Gridley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Gridley, California.
- Location
- 246 Spruce Street, Gridley, California 95948
- CMS Provider Number
- 555776
- Inspections on file
- 31
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Gridley Post Acute during CMS and state inspections, most recent first.
The facility failed to refer two residents for a level II PASARR after they were diagnosed with new serious mental illnesses. One resident, with severe cognitive impairment, had new diagnoses of psychosis, manic episode, and depression, while another resident, with moderate cognitive impairment, was diagnosed with bipolar and anxiety disorders. The DON acknowledged the lack of updated PASARRs, indicating a misunderstanding of the requirements.
A resident with moderate cognitive impairment was transferred to the hospital without receiving a timely bed hold notice, as required by facility policy. The Admissions Director admitted to not issuing the notice promptly, and the DON confirmed that the notice should have been provided immediately upon transfer. The Administrator noted challenges in delivering the notice if the resident is their own responsible party, but emphasized the importance of timely communication with responsible parties.
A facility failed to develop a comprehensive care plan for a resident with bilateral leg edema, despite the resident's medical history of diabetes and hypertension. The resident showed signs of edema, and although orders were in place to monitor the condition and use TED hose, no care plan was documented. Interviews with staff confirmed the absence of a care plan, and the Director of Nursing and Administrator acknowledged that a care plan should have been initiated.
A resident with moderate cognitive impairment and a history of atrial fibrillation and type 2 diabetes experienced an eight-day delay in receiving antibiotic therapy for a urinary tract infection. Despite a urinalysis with culture and sensitivity being ordered and results reported, the prescribed Bactrim DS was not initiated until eight days later. The DON and NP acknowledged the delay, with no reason provided for the lapse.
A resident with moderate cognitive impairment was found to have a space heater in their room, contrary to the facility's policy prohibiting such devices to prevent accidents. The heater was used due to the absence of a heating unit, and staff were unaware of federal regulations against space heaters in skilled nursing facilities. No incidents were reported, but the facility acknowledged the oversight and planned to remove space heaters from resident rooms.
A resident with moderate cognitive impairment and a history of atrial fibrillation and type 2 diabetes was not promptly treated for a urinary tract infection due to the facility's failure to notify the physician of lab results. The urine culture was finalized on 12/22/2024, but the resident was not started on antibiotics until 12/30/2024. Interviews with the DON, NP, and Administrator confirmed the expectation for timely communication, which was not met.
A resident with moderate cognitive impairment was administered Rexulti without informed consent in a language understood by her and her responsible party (RP), both Spanish speakers. The facility's policy required informed consent before administering psychotropic medication, but it was not documented. The RP was not informed by the physician about the medication and only discussed it with a CNA. The RP later requested discontinuation due to the resident's flat expression on the medication. The physician could not recall observing the resident's behavior or signing an informed consent.
A resident with dementia and other conditions was prescribed Rexulti by the MD, who failed to document the need for the medication, its administration, or the reason for its discontinuation. The MD could not recall details about the prescription or observe the resident's behavior, leading to potential miscommunication and unclear care expectations.
A resident with dementia was prescribed Rexulti without documented necessity or monitoring, contrary to facility policy. The DON admitted to not monitoring the resident for side effects or effectiveness, and the RP was not informed about the medication's risks. The MD was unaware of the medication's boxed warning, and the facility's actions put the resident at risk for adverse consequences.
Failure to Conduct Level II PASARR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer two residents to the appropriate state-designated authority for a level II Preadmission Screening and Resident Review (PASARR) after they were diagnosed with new serious mental illnesses. Resident #2, admitted on 05/22/2018, had a medical history of spastic hemiplegic cerebral palsy and received new diagnoses of psychosis, manic episode, and depression on 12/06/2023. An annual Minimum Data Set (MDS) assessment indicated severe cognitive impairment and active diagnoses of depression, bipolar disorder, and psychotic disorder. However, there was no evidence in the medical record that the facility referred Resident #2 for a level II PASARR evaluation following these new diagnoses. Similarly, Resident #1, admitted on 06/27/2024, had a medical history including atrial fibrillation, hypertension, and muscle weakness, and was diagnosed with bipolar disorder and anxiety disorder on 02/25/2025. A quarterly MDS assessment showed moderate cognitive impairment and active diagnoses of anxiety disorder, depression, and bipolar disorder. The facility also failed to refer Resident #1 for a level II PASARR evaluation after the new mental illness diagnoses. During interviews, the Director of Nursing (DON) acknowledged the lack of updated PASARRs for both residents, indicating a misunderstanding that a new PASARR was only needed for new qualifying diagnoses.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice upon the transfer of a resident to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed-hold policies at least twice: once in advance of any transfer and again at the time of transfer, or within 24 hours if the transfer is an emergency. In this case, a resident with a history of atrial fibrillation and type 2 diabetes mellitus, who had moderate cognitive impairment, was transferred to the hospital for further evaluation of blood in their urine and hallucinations. However, there was no evidence of a bed hold notice being provided at the time of transfer. The Admissions Director acknowledged that the bed hold notice was not issued in a timely manner, as it was only addressed after the resident returned to the facility. The Director of Nursing confirmed that the responsibility for sending out bed hold notices lies with the Admissions Director and emphasized that the notice should be issued immediately upon transfer. The Administrator noted that if a resident is their own responsible party, it might be challenging to deliver the notice, but if there is a responsible party, the notice should be given as soon as possible, ideally by the next day after the transfer. The facility's failure to provide the bed hold notice in a timely manner was acknowledged by the staff involved.
Failure to Implement Care Plan for Resident's Edema
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who experienced bilateral leg edema. The resident, who was admitted with a medical history of type 2 diabetes mellitus with diabetic neuropathy and essential hypertension, showed signs of edema as early as December 2024. Despite the presence of orders to monitor the resident for edema and the prescription of thrombo-embolic deterrent (TED) hose to manage the condition, there was no evidence of a care plan addressing the edema in the resident's records. Interviews with facility staff, including a Certified Nursing Assistant, a Registered Nurse, a Licensed Vocational Nurse, the MDS Coordinator, and the Director of Nursing, confirmed the absence of a care plan for the resident's edema. The staff acknowledged that a care plan should have been initiated when the edema was first noted and when the TED hose was ordered. The Director of Nursing and the Administrator both stated that they expected a care plan to be developed and implemented in a timely manner to address the resident's needs.
Delayed Antibiotic Therapy for Resident
Penalty
Summary
The facility failed to timely initiate antibiotic therapy for a resident, leading to a deficiency. The resident, who was admitted with a medical history of atrial fibrillation and type 2 diabetes mellitus, had a moderate cognitive impairment as indicated by a BIMS score of 9. A urinalysis with culture and sensitivity was ordered by the physician on 12/22/2024, and the results were reported on the same day. However, the nurse practitioner did not start the resident on the prescribed antibiotic, Bactrim DS, until 12/30/2024, resulting in an eight-day delay. The Director of Nursing could not provide a reason for this delay, and the nurse practitioner acknowledged that the delay was excessive.
Space Heater Use in Resident Room Against Facility Policy
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, specifically by allowing a space heater in the room of a resident with moderate cognitive impairment. The facility's policy, revised in January 2011, explicitly prohibited portable space heaters to protect residents from potential injuries such as electrocution, burns, and fire. Despite this policy, a space heater was observed in the resident's room on multiple occasions, plugged in and operational, with a sign warning against placing items on it due to fire hazard concerns. The resident, who had a medical history of atrial fibrillation, hypertension, and muscle weakness, was admitted to the facility in June 2024 and had been using the space heater since winter due to the absence of a heating unit in their room. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the space heater had been in use for several weeks to a month, and no incidents related to the heater had been reported. The Maintenance Director believed the space heater was compliant with state regulations, citing criteria such as being UL-rated and oil-based. However, he was unaware of the need to adhere to federal regulations prohibiting space heaters in skilled nursing facilities. The Administrator acknowledged the Maintenance Director's efforts to meet the resident's needs but confirmed that space heaters would not be allowed in resident rooms going forward.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to timely notify the physician of laboratory results for a resident who was admitted with a medical history of atrial fibrillation and type 2 diabetes mellitus. The resident had a moderate cognitive impairment as indicated by a BIMS score of 9. On 12/22/2024, a physician ordered a urinalysis with culture and sensitivity for the resident. The urine culture was collected on 12/20/2024, and the results were finalized and reported on 12/22/2024. However, there was no documentation to indicate that the physician was notified of these results. The deficiency was further highlighted during interviews conducted on 03/27/2025. The Director of Nursing (DON) confirmed the lack of documentation regarding physician notification. The nurse practitioner (NP) expressed that her expectation was for the staff to promptly communicate the results to the provider, as she and other providers were available 24/7. The Administrator also stated that he expected staff to follow through with timely physician notification of laboratory results. Despite these expectations, the resident was not started on the prescribed antibiotic, Bactrim DS, until 12/30/2024, indicating a delay in treatment due to the failure in communication.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident and her responsible party (RP) of the risks and benefits of a psychotropic medication, Rexulti, in a language they could understand, which was Spanish. The resident, who had moderate cognitive impairment and was diagnosed with dementia, glaucoma, dysphagia, and type 2 diabetes, was administered Rexulti without documented informed consent. The facility's policy required informed consent to be obtained and documented before administering such medication, but this was not done. The Director of Nursing (DON) and the Administrator confirmed that the informed consent was not present in the resident's medical record. The resident's RP stated she was not informed by the physician about the medication and only discussed it with a Certified Nursing Assistant (CNA). The RP agreed to the medication without understanding its risks and benefits, and later requested its discontinuation due to the resident's flat expression while on the medication. The physician who prescribed Rexulti could not recall observing the resident's behavior before or during the medication administration and did not remember signing an informed consent. The DON admitted to suggesting the medication to the physician, but no informed consent was located for the resident.
Inadequate Documentation and Oversight by Medical Director
Penalty
Summary
The Medical Director (MD) failed to provide adequate progress notes for a resident, which should have reflected a comprehensive review of the resident's care, current condition, and the appropriateness of the medical regimen. The resident, who was admitted with diagnoses including dementia, glaucoma, dysphagia, and type 2 diabetes, was prescribed Rexulti for psychotic behaviors associated with dementia. However, the MD did not document the behaviors that warranted the medication, nor did they document the administration of the medication in the progress notes for September, October, and November 2024. Additionally, the MD did not provide a rationale for discontinuing the medication in November 2024. The MD admitted to prescribing Rexulti due to aggression and agitation issues but could not recall specific details about the prescription timeline or the resident's behavior before and during the medication period. The MD also failed to observe the resident's behavior prior to prescribing the medication and did not remember if informed consent was obtained. This lack of documentation and oversight had the potential to result in miscommunication regarding the resident's medical diagnosis and treatment, as well as unclear expectations for direct care staff.
Inadequate Documentation and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to adequately document the necessity of a psychotropic medication, Rexulti, for a resident with dementia, glaucoma, dysphagia, and type 2 diabetes. The resident, who had a moderate cognitive impairment, was prescribed Rexulti by the Medical Director without documented behaviors indicating the need for the medication. The medication was administered from early September to early November, but there was no documentation of the reason for its discontinuation. The facility's policy required a comprehensive assessment and documentation of the necessity for psychotropic medications, which was not followed in this case. The Director of Nursing (DON) admitted that the facility did not monitor the resident for at least three days after starting the medication, as required by their policy. The DON also failed to enter monitoring parameters into the resident's Medication Administration Record (MAR) for behaviors and side effects. The facility did not assess the effectiveness of the medication or attempt to reduce the dosage. The DON did not communicate relevant information regarding medication monitoring to other staff members, and the Interdisciplinary Team (IDT) did not determine which behaviors to monitor. Interviews revealed that the resident's Responsible Party (RP) was not informed about the risks and benefits of the medication and only learned about the resident's condition through a housekeeper. The RP requested the discontinuation of the medication due to the resident's flat expression. The Medical Director was unaware of the boxed warning associated with Rexulti and did not observe the resident's behavior before or during the medication period. The facility's failure to document and monitor the use of Rexulti put the resident at risk for adverse consequences, as the medication is not approved for dementia-related psychosis due to increased mortality risks.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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