident for afternoon showers on Tuesdays and Fridays. Documentation for 2/1/26 through 2/28/26 showed “NA” entries for bathing/shower on several Mondays, with the DSD explaining that “NA” also indicated refusals, and there were no other days marked showing that showers or bed baths were provided. A task record for shower/bath showed refusals documented on three dates, with no other days marked as completed. Weekly shower checklists indicated refusals on two dates and one bed bath on another date, with no additional checklists available. Staff interviews indicated that when residents refused showers, they would typically offer bed baths or alternative times, but the DSD confirmed there were no other days documented when alternative schedules were offered and acknowledged that the resident’s needs were not met. The facility’s policy stated that residents were to be assisted with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues, but this was not consistently carried out for this resident during the review period.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide ordered and needed care and treatment to two residents by not following hospital discharge instructions for a cardiology follow-up and by not notifying the physician of poor oral intake and weight loss. For the first resident, the admission record dated 3/6/26 showed diagnoses including respiratory failure, heart failure, and hypertension, and an MDS dated 2/19/26 documented a BIMS score of 12/15, indicating moderate cognitive impairment. The resident’s care plan report dated 12/2/25 identified altered cardiovascular status and hypertension, with an intervention to notify the MD of significant abnormalities. The acute hospital discharge summary dated 11/18/25 contained an order to follow up with a cardiologist in two weeks, but this order was not transcribed into the resident’s electronic order summary report. The first resident reported during interview that she had scheduled cardiology appointments on 1/7/26 and 1/21/26, that the Social Services Director (SSD) had been informed, and that both appointments were missed. She produced two letters from the cardiologist documenting the missed appointments. The resident stated she later called the cardiologist’s office on 2/23/26 to make an appointment and learned an appointment had already been scheduled for 2/25/26, which she had not been informed about by staff. Licensed nursing staff interviewed stated they were not aware of the cardiology appointments, and review of the order summary report confirmed there was no cardiologist referral order documented. The SSD acknowledged being aware of the 1/7/26 and 1/21/26 appointments, stated that the appointments were missed due to lack of communication and poor coordination between departments, and admitted he did not upload the appointment information into the resident’s electronic file, resulting in the referral order not being followed through or carried out. For the second resident, the admission record dated 3/10/26 showed diagnoses including stage 3 kidney disease, diabetes, and vascular dementia, with an MDS BIMS score of 11/15 indicating moderate cognitive impairment. A complainant reported that this resident had not been feeling well for several days and had not been eating for almost seven days before transfer to an acute hospital. The facility’s documentation survey report for February showed multiple consecutive meals from 2/13/26 through 2/17/26 where the resident either refused meals or consumed 0–25% of meals, including repeated entries of “RR” (resident refused) and “0” for intake. Weight and vitals documentation showed a decrease from 163.8 lbs on 2/8/26 to 155.8 lbs on 2/16/26. Physician progress notes dated 1/27/26 and 2/14/26 directed staff to monitor weight and intake/output and to notify the MD/provider if there was abnormal weight loss or poor PO intake. Certified nursing staff reported that when residents refused meals they informed the charge nurse and offered snacks or alternatives, and nursing staff stated that for low meal intake they would complete a change of condition form and notify the primary care physician (PCP) and registered dietitian (RD). However, the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that, despite the documented poor intake and weight loss, the PCP and RD were not notified during the period of low intake and weight decline. The ADON later verified that the PCP and RD were not notified until 3/4/26. Facility policies on Weight Monitoring and Nutritional Management required that the physician be informed of significant changes in weight, intake, or nutritional status, but this notification did not occur during the days when the resident had repeated meal refusals and low intake and experienced documented weight loss.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and care for two residents. For the first resident, who had diabetes, muscle weakness, musculoskeletal symptoms, moderate cognitive impairment, and documented MASD on bilateral buttocks, the care plan and orders required use of a low air loss (LAL) mattress and specific buttocks skin care with normal saline and calmoseptine every shift. During a planned power shutoff in the resident’s room while maintenance worked in an adjacent room, the resident’s oxygen concentrator was switched to an oxygen tank, and the resident reported to a licensed nurse that her LAL mattress was deflating. The nurse responded that the power would be off for 15–20 minutes and did not indicate any alternative plan to keep the LAL mattress functioning. Another nurse later stated the LAL mattress should have been plugged into an emergency outlet before the power was turned off and told the resident it would be plugged into an emergency outlet. In follow-up interviews, the first nurse stated that maintenance had informed her about the power shutoff but she did not know the protocol for using emergency extension cords to keep the LAL mattress operating. The Director of Staff Development confirmed that the orientation checklist for that nurse did not include training on the use of emergency extension cords and emergency outlets to maintain electrical equipment during power shutoffs. The Director of Nursing stated she would have expected the nurse to ask other nurses for assistance and acknowledged that a deflated LAL mattress could be uncomfortable and potentially a reason for skin breakdowns. The facility’s user manual for the LAL mattress system described its purpose as helping reduce the incidence of pressure ulcers, and the facility’s Pressure Injury Prevention Guidelines policy required prevention devices to be used in accordance with manufacturer recommendations. For the second resident, who also had diabetes, muscle weakness, musculoskeletal symptoms, and moderate cognitive impairment, there was a concern reported by a complainant that the resident experienced a burning sensation around the buttocks. The resident later stated his bottom was hurting. Physician orders and the Treatment Administration Record showed that the coccyx area was to be washed with soap and warm water, patted dry, and calmoseptine applied every shift. A CNA reported that the resident had skin issues on the buttocks and around the anal region, with a small peeled area of skin, and stated she repositioned the resident every two hours and kept him clean and dry. A licensed nurse reported that on the previous day she had observed only skin redness with no open area on the buttocks and coccyx, and that preventive measures included keeping the resident clean and dry, reporting skin changes, and rotating his position every two hours in bed. On a subsequent observation with the same nurse, the resident was found to have an area on the coccyx where the outer skin had come off, now an open wound measuring approximately 0.3 cm by 0.4 cm with slight drainage. The nurse stated that the area had been smaller and not open the day before and that it was now bigger and open, and she acknowledged the resident might not have been turned and repositioned as frequently as required. Review of the resident’s care plan documentation showed there was no care plan addressing his high risk for skin breakdown, and no documented interventions to prevent development or worsening of pressure ulcers. The nurse confirmed there was no skin integrity care plan and stated there should be one to guide staff, and that without a skin care plan there would be no interventions for staff to follow, which could increase the occurrence or worsening of pressure injuries. The Administrator also stated that residents at high risk for skin breakdown should have a care plan to help prevent further skin issues that could lead to infection and a decline in general health. The facility’s Pressure Injury Prevention Guidelines and Comprehensive Care Plans policies required evidence-based interventions for at-risk residents to be documented in the care plan and used to meet resident needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves facility staff accepting and using a resident’s personal funds to purchase food for themselves while accompanying the resident out on pass. The resident involved had diagnoses including sensorineural hearing loss, cognitive communication deficit, and focal traumatic brain injury with loss of consciousness. According to the resident’s admission record and subsequent progress notes, the resident reported that the facility driver and a Restorative Nurse Assistant (RNA) used his own money to buy food during an outing. Interdisciplinary team documentation and care plan entries identified an allegation of financial abuse, noting that the resident stated the driver and RNA used his money to buy food. A facility form titled “Patient Loss/Refund Request Form” recorded that staff members used the resident’s debit card to purchase a lunch meal in the amount of $63.77, and a restaurant receipt showed a total of $63.77 paid in cash with change given. Interviews with leadership, including the Director of Staff Development, Social Services Director, and Assistant DON, confirmed that staff were not allowed to have access to residents’ money or cards and were not permitted to accept gifts, compensation, or food from residents, even if offered. These leaders acknowledged that in this incident the driver and RNA accepted the resident’s offer to buy them food and used the resident’s funds for that purpose. Interviews with the driver and RNA provided additional detail about the events. They stated that they transported the resident to a bank, a phone provider store, a restaurant, and a retail store. Both reported that the resident said he was hungry, offered to treat them with food, and gave the RNA $100 in cash to place the order at a local restaurant. After seeing the receipt and change, the resident became upset about the cost and cancelled part of the order, later complaining that staff had used his money to buy food. The Administrator confirmed that the resident told her he had offered to get food for staff but did not know how much it would cost and became upset when he saw the amount. Facility policy on Abuse, Neglect and Exploitation and the Code of Conduct identified misappropriation of patient funds as prohibited conduct, and staff acknowledged that by accepting food purchased with the resident’s money, they violated facility policy regarding misappropriation and acceptance of gifts.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and follow effective interventions to keep two residents with a known history of altercations apart, resulting in a second physical altercation and injuries to one of the residents. Resident 1 was admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury and was listed as his own responsible party, with a representative payee only for financial matters. Resident 2 was admitted in 2025 with diagnoses including unspecified intracranial injury and generalized anxiety disorder and had a documented history of aggressive behavior toward staff, including laying hands on a CNA during redirection. Staff interviews described Resident 2 as sometimes nice and sometimes not nice, with episodes of yelling at staff when he did not get his way, and being aggressive, including grabbing a CNA by the shirt. On 1/1/26, Resident 1 and Resident 2 were involved in a physical altercation in the dining room. The Director of Rehab (DOR) reported witnessing Resident 2 stand up from his wheelchair, push Resident 1, and then hit Resident 1, after Resident 1 allegedly tried to grab food from Resident 2’s mother’s plate. Documentation for both residents on 1/1/26 described a physical altercation and indicated that both residents were “physically abused.” Interdisciplinary notes for both residents stated that they would be separated by station and monitored for delayed mental and physical injuries. Resident 1’s care plan, initiated on 1/2/26 and revised on 1/7/26, identified a focus of an alleged resident-to-resident altercation with a goal of no altercation and included interventions such as monitoring for pain and separating the residents. Resident 2’s care plan, initiated on 1/2/26, also focused on an alleged resident-to-resident altercation with a goal of no altercation and an intervention to separate the residents. Despite these documented interventions, the residents were again together in the dining room on 1/5/26, when a second altercation occurred. Multiple staff, including the Social Services Director, DOR, DON, LNs, and CNAs, reported that Resident 2 approached Resident 1 in his wheelchair and struck Resident 1 multiple times in the head and face, while Resident 1 tried to shield himself with his left arm. The DON, SSD, LNs, and CNAs stated that Resident 2 had been aggressive in the past and that Resident 2 should have been monitored more closely and kept away from Resident 1 after the first incident. The DON and other staff acknowledged that the intervention to keep the residents separate was not followed and that the second altercation could have been avoided if Resident 2 had been monitored for aggressive behavior and the residents had been kept apart. As a result of the second altercation, Resident 1 sustained injuries including swelling of the left wrist and swelling under the left lower eye, a hematoma of the left zygoma, and an abrasion to the forehead. Progress notes and hospital emergency records documented that Resident 1 complained of pain, rated at 6 out of 10, and was nauseated and vomited. A splint was applied to Resident 1’s left wrist, and he was transferred to the hospital for further evaluation and treatment of his injuries. Resident 1, who had a traumatic brain injury and was described as unable to verbalize coherent thoughts and repetitive in his statements, was later transferred from the hospital to a sister facility. The Administrator stated that she did not discuss the transfer with Resident 1, and the Representative Payee stated she was not notified of the transfer and that she was only responsible for Resident 1’s financial matters. The facility’s abuse policy stated that it would identify, assess, care plan, and monitor residents with behaviors that might lead to conflict and ensure residents are protected from physical and psychosocial harm and additional abuse during and after investigations, but the documented separation interventions for these two residents were not implemented at the time of the second incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a resident’s right to return following a transfer to the emergency room and to follow required transfer/discharge and bed-hold procedures. The resident had been admitted in 2025 with traumatic subarachnoid hemorrhage, unspecified intracranial injury, dementia, cognitive decline secondary to traumatic brain injury, and anxiety, and was documented as his own responsible party. Staff, including the SSD, DOR, CNA, and LN, consistently described the resident as friendly, approachable, and generally without behavioral issues, though he sometimes repeated himself and could be confused. A BIMS score of 13 indicated he was cognitively intact prior to the transfer. The resident was involved in resident-to-resident altercations on two dates, with documentation on 1/1/26 of a physical altercation and on 1/5/26 of an incident in which another resident struck him multiple times in the face, causing swelling to his left wrist and lower left eye. Following the 1/5/26 altercation, the resident was sent to the hospital for evaluation. The Administrator stated that at the time the resident was sent to the emergency room, it was considered a transfer with the expectation that he would return to the facility. However, after the Administrator’s investigation of the incident and review with the team, it was decided that the resident would be discharged from the facility and admitted to a sister facility, with the Administrator calling the hospital to inform them of this plan. The Administrator confirmed that the discharge was facility-initiated and that the stated reason was that the resident’s safety was endangered by his own presence in the facility due to the continued presence of the other resident involved in the altercations. The Administrator also confirmed that the resident was not endangering the safety of others. The facility’s own transfer/discharge policy listed limited, specific reasons for facility-initiated discharge, including when the resident’s needs cannot be met, when the resident’s health has improved, when the resident endangers the safety or health of others, nonpayment, or facility closure; the documentation did not show that any of these criteria were met in this case. The facility also failed to provide required notices and documentation associated with the transfer and discharge. The Administrator acknowledged that she did not discuss the transfer to the sister facility with the resident, even though he was listed as his own responsible party. The Representative Payee confirmed she was not notified about the transfer and clarified that she was only responsible for financial decisions, not healthcare decisions. Review of the electronic medical record showed no physician note regarding the resident’s discharge from the facility, and no physician documentation of needs that could not be met by the facility, what was attempted to meet those needs, or what needs the accepting facility could meet that the current facility could not. Although there was a physician order allowing a seven-day bed hold, the Administrator confirmed that a bed-hold notice was not given to the resident, despite the facility’s bed-hold policy requiring written information about bed-hold practices at the time of transfer or within 24 hours in an emergency. As a result of these actions and omissions, the resident was inappropriately discharged to a sister facility after an emergency room visit and was not afforded the right to return to his original facility following the transfer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide a required written notice of transfer/discharge to a resident and to the State Long-Term Care Ombudsman when the resident was transferred to the emergency room and subsequently discharged to a sister facility. The resident had been admitted in 2025 with diagnoses including traumatic subarachnoid hemorrhage and unspecified intracranial injury, and a physician progress note documented dementia, cognitive decline secondary to traumatic brain injury, anxiety, and a need for frequent reorientation and redirection. The admission record identified the resident as his own responsible party, and the Social Services Director reported that the resident had a BIMS score of 13, indicating cognitive intactness, prior to transfer to the sister facility. On the date of the incident, the resident was involved in a resident-to-resident altercation in which another resident struck him multiple times on the left side of the face. Facility documentation described physical abuse with swelling of the left wrist and lower left eye, and progress notes indicated the resident was struck multiple times and transported by ambulance to the hospital. Interviews with the ADON, DON, and Administrator confirmed that the resident was sent to the hospital following the altercation and that the decision was later made by facility leadership to discharge the resident and have him admitted to a sister facility, characterized as being for the resident’s safety and to keep him separated from the other resident involved in the altercations. The Administrator stated she contacted the hospital and informed them that, upon discharge from the emergency room, the resident would be admitted to the sister facility, and the hospital emergency record documented this communication. However, the Administrator, Social Services Director, and other staff were unable to locate any documentation that the resident was notified of the facility-initiated discharge or transfer to the sister facility, and the Administrator confirmed that a discharge notice was not given. The Ombudsman confirmed that no notice of transfer/discharge was received regarding this resident. This was inconsistent with the facility’s own transfer and discharge policy, which requires written notice to the resident and resident representative, including reasons for transfer/discharge, effective date, receiving location, appeal rights, and Ombudsman contact information, and requires evidence that notice was sent to the Ombudsman.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of employee-to-resident physical abuse was reported to the state agency as required. A resident alleged that a Licensed Nurse twisted his arm and took away his cat food, an incident reportedly witnessed by a CNA. The resident stated he informed the DON about being physically hurt and also called the police to make a report. Despite the resident's statements and the police being involved, the facility did not report the allegation to the state agency or other required authorities. Interviews and record reviews revealed that the DON was aware of the abuse allegation but did not report it, citing information from a police officer that the resident had recanted the story. However, review of the police report showed no evidence that the resident recanted, and the DON did not confirm this with the resident or document it in the medical record. The DON also did not interview other potential witnesses, such as the resident's roommate, nor did the facility conduct its own investigation or complete the required notifications per facility policy. Facility policy required immediate investigation and reporting of all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified time frames. The Administrator confirmed that the expectation was for all staff to report allegations immediately and make all required notifications within two hours. The failure to follow these procedures resulted in a delayed abuse investigation and a lack of required notifications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of employee-to-resident physical abuse in a timely manner. A resident reported that a licensed nurse twisted his arm and took away his cat food, an incident witnessed by a certified nursing assistant. The resident stated he informed the Director of Nursing (DON) about being physically hurt and expressed that he no longer wanted the nurse to care for him. The resident also contacted the police and made a report regarding the alleged abuse. Despite being made aware of the allegation, the DON did not conduct a complete investigation, relying instead on information from a police officer who stated the resident had recanted the story and that no police report would be made. The DON did not confirm this with the resident, nor did she document this information or interview other potential witnesses, such as the resident's roommate. The facility's policy requires immediate and thorough investigation of abuse allegations, including interviewing all involved parties and documenting the process, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident's personal belongings, including a cell phone and wallet containing cash and important identification cards, went missing while the resident was hospitalized. The resident, who had incomplete paraplegia and limited mobility, had requested that CNAs secure his wallet, cell phone, and other personal items prior to his transfer to the hospital. Upon his return, the resident discovered that his wallet, clothing, and cell phone were missing. Although the wallet was eventually found by a housekeeper, only the identification card was returned, and the cell phone and other items remained missing. The resident reported emotional distress due to the loss and was using a loaner phone from a friend. Facility staff interviews and record reviews revealed that the process for handling and storing residents' belongings during hospitalizations was inconsistent and lacked proper tracking. Staff described that belongings were typically bagged and placed in a former shower room or storage area, sometimes with a four-digit code accessible to all staff. Inventory sheets were supposed to be completed and signed by both a CNA and a licensed nurse, but there were discrepancies in documentation, and the missing cell phone was not consistently listed on inventory records. The Social Services Director and other staff acknowledged that valuable items were not always separated or securely stored, and the Administrator confirmed that there was no effective tracking or monitoring process for residents' belongings during absences. Facility policies required that all resident possessions be inventoried, treated with respect, and protected from loss or theft, with documentation retained in the medical record. However, the actual practices did not align with these policies, as belongings were stored in unsecured areas and not adequately tracked. This failure resulted in the loss of the resident's property and caused emotional distress, with the potential for similar incidents affecting other residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its boiler heating system, resulting in an inoperable boiler that affected all 95 residents and all five smoke compartments. During an onsite investigation and interview with the Administrator, surveyors observed that the boiler heating system located in the mechanical room was not operational. This deficiency was identified through direct observation and confirmed by facility staff. As a result of the inoperable boiler, the facility was unable to maintain the required temperature levels throughout the building. The deficiency impacted the entire resident population, as the heating system is essential for maintaining a safe and comfortable environment. The report notes that the boiler could not be repaired after multiple attempts by heating and air system vendors, and the system remained nonfunctional for a period of time. The failure to maintain the boiler system and ensure its operability led to the inability to provide adequate heating for the residents. The deficiency was directly related to the lack of a functioning heating system, as evidenced by the observations and interviews conducted during the survey.

Plan Of Correction

1/5/26: POC approved by Cynthia Luc, SSM-I The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. The facility will monitor the plan of correction in the QAPI meeting. The weekly parameter checks and monthly safety shutoff testing will be completed and logged by the Maintenance Director and reported weekly and monthly to the Administrator. Quarterly vendor inspection reports will be reviewed by the Maintenance Director and reported to the Administrator. These findings will be reported in the QAPI meeting for trending, analysis, and any further recommendations. Any audit discrepancies will trigger immediate corrective action, retraining, and evaluation. If no negative trends are identified after six months, the item will be removed from the QAPI agenda. All corrective actions will be fully implemented by 1/4/2026. HVAC - Operating Features: The facility will follow the Emergency Operations Plan for notification to state survey agency of nursing home situation. Immediately upon discovering the failure to report the unusual occurrence, the facility discussed the incident in question with the CDPH surveyor who was conducting an abbreviated survey. An internal review of the incident was completed to determine root causes. The Administrator was interviewed and re-educated on reporting requirements. To ensure no similar oversight occurred, the previous 30 days of incident logs, nursing notes, and daily shift reports were audited by the Administrator on 12/19/25. Any event fitting CDPH's definition of an unusual occurrence was reviewed to verify it had been properly reported. No additional unreported unusual occurrences were identified. On 12/16/25, the Administrator received education from the Regional Operations Director on Title 22 §72541 reporting requirements, definitions of unusual occurrences, and required timelines and reporting processes. A CDPH Reporting Log was implemented to track all facility reported incidents from initial notice through CDPH submission. To ensure sustained correction, the Administrator will perform a weekly audit of all incidents for 12 weeks. After 12 weeks, audits will continue monthly for an additional 6 months. Findings will be reported at the Quality Assurance Performance Improvement (QAPI) meeting each month. Any identified gaps will result in immediate retraining and corrective action. All corrective actions will be fully implemented by 1/4/2026.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) provided care to a resident with significant medical needs, including cerebral infarction, left hemiplegia, and severe obesity, without the required assistance of a second staff member. The resident's care plan specified that two or more staff were needed for bed mobility and repositioning due to the resident's left-sided weakness and high body weight. Despite this, the CNA assisted the resident alone during a brief change, instructing the resident to turn to his left side, which led to the resident sliding off the bed and falling to the floor. At the time of the incident, the resident was using an air mattress that had been installed the previous day. The air mattress was not ordered by a physician, and there was no documentation in the resident's treatment or medication administration record to ensure that the mattress settings were appropriate for the resident's weight or that the mattress was being monitored for proper inflation. The CNA reported that the mattress was unstable and deflated on one side when the resident turned, contributing to the fall. The facility's protocol required verification of mattress settings and monitoring, but these steps were not followed for this resident. As a result of these failures, the resident fell from the bed and sustained an acute fracture of the right great toe. Interviews with staff confirmed that the air mattress was moved from another resident's bed without a physician's order and that the required two-person assistance for care was not provided at the time of the incident. The lack of adherence to established protocols for both staffing and equipment use directly led to the resident's injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that outside garbage bins were kept covered, as observed on multiple occasions when the lids were left open. During these observations, both the Director of Nursing (DON) and the Dietary Manager (DM) confirmed the bins were not properly closed. The DM acknowledged that the open bins could attract pests to the kitchen. Additionally, the DON confirmed the presence of a cockroach on the wall in the conference room, and the Registered Dietitian (RD) stated awareness of pests in the kitchen. The RD further explained that cockroaches could lead to food contamination, putting residents at risk for foodborne illness. These findings were based on direct observations and staff interviews, with staff confirming both the improper disposal practices and the presence of pests within the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that essential kitchen equipment, specifically the right-side door of a double oven, was maintained in good working order. During an observation, the oven door was found hanging open and not attached, rendering the oven unusable. Interviews with dietary staff and the Registered Dietitian revealed that the oven door had been broken for three to four months, and both the Dietary Manager and the Registered Dietitian had informed the Administrator about the issue. The Administrator confirmed awareness of the broken oven door over this extended period. The malfunctioning oven was identified as a crucial part of the kitchen, and its condition raised concerns about the ability to cook and maintain food at safe temperatures for the 87 residents receiving meals from the kitchen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A licensed nurse left two liquid medications, protein supplement and lactulose, on a resident's bedside table without directly observing the resident take them. This was observed during a visit, and the resident confirmed the medications were hers. Review of the Medication Administration Record confirmed these medications were prescribed for the resident. The nurse acknowledged leaving the medications at the bedside and stated that he should have observed the resident taking them, as per professional standards and facility policy. The Assistant Director of Nursing also confirmed the importance of not leaving medications at the bedside, citing the risk that another resident could take the medication. Facility policy requires that medications be administered by licensed nurses in accordance with professional standards, including observing the resident consume the medication. The failure to follow this policy resulted in a deficiency related to medication administration practices.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received food and drink at safe and appetizing temperatures. During an interview, the resident reported that their food was always cold and drinks were always warm. Observation and temperature checks of the resident's lunch tray confirmed that the taco casserole was served at 115°F, mixed vegetables at 102°F, and cranberry juice at 60°F. These temperatures were below the recommended safe holding temperature for hot foods and above the recommended temperature for cold drinks. The Registered Dietitian confirmed that the food items were within the 'danger zone' for food safety, which is between 40°F and 140°F, a range that allows for rapid bacterial growth. The failure to provide food and drink at appropriate temperatures had the potential to make the food unpalatable and could negatively affect the resident's nutritional intake, as directly stated by the resident and observed by staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's right to dignity by not offering her the opportunity to wear her own clothing, despite her personal clothes being available in her closet. Multiple observations over two days found the resident consistently dressed in a hospital gown, and interviews with the resident revealed she felt neglected, discriminated against, and emotionally distressed by not being allowed to wear her own clothes. The resident expressed these concerns during a care conference attended by an Ombudsman, who also questioned the facility about the resident's attire. Certified Nurse Assistants (CNAs) and the Assistant Director of Nursing (ADON) confirmed that the resident had her own clothing available and that she was not offered the option to be dressed in them. The ADON acknowledged that the facility's policy and procedure for Activities of Daily Living (ADLs), which requires care to be provided based on resident preferences and needs, was not followed. The resident's care plan did not indicate any refusal or preference to remain in a hospital gown, and staff interviews confirmed that the resident was not asked about her clothing preferences, resulting in a failure to uphold her dignity.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints in a timely and non-retaliatory manner.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that anxiety medication was available for a resident with diagnoses of post-traumatic stress disorder (PTSD) and anxiety. The resident reported feeling distressed and experiencing increased anxiety after running out of Xanax, which was prescribed as needed every eight hours for anxiety. The medication administration record confirmed that the resident missed two doses of Xanax when it was not available, and the next dose was not administered until the pharmacy delivered the medication later that day. Interviews with facility staff and the pharmacist revealed that the process for refilling controlled substances required nurses to print the refill request, obtain the physician's signature, and fax it to the pharmacy. Staff acknowledged that the refill order should have been placed when only two to three days of medication remained, but this was not done, resulting in the missed doses. The facility's policy also indicated that medications should be reordered in advance if not using an automated refill system. Staff confirmed that the failure to order the medication in a timely manner led to the resident missing doses of her prescribed anxiety medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of psychosis, toxic encephalopathy, and exit-seeking behavior eloped from the facility for the third time. The resident had previously eloped on two separate occasions, and each time, the facility implemented or continued 15-minute visual checks as the primary intervention. Despite being identified as high risk for elopement and having a care plan in place, the resident was not placed on 1:1 supervision, and the visual checks were inconsistently documented, with significant gaps and missing staff signatures on the monitoring logs. Multiple facility exit doors were found to be inadequately secured or alarmed. The main lobby door's wander guard system was routinely turned off during the day, and the code to unlock another exit was visibly written on the equipment. The kitchen/laundry access door and staff exit door lacked any alarm system and were sometimes left open, providing unrestricted access to the parking lot. Additionally, a side perimeter door was broken and unlocked, allowing entry and exit from both inside and outside the facility. Staff interviews confirmed awareness of these security lapses, and some staff expressed that the facility was not equipped to manage residents with significant mental health needs. On the day of the third elopement, the resident was noted to be confused and aggressive, and staff discovered a door open near the resident's room. The resident was not found during a facility search and was later located at a hospital after being missing for four days, having been admitted for sepsis and pneumonia. The facility's own policy required systematic monitoring and modification of interventions for residents at risk of elopement, but the interventions in place were not effective or consistently implemented, and environmental hazards were not addressed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe and hazard-free environment when one of two resident lift devices had its wheels unlocked. This was observed during a concurrent observation and record review with a Certified Nursing Assistant (CNA), who confirmed that the resident lift device located on the east wing had wheels that were not locked and secured in place. The CNA acknowledged that the wheels should have been locked when not in use, as it posed a fall risk to both staff and residents. Interviews with various staff members, including a Licensed Nurse (LN), the Administrator (ADM), and the Assistant Director of Nursing (ADON), revealed a consensus that the resident lift devices should be locked if left unsupervised in the hallway. They all expressed concerns that an unlocked lift device could be moved by any resident, increasing the risk of falls and injury. The facility's policy and procedure on accidents and supervision, dated 2024, indicated that the resident environment should remain as free of accident hazards as possible, highlighting the potential for injury due to environmental hazards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a written Notice of Transfer/Discharge to the appropriate parties, including the Long Term Care (LTC) Ombudsman, for a resident who was transferred to an acute care hospital. The resident, who was admitted to the facility in 2018 with paraplegia, was sent to the hospital due to concerns of abdominal pain. During a review, it was found that the fax confirmation sheet indicated the notice did not go through, and the Director of Nursing (DON) confirmed that the Ombudsman did not receive the written notice. The facility's policy requires that the notice be provided to the resident, their representative, and the LTC Ombudsman as soon as practicable before transfer or discharge. However, the facility did not ensure the notice was sent, as evidenced by the failed fax attempt and lack of follow-up. This oversight resulted in the State LTC Ombudsman not being informed of the resident's transfer, removing the opportunity for advocacy on the resident's behalf.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to re-admit a resident after hospitalization, despite the resident being ready for discharge and the facility having available beds. The resident, who had been living at the facility since 2018 and was diagnosed with paraplegia, was transferred to an acute care hospital and was ready to return. However, the facility did not re-admit the resident, citing a lack of isolation rooms for the resident's Carbapenem Resistant Enterobacteriaceae (CRE) infection, despite having multiple unoccupied beds. Interviews with facility staff, including licensed nurses and the Admission Coordinator, confirmed the availability of unoccupied beds and the presence of residents on isolation precautions. The facility's Infection Prevention Nurse and Director of Nursing stated that the facility could not accommodate residents with CRE infections, and there was no communication with the hospital regarding the resident's infection status. The facility did not attempt to cohort other residents to make room for the returning resident, and there was no documentation in the resident's electronic health record discussing the CRE infection or the risk of spreading it. The resident expressed frustration at being unable to return to the facility, where they had lived for nearly seven years. The California Department of Public Health's guidelines indicate that admission or readmission should not be denied based on colonization or infection with multidrug-resistant organisms, including CRE. The facility's failure to re-admit the resident violated the resident's right to return and had the potential to cause psychosocial harm.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update or revise the care plans for three residents, leading to deficiencies in their care. Resident 7's care plan for contact isolation precautions was not revised after the resident was cleared by a doctor following treatment for possible scabies. Despite the resident no longer requiring isolation, the care plan remained unchanged, which was confirmed by the Licensed Nurse, Infection Preventionist, and Director of Nursing. This oversight was contrary to the facility's policy that mandates care plans be revised as residents' conditions change. Resident 48, who has a hearing and speech disability, did not have her care plan properly implemented. The resident relied on a whiteboard for communication, but it was not consistently available to her, and there was no marker in her room. During observations, it was noted that the whiteboard was not within reach, and the resident was without it during meals. The facility's policy required the use of alternative communication tools, but this was not adequately provided, as acknowledged by the Administrator and Director of Nursing. Resident 40 reported missing money, which he suspected was taken by staff. Despite a previous incident of missing items, the facility did not revise his care plan to address the new allegation. The Social Service Director and Assistant Director of Nurses confirmed the absence of a care plan related to the incident, which could have provided staff with guidance and supported the resident's emotional needs. The facility's failure to document and address the incident in the care plan was noted by the Administrator and Ombudsman, highlighting a lack of proper response to the resident's concerns.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a resident-centered activity program for two residents, Resident 23 and Resident 54. Resident 23, who was on contact precautions due to osteomyelitis, MRSA infection, and a pressure ulcer, did not receive the required one-on-one room visits for activities while in isolation. The Activity Director confirmed that there was no documentation of these visits, which were supposed to occur at least twice a week, and admitted that the visits had not been scheduled as required. Similarly, Resident 54, who had heart disease and cerebral infarction and preferred to remain in his room, did not receive the necessary one-on-one room visits for activities. The Activity Director acknowledged the lack of documentation for these visits, which were also supposed to occur at least twice a week. The last Activities-Participation Review for Resident 54 was conducted several months prior, indicating a lapse in ongoing assessment and engagement. The Administrator confirmed that the expected one-on-one visits and documentation were not provided as appropriate.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safety of a resident at risk for elopement, identified as Resident 43, who had a history of schizoaffective disorder. Despite being assessed as a high risk for elopement, the resident's care plan, which included 1:1 monitoring and 30-minute visual checks, was not effectively implemented. On multiple occasions, the monitoring times were missed, and the resident managed to leave the facility unnoticed, resulting in a fall and subsequent hospitalization. Interviews with staff revealed lapses in supervision, as the assigned CNA left the resident unattended, and there was no physician's order for the monitoring, although it was part of the care plan. The facility also failed to maintain safety standards in the laundry area, where lint traps in two dryers were found to be full, posing a fire hazard. The Housekeeping/Laundry Supervisor and Housekeeping Assistant acknowledged that the lint traps were not cleaned according to the facility's schedule, which required cleaning every two to three hours. This oversight was confirmed during interviews and a review of facility documents, which emphasized the importance of regular lint trap maintenance to prevent fire risks. Additionally, the facility did not ensure that a sliding door in a resident's room was operational, which could have compromised the resident's ability to access fresh air and exit safely in an emergency. The resident, identified as Resident 45, reported difficulty opening the door, which was confirmed by staff observations. The Maintenance Supervisor noted the absence of wheels on the door track, which hindered its operation. This issue was recognized as a safety hazard, as the door could serve as a fire exit, and the resident expressed feelings of anxiety due to the inability to access the outdoor area.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that direct care staffing information was posted daily as required, affecting a census of 92 residents. This deficiency was identified through observations, interviews, and record reviews. During an interview with the Director of Staff Development (DSD), it was revealed that the Per Patient Day (PPD) Spreadsheet, which is used to calculate daily staffing needs, was kept in a binder in the DSD's office and was not posted for residents and visitors to view. The Director of Nursing (DON) confirmed that the PPD and census information were not posted, and the document used for the nursing schedule lacked essential details such as the facility's census and the hours scheduled and worked by licensed and non-licensed staff. The facility's document titled "Posting Direct Care Daily Staffing Numbers" outlined the requirements for posting staffing information, including the resident census and actual hours worked by nursing staff. However, the facility did not adhere to these requirements, as the necessary information was not made available for public viewing. This oversight prevented residents and visitors from accessing important information about the staffing levels and care being provided at the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, affecting 85 out of 92 residents who consumed meals prepared by the facility. During an initial kitchen tour, it was observed that several containers of spices had their lids left open, which the Certified Dietary Manager (CDM) confirmed. This practice contradicts the facility's guidelines that require spices to be kept dry and tightly covered to prevent pest contamination and maintain freshness. Additionally, an expired food item, a bag of tortillas, was found in the dry storage area, which the CDM acknowledged should have been discarded according to the facility's policy. During a lunch meal preparation observation, a dietary staff member, referred to as DC 1, was seen handling ready-to-eat food without wearing gloves, which she admitted was against the facility's food handling policy. Furthermore, DC 1 failed to perform hand hygiene after touching a dirty surface, specifically the lid of a trash bin, before handling food again. This action was contrary to both the facility's policy and the FDA Food Code, which emphasize the importance of handwashing to prevent foodborne illnesses. The facility also did not use appropriate measuring utensils during food distribution, as observed during a lunch trayline. DC 1 used the same scoop for all meal portions, regardless of size, which could affect residents on weight management programs. The CDM confirmed that different scoop sizes should have been used. Additionally, the facility lacked color-coded chopping boards, which are recommended by the FDA Food Code to prevent cross-contamination. The CDM stated that using one color-coded chopping board was intended to avoid confusion, despite the potential risk of cross-contamination.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during a high-contact care activity involving a resident with a feeding tube. A Licensed Nurse (LN) did not wear a gown while administering medication through the feeding tube, despite the EBP policy requiring both gloves and a gown for such activities. This oversight was acknowledged by the LN and the facility's Infection Preventionist (IP), who confirmed that the policy was clear and that staff had been educated on its requirements. The facility also failed to maintain a clean and safe environment for its residents. One resident's bed mattress was in poor condition, with exposed and stained foam, making it impossible to clean effectively and posing an infection control risk. Despite the resident and staff being aware of the issue, no work order was submitted to replace the mattress. Additionally, another resident's bathroom was found to be dirty, with urine and stool on the toilet seat, leading the resident to leave their isolation room to use a communal bathroom, thereby breaching isolation precautions. Furthermore, the facility did not appropriately manage contact/isolation precautions for a resident exposed to scabies. The resident completed prophylactic treatment but remained on isolation precautions unnecessarily, as the facility failed to update the resident's status and move them to a different room. This oversight was attributed to a lack of communication and follow-up during the absence of the regular IP. Additionally, a used gastronomy tube dressing was found on the floor beside a resident's bed, indicating a failure to properly dispose of medical waste, which posed an infection control risk.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a home-like environment for two residents, leading to discomfort and unsanitary conditions. Resident 66 experienced an uncomfortable sleeping environment due to a bed mattress with tears in the plastic barrier and a slope to the left side. The resident expressed fear of falling out of bed and discomfort due to the condition of the mattress. Observations by staff, including a Licensed Nurse, Maintenance Supervisor, and Certified Nursing Assistant, confirmed the mattress's poor condition, which could not be properly cleaned and was not conducive to a home-like environment. Resident 87 faced unsanitary bathroom conditions, with stool and urine on the toilet seat, toilet paper on the floor, and a non-operational soap dispenser. Despite being on isolation precautions, the resident refused to use the bathroom in his room due to its unclean state and instead used a communal bathroom. Staff observations confirmed the bathroom's unsanitary condition, which had persisted for over a day, and acknowledged that it did not provide a home-like environment. Interviews with facility staff, including the Housekeeping/Laundry Supervisor and the Infection Preventionist, revealed that the facility's policies and procedures for maintaining a safe, clean, and comfortable environment were not followed. Both residents' situations highlighted a failure in communication and action among staff to address and rectify the deficiencies in a timely manner, leading to a breach of resident rights to a safe and home-like environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of stolen property when a resident reported his suspicion that two CNAs had stolen his money. The resident, who had been diagnosed with depression and anxiety, reported that $2400 in cash was missing from his possession. Despite the resident's report and the facility's investigation, the facility decided not to reimburse the missing cash, citing that the money reported missing did not match the amount released to the resident. The facility's policy required immediate reporting of such allegations to the Administrator and appropriate agencies, but this was not done, resulting in a delay in the state survey agency's investigation. The resident had previously signed a document taking responsibility for the money withdrawn from the facility's safe, which the facility used as a basis for not reimbursing him. The Social Services Director and the Administrator were aware of the situation, but the Administrator was not informed of the resident's possession of cash until later. The resident expressed his distress over the incident during a Resident Council Meeting, and the Ombudsman confirmed his upset state. The facility's failure to report the incident as required by their policy had the potential to put residents' psychosocial and physical health and safety at risk.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an accurate assessment for one resident, identified as Resident 48, who had a hearing and speech disability. The deficiency was identified through observations, interviews, and record reviews. Resident 48's clinical records indicated a diagnosis of hearing loss, and it was noted that she was deaf and mute. However, during the assessment process, the Minimum Data Set (MDS) Nurse inaccurately documented that Resident 48 had adequate hearing and clear speech. This incorrect assessment could have led to Resident 48 not receiving the necessary communication aids and services, as the MDS assessment is crucial for determining the resident's needs. Observations revealed that Resident 48 relied on a whiteboard for communication, which was not always accessible to her. During interactions, staff members noted the absence of a more effective communication tool, such as a communication board with pictures. The facility's policy and procedure for conducting accurate resident assessments were not followed, as acknowledged by the Administrator and Director of Nursing. This oversight in accurately assessing Resident 48's condition could have impacted the services she received, as the assessment serves as baseline data for ongoing evaluation of resident progress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe cleaning and sanitization of a shared glucometer between resident uses, as observed during a medication administration for one resident. Licensed Nurse 9 (LN 9) was observed using a single Sani-Cloth-Bleach wipe to wrap the glucometer without properly cleaning and sanitizing it according to the facility's policy and manufacturer specifications. LN 9 acknowledged not following the two-step process required for cleaning and sanitizing the glucometer, which involves using one wipe to clean and a second wipe to disinfect, ensuring the surface remains wet for the required time. Interviews with the Infection Prevention (IP) nurse and the Director of Nursing (DON) confirmed that the facility's policy requires the use of two wipes for cleaning and disinfecting glucometers, as per the manufacturer's instructions. The IP nurse stated that the glucometer should remain wet for 4 minutes with the Sani-Cloth Bleach wipe. The facility's policy and the manufacturer's guidelines both emphasize the importance of cleaning and disinfecting shared glucometers to prevent the spread of infections. The failure to adhere to these procedures had the potential to spread infection among residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide quality care for Resident 56 by not addressing physician orders for cardiology, urology, psychiatry consults, and a neurology referral. Resident 56, who was admitted in February 2022, has a medical history that includes paraplegia, spina bifida, PTSD, anxiety disorder, major depressive disorder, and insomnia. Despite having orders for these consults, they were not scheduled, which could lead to unaddressed health concerns and adverse events. During an observation and interview, Resident 56 expressed that he was supposed to have appointments with a neurologist and urologist, which had not been scheduled. He mentioned frequent infections and the need for a urologist due to his use of a straight catheter. He also requested psychiatric help from a female doctor in person, as he did not approve of telehealth services. The facility's Social Service Director (SSD) was responsible for scheduling these appointments but failed to do so, as confirmed by the Director of Nurses (DON) and the SSD himself. The SSD acknowledged the importance of timely scheduling of consults due to clinical concerns for residents and admitted to not placing notes regarding the scheduling of the urology, cardiac, and psychiatry consults. The DON confirmed that there were no progress notes regarding appointment scheduling and emphasized the importance of consults for better assessment and medical needs evaluation. The facility's policy indicated that social services should coordinate resident referrals and document them in the medical record, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care and services for a resident receiving enteral feeding through a gastrostomy tube. The enteral feeding formula container was not labeled with a stop time and a re-start time, which is necessary to track the duration of use and ensure the resident receives the correct amount of nutrients. During an observation, it was noted that the feeding bottle was still full at 4:45 p.m., despite being started at 6 a.m. The Licensed Nurse confirmed that she had restarted the feeding at 4 p.m. without noting the start time, and there was no stop time recorded from the initial start. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of having start and end times to prevent spoilage and ensure proper nutrient delivery. Additionally, the water flush bag used for the resident was not labeled with the resident's name, room number, date, time started and stopped, administration rate, or the initials of the nurse. This lack of labeling could lead to the use of an incorrect or expired water flush bag. The Licensed Nurse confirmed the absence of labeling, and both the Assistant Director of Nursing and the Director of Nursing stated that proper labeling is a standard nursing practice and expected according to facility policy. The facility's policy on the care and treatment of feeding tubes emphasizes the importance of following physician orders and ensuring that feeding products do not exceed their expiration date.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe and timely medication acquisition, handling, use, and disposition, affecting a resident census of 92. The medication destruction logs for non-controlled prescription medications were either not signed or not co-signed by licensed nurses in the destruction medication binder at the East nurse station. This lack of proper documentation was acknowledged by the Licensed Nurse and confirmed by the Director of Nursing (DON), who stated that not following the established facility policy increases the risk of drug diversion. Resident 83 did not receive a prescribed medication, Eliquis, in a timely manner due to a failure in the reordering process. The medication was not available in the medication cart, and the Licensed Nurse did not reorder it promptly, resulting in the resident missing a full day of the medication. The DON confirmed that the provider pharmacy delivered medications multiple times per day and that the nurses could have expedited the delivery. The absence of Eliquis, a blood thinner, increased the risk of stroke and blood clot formation for the resident. Resident 45 experienced multiple missed doses of prescribed medications, including trazodone, zolpidem, and gabapentin, due to delays in reordering and pharmacy delivery. The resident reported being in constant pain and experiencing delays in receiving pain-related medications. The Licensed Nurse confirmed the missed doses and acknowledged that the resident's pain and anxiety could worsen due to the lack of medication. The Assistant Director of Nurses (ADON) confirmed the missed doses and stated that the nursing staff should have reordered the medications well in advance and notified management if not delivered. The Medical Doctor (MD) confirmed the missed doses and expressed concerns about the potential risks of sudden withdrawal symptoms.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe use of psychotropic medications for four residents, leading to deficiencies in medication management and documentation. Resident 11 and Resident 43 were prescribed lorazepam on a PRN basis without a specified duration of use, and their medication use was not reassessed for effectiveness. The Assistant Director of Nursing (ADON) confirmed that the PRN orders lacked a duration, which was not a safe practice. The Director of Nursing (DON) expected staff to follow regulatory requirements, which include reassessing the effectiveness of PRN medications. Additionally, Resident 11 and Resident 23 were prescribed psychotropic medications without specific mental health diagnoses documented in their medical records. Resident 11's records included a diagnosis of psychotic disorder, but it was not specific to the condition and behavior. Resident 23 was prescribed Buspar for anxiety, but there was no documented diagnosis of anxiety in the medical records. The ADON confirmed the lack of specific diagnoses and stated that the facility had copied records from a previous nursing home without conducting a psychiatric consult. Furthermore, Resident 56's mental health consult notes and medication recommendations via telehealth were not communicated to the medical doctor or nursing staff. The Social Service Director (SSD) admitted to not forwarding the telehealth consult notes to the medical care provider, assuming someone else would handle it. The DON acknowledged communication issues and challenges with uploading documents into resident charts, which could affect residents' physical and mental well-being. The facility's policies required the attending physician to lead medication management and ensure all residents receive necessary behavioral health services, but these were not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 14.29%, which is above the acceptable threshold of 5%. This was observed in three residents during medication administration. Licensed Nurse 1 (LN 1) administered medications to Resident 17 without following proper procedures. LN 1 did not assist Resident 17 in rinsing his mouth after using the Breo Ellipta inhaler, which is necessary to prevent oral thrush. Additionally, LN 1 administered amlodipine despite the resident's heart rate being below the prescribed threshold, acknowledging that the medication should have been held. Licensed Nurse 4 (LN 4) also failed to adhere to medication administration protocols while administering medications to Resident 5. LN 4 did not measure the resident's blood pressure or pulse before administering Losartan and Metoprolol, both of which have specific hold parameters based on vital signs. Furthermore, LN 4 crushed an extended-release Metoprolol tablet, which should not have been crushed, potentially causing dangerous side effects. LN 4 was unable to provide documentation of the vital signs taken, and the recorded vital signs were inconsistent with the time of medication administration. Licensed Nurse 5 (LN 5) did not follow the prescribed procedure for administering medications via a gastronomy tube to Resident 76. LN 5 failed to flush the tube with 30 mL of water before administering the first medication, as required by the medication administration order. This step is crucial to ensure the patency of the tube and prevent blockages. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed that staff should adhere to medication administration instructions, as outlined in the facility's policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate medical records for two residents, resulting in the inclusion of Protected Health Information (PHI) of other residents in their electronic medical records. In the case of one resident, the History and Physical (H&P) document of a different resident who had been discharged was mistakenly scanned into their electronic medical record. This error was confirmed by both the Assistant Director of Nursing (ADON) and the Medical Record Lead (MRL) during interviews and record reviews. The MRL acknowledged that the transition from paper charts to an electronic medical record system required many documents to be scanned quickly, which led to this mistake. For another resident, an Order Listing Report containing the names and PHI of five other residents was uploaded into their electronic medical record. This was confirmed by the ADON and the MRL, who stated that the report should have been redacted before being scanned. The facility's policy on HIPAA Security Measures emphasizes the importance of protecting and maintaining the confidentiality of residents' identifiable information, but these incidents demonstrate a failure to adhere to these standards, potentially compromising the privacy and confidentiality of residents' health information.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the protection of a resident's personal funds by filling out documentation to receive the resident's Social Security payments without the resident's knowledge and consent. The resident, who was admitted with diagnoses including depression and multiple sclerosis, was his own responsible party. The facility applied for a representative payee to receive the resident's Social Security payments, which were then used to cover the resident's arrearages without informing him. This action was discovered when the resident did not receive his Social Security payment and sought assistance from the Ombudsman. Interviews with facility staff revealed that the Business Office Manager (BOM) completed the application for a representative payee under pressure from a facility biller, without discussing it with the resident or obtaining his permission. The BOM acknowledged that the resident did not approve the application or the sharing of his personal health information. The Administrator confirmed that personal health information should not have been sent without the resident's consent. The Social Security Administration guidelines indicate that benefits are usually paid directly to legally competent adults unless they are unable to manage their own benefits, which was not the case for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to safeguard and properly manage the personal property of a discharged resident, identified as Resident 1, which led to the resident not receiving his belongings. Resident 1, who had a diagnosis of depression, left the facility against medical advice. Subsequently, his personal property was given to a family member, FM 1, without Resident 1's knowledge or consent. The facility did not require FM 1 to sign for the items on the inventory sheet, which is a standard procedure to track personal items. During interviews, Resident 1 expressed that he was unaware his belongings had been picked up by FM 1, with whom he was not in contact. FM 1 confirmed picking up some items but noted that many were missing and that she was not asked to sign for them. The facility's policy mandates that personal belongings should be returned to the resident or their representative with a legal signature acknowledging receipt, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a homelike environment in seven resident rooms, which were found to be dirty and unkempt during a survey. Observations included stained floors, curtains not hanging correctly with hooks off the track, torn inner linings, and dirty privacy curtains with various sized stains. Additionally, one room had an overbed table with ashes and cigarette butts, and the table was in disrepair. These conditions were confirmed by a licensed nurse during an observation and interview. The Director of Nursing and Infection Preventionist acknowledged the issues, noting that the dirty floors posed an infection control problem and that the curtains needed to be functional to maintain room temperature and a homelike environment. The facility's policy on Resident Rights emphasizes the residents' right to a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the privacy of a resident during wound care, compromising the resident's right to privacy and dignity. The resident, who was admitted with pressure ulcers and a suprapubic catheter, was exposed during wound care as the licensed nurse did not draw the privacy curtain or close the door to the resident's room. This oversight allowed anyone walking by to see the resident, as acknowledged by the licensed nurse during an interview. The Director of Nursing and the Infection Preventionist emphasized the importance of drawing the privacy curtain to maintain the resident's dignity. The facility's policy on resident rights, dated 2023, includes the right to personal privacy during medical treatment and personal care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its infection prevention and control program during wound care for a resident, identified as Resident 8. The resident was admitted with diagnoses including pressure ulcers and a suprapubic catheter. During a wound care observation, a licensed nurse (LN 1) did not adhere to Enhanced Barrier Precautions (EBP) and other infection control practices. LN 1 gathered supplies without donning a gown, placed clean supplies on a potentially contaminated bedside table, and did not perform hand hygiene at critical points during the procedure. LN 1 removed the dressing from the resident's suprapubic catheter, cleansed the area, and applied a new dressing without performing hand hygiene between steps. Additionally, LN 1 did not change gloves between handling different wound sites and accessed the wound treatment cart with contaminated gloves. The nurse used scissors from the cart to cut a dressing and returned both the scissors and unused dressing to the cart without cleaning them, further risking cross-contamination. Interviews with LN 1, the Director of Nursing (DON), and the Infection Preventionist (IP) confirmed the lapses in infection control practices. LN 1 acknowledged the risk of infection due to placing clean dressings on a dirty surface and not performing hand hygiene. The DON and IP emphasized the importance of following EBP to prevent cross-contamination, highlighting the risk posed by contaminated items in the wound treatment cart.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect the rights of a resident, identified as Resident 2, by not allowing him to re-enter the facility after he left on a pass. On the morning of 9/1/24, Resident 2 left the facility using an electric wheelchair borrowed from another resident. Upon his return in the afternoon, he was denied entry back into the facility. The facility claimed that Resident 2 left against medical advice (AMA) but did not provide him with an explanation, a copy of the AMA form, or notify Adult Protective Services as per their policy. Resident 2, who had been admitted to the facility in the fall of 2023 with diagnoses including lower back pain, cirrhosis of the liver, depression, and schizophrenia, was left waiting in the hospital for two days after the facility refused to allow him to return. The hospital attempted to transfer him back to the facility, but the facility declined, resulting in Resident 2 being placed in another facility out of the area. This situation potentially caused emotional distress for Resident 2 due to leaving a familiar environment. Interviews with facility staff and review of records revealed that the facility did not follow proper procedures for AMA discharges. The Director of Nursing confirmed that Resident 2 did not sign the AMA form or receive a copy, and Adult Protective Services was not notified. Additionally, there was no transfer or discharge notice in Resident 2's medical record, and he did not receive a medication reconciliation list or discharge instructions. The facility's actions were inconsistent with their policies, which require notifying the resident's physician and providing an opportunity for the physician to convince the resident to stay, as well as notifying Adult Protective Services.