Lincoln Meadows Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, California.
- Location
- 1550 Third Street, Lincoln, California 95648
- CMS Provider Number
- 555333
- Inspections on file
- 45
- Latest survey
- May 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lincoln Meadows Care Center during CMS and state inspections, most recent first.
Two residents with moderate cognitive impairment and significant medical needs were found to have non-functioning call light systems in their room and bathroom. Staff, including the DON, DSD, and an RN, confirmed that the call lights did not activate as required, and attempts to repair or use the system were unsuccessful. Both residents reported delays in receiving assistance, and the facility's policy requiring a functional call system at all times was not met.
During a meal service, staff did not follow prescribed menus and portion controls for various therapeutic diets, resulting in residents receiving incorrect portion sizes and meal components. Residents on regular, CCHO, CCHO renal, small portion, fortified, and finger food diets were all affected, with issues such as oversized pasta servings, full desserts instead of half portions, missing fortified margarine, and lack of required garnishes. These discrepancies were confirmed by dietary staff and were not in accordance with facility policies or physician orders.
Surveyors identified multiple deficiencies in food safety and sanitation, including improperly cleaned and stored metal pans, unclean storage areas, a poorly maintained can opener, and dietary staff unable to correctly describe or perform manual dishwashing and sanitizing procedures. Additionally, staff failed to use proper hair restraints and did not consistently label, date, or discard resident food in the refrigerator, which was also found to be unclean. These failures were confirmed through observation, staff interviews, and review of facility policies.
Several residents with cognitive and mobility impairments experienced significant delays in receiving incontinence care or assistance to the bathroom, resulting in episodes of incontinence, emotional distress, and skin discomfort. Documentation showed that individualized care plans for incontinence were lacking for some residents, and staff interviews confirmed that timely care was not consistently provided.
The facility failed to ensure dietary staff were properly trained and competent in food safety procedures, including manual dishwashing, cleaning and sanitizing food contact surfaces, and preparing sanitizer solutions. Two dietary aides lacked required food handler certifications and demonstrated incorrect practices, placing the majority of residents at risk for foodborne illness.
Surveyors found that oxygen and catheter tubing for several residents were in contact with the floor, and enteral feeding tubing was left uncapped and open to air while disconnected. Staff and facility policies confirmed these practices were not in line with infection control standards, as the tubing should not touch the floor or be left open to air due to contamination risks.
A resident with muscle weakness, difficulty walking, and a history of falls did not have their call light within reach on multiple occasions, despite requiring partial to moderate assistance with ADLs. The resident was unable to request help, and staff confirmed the call light was not accessible. Facility policy requires call lights to be within easy reach, but this was not followed.
A resident with a stage 4 pressure ulcer and chronic pain did not receive appropriate pain management during wound care. The nurse did not assess pain using a standardized scale or administer pain medication prior to the procedure, despite the resident expressing significant discomfort. The procedure was further prolonged due to lack of preparation, causing the resident to remain in pain for an extended period. Facility policies and care plan expectations for pain management and wound care preparation were not followed.
A facility failed to follow infection control practices when a nurse did not wear a gown during wound care for a resident with chronic osteomyelitis and bacteremia. Despite Enhanced Barrier Precautions requiring gowns for high-contact care, the nurse confirmed the oversight. Interviews with the Infection Preventionist and DON highlighted the necessity of gowns to prevent infection spread, as per facility policy.
A facility failed to report an alleged abuse incident involving a resident with hemiplegia and hemiparesis. The resident reported being disrespected by a CNA, who pushed her fingers into his chest and made demeaning comments. Despite the grievance being documented, staff members did not perceive the incident as abuse and did not report it to the State Survey Agency or local law enforcement, contrary to the facility's policy.
A resident with memory issues and aphasia was transferred to the hospital due to aggressive behavior, but the facility failed to notify the resident's representative as required. The representative only learned of the transfer from the hospital, leading to feelings of astonishment and upset. Documentation discrepancies were noted in the timing of notifications.
The facility failed to provide appropriate respiratory care for three residents. Two residents received incorrect oxygen levels, and one resident was not provided with an incentive spirometer as ordered by the physician. These discrepancies were confirmed by staff and the Director of Nursing, indicating a failure to follow the facility's policies on oxygen administration and physician orders.
The facility failed to ensure accurate accountability and effective storage of controlled medications for three residents. Controlled medications did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). The Director of Nursing confirmed that staff were expected to document on both records, as per facility policy.
The facility had a 10.42% medication error rate during a medication pass for two residents. Errors included not instructing a resident to rinse and spit after using an inhaler, not priming insulin pens, not swabbing a heparin vial, and administering insulin after a meal. The DON confirmed these actions were against the facility's policies.
A resident with left side hemiplegia and muscle weakness was not provided with a rocker knife, as required by her care plan, leading to her inability to cut food and subsequent weight loss. Staff confirmed the absence of the rocker knife and the facility's failure to notify appropriate personnel about its unavailability.
The facility failed to store food in a sanitary manner, with staff not using hair nets and beard guards, and several food items not labeled with open dates or expired. This included expired left-over roast beef that a Dietary Cook was about to reheat.
The facility failed to follow proper infection control practices when a dietary cook did not perform proper hand hygiene in the kitchen and a licensed nurse did not change gloves or perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. These failures had the potential to spread infection within the facility.
A facility failed to ensure that a resident's self-administered albuterol inhaler was reviewed and approved by a physician. The inhaler, brought from the hospital, was found at the resident's bedside without a pharmacy label or physician's order. The Director of Nursing confirmed that a physician's order and proper storage were required for safe self-administration.
A resident with asthma and a left lower limb infection reported being unable to reach the call light while in her wheelchair because it was located on the other side of her bed. The DON confirmed that the call light should have been within reach, as per the facility's policy.
A resident with paraplegia and other medical conditions returned from the hospital to find her room cluttered with personal belongings. Despite her requests for assistance, staff did not help her unpack, leading to an unsafe and disorderly environment. The clutter prevented proper cleaning and created hazards, as the resident could not adjust her bed or use the call light. The facility failed to follow the care plan and policy for a homelike environment.
The facility failed to ensure accurate MDS assessments for three residents. One resident's vision impairment was not documented, another's feeding tube was not recorded, and a third resident's discharge status was incorrectly noted as hospitalization instead of home. These inaccuracies could impact care plans and interventions.
The facility failed to develop and provide a baseline care plan (BCP) and written summary for a resident within 48 hours after admission. The BCP was not completed until several days later, and the summary was not provided to the resident or her representative. The DON confirmed the oversight, which is against the facility's policy.
A facility failed to develop a comprehensive care plan for a resident with COPD, omitting physician's orders for an incentive spirometer and compression stockings. This was confirmed through interviews and record reviews, highlighting a lapse in following the facility's policy for timely care plan development.
A resident received an incorrect dose of heparin when a nurse failed to expel air from the syringe before administration. The nurse acknowledged the error, and the Director of Nursing confirmed that proper medication administration is a staff competency expectation.
The facility failed to assist a resident with the arrangement of an eye doctor consultation, despite the resident's repeated requests and documented need for vision care. The resident, who experienced headaches from provided reading glasses, had not seen an eye doctor since the request was made in August 2023.
A facility failed to follow a physician's treatment order for a stage 4 pressure ulcer on a resident's left posterior leg. The prescribed treatment included cleansing with normal saline, applying collagen, hydroferra blue, triad cream, and a silicone border foam dressing with skin prep. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed. This was confirmed by the nurse and the Director of Nursing.
A facility failed to properly check the functionality of a roam signal device for a resident with paranoid schizophrenia and Alzheimer's disease, leading to an increased risk of elopement. The current method involved taking the resident near the main door, which the DON acknowledged needed improvement for safety.
The facility failed to ensure routine care and dressing changes for a resident's midline catheter, leading to an increased risk of infection. The dressing was not changed for 21 days, and there were no orders or documentation for flushing and locking the catheter. The DON confirmed that nurses did not follow the facility's policies.
A nurse left a med cart unattended in the hallway with a bubble pack containing six hyoscyamine 0.125 mg tablets on top. The facility's policy stated that no medications should be kept on top of the cart.
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically in the cooling down process for turkey and the proper procedures for pureeing food. Dietary Cook 1 did not follow correct procedures, use recipes, or measuring tools, which was confirmed by the Kitchen Dietary Manager and the Food Service Efficiency Consultant.
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, vegetables, and starch. This deficiency was confirmed by the dietary cook and the Food Service Efficiency Consultant, and it had the potential to decrease the nutrients in the food served to five residents on a pureed diet.
The facility failed to post complete daily staffing information at the beginning of each shift for a census of 90 residents. The Staffing Coordinator posted incomplete staffing information in the afternoon, missing the total number and actual hours worked per shift for licensed and unlicensed staff. This was observed on multiple occasions, and the SC confirmed the deficiency.
Non-Functioning Call Light System in Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents residing in the same room. Both residents had moderate cognitive impairment and required assistance due to their medical conditions, including a displaced comminuted fracture of the left patella and surgical aftercare following digestive system surgery. Observations and interviews revealed that the call light in their room did not activate the light above the door or register at the nurse's station, and one resident reported not being given a call bell. Both residents described significant delays in receiving assistance, with one stating she had to call out for help and the other reporting waits of up to two hours. Multiple staff members, including the DON, DSD, and an RN, confirmed through direct observation that the call light system was not working as intended. Attempts to replace the call light cord and activate the system were unsuccessful, and the emergency call light in the bathroom required excessive force to activate. The facility's policy required the call system to remain functional at all times, but this was not maintained, as confirmed by staff interviews and direct testing of the system.
Failure to Follow Therapeutic Diet Menus and Portion Controls
Penalty
Summary
The facility failed to ensure that planned menus were followed for therapeutic diets during a lunch meal service. Observations revealed that residents received incorrect portion sizes and meal components that did not align with their prescribed diets. Specifically, residents on regular diets received larger portions of pasta than indicated, those on consistent carbohydrate (CCHO) and CCHO renal diets received full servings of dessert and larger pasta portions instead of the prescribed reduced amounts, and residents on small portion diets were served full portions of dessert, pasta, and chicken rather than the smaller amounts required. Additionally, residents on fortified diets did not receive the extra margarine intended to increase caloric intake, and those on finger food diets did not have their desserts appropriately portioned for ease of handling. All residents who received meals from the facility kitchen did not receive the required garnish, which was specified in the menu to enhance meal presentation and potentially stimulate appetite. The discrepancies were confirmed through interviews with kitchen staff, the dietary manager, and the registered dietitian, who all acknowledged that the menu and portion guidelines were not followed during meal preparation and service. The facility's own menu spreadsheets and diet guidelines clearly outlined the correct portions and meal components for each therapeutic diet, but these were not adhered to during the observed meal service. A review of facility policies and job descriptions further confirmed that staff were expected to follow prepared menus, portion control guides, and special diet requirements accurately. The failure to do so resulted in residents receiving meals that did not meet their individualized nutritional needs as prescribed by their physicians and outlined in the facility's diet manual. These actions and inactions directly led to the deficiency cited in the report.
Multiple Food Safety and Sanitation Deficiencies Identified in Dietary Services
Penalty
Summary
The facility failed to ensure that food was prepared, stored, served, and distributed in accordance with professional standards, as evidenced by multiple deficiencies observed during survey. Metal pans in the clean and ready-to-use storage areas were found stacked while still wet and with food particles present, indicating improper cleaning and drying procedures. The storage areas themselves were not clean, with food debris noted on surfaces. Additionally, the blade of the can opener was discolored and chipped, and the dietary staff did not consistently demonstrate or verbalize correct procedures for manual dishwashing, cleaning, sanitizing, or preparing and testing sanitizer solutions. For example, one dietary aide was unable to describe the full manual dishwashing process, omitting the sanitizing step, and another did not follow correct procedures for cleaning food contact surfaces or using sanitizer test strips. Further observations revealed that dietary staff did not always use proper hair restraints, with one aide's hair not fully covered by a cap or hairnet. The resident food refrigerator located at the nurse station was found to be unclean, with dry liquid spills and improperly labeled or outdated food items present in the freezer. Food items lacked resident names, received dates, or were past their expiration dates, and there was no set schedule for cleaning the refrigerator. Interviews with nursing and housekeeping staff revealed confusion over responsibilities for monitoring and cleaning the refrigerator, with inconsistent practices regarding labeling, dating, and discarding perishable foods. Facility policies and procedures reviewed during the survey supported the need for proper dishwashing, sanitation, maintenance of equipment, labeling and dating of resident food, and regular cleaning of storage and refrigeration areas. However, staff interviews and direct observations confirmed that these procedures were not consistently followed, leading to unsanitary conditions and potential food safety risks for all residents receiving food from the facility kitchen.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with incontinence care for four residents who required varying levels of support for toileting hygiene. Documentation and interviews revealed that these residents experienced delays in receiving help, resulting in episodes of incontinence and emotional distress. For example, one resident with a history of left femur fracture and moderate cognitive impairment reported being unable to access the restroom due to physical barriers and lack of staff response, leading to an incontinence episode. Another resident with spinal stenosis and impaired mobility stated that staff took a long time to assist her to the bathroom, despite her preference to use a commode or toilet rather than remain in a brief. Care plan reviews showed that some residents who were always or frequently incontinent did not have individualized care plans addressing their incontinence needs. For instance, residents with documented incontinence episodes throughout all shifts lacked specific interventions in their care plans to manage bladder incontinence. One resident with enterocolitis due to C. difficile, who was always incontinent with bowel movements, reported significant discomfort and skin irritation due to delays in incontinence care, stating it took hours to receive assistance after an episode of diarrhea. Staff interviews confirmed that the expectation was to provide incontinence care as soon as possible to maintain skin integrity and prevent irritation or infection. However, multiple residents described long wait times for assistance, leading to feelings of anger, distress, and being unvalued. Observations and interviews corroborated that the facility did not consistently provide timely and appropriate care for residents who were continent or incontinent of bowel/bladder, as required by facility policy.
Deficient Food and Nutrition Service Staff Training and Competency
Penalty
Summary
The facility failed to ensure that dietary staff had the appropriate skills and knowledge to safely perform food and nutrition service operations. Dietary Aide 1 was unable to correctly verbalize the manual dishwashing process using a 2-compartment sink, omitting the sanitizing step and not knowing the required sanitizer concentration. Facility policy required washing, rinsing, sanitizing at 200-400 ppm for at least 1 minute, and air drying, but DA 1 could not state these requirements. Additionally, DA 1 did not possess the required food handler's certificate as per the job description. Dietary Aide 2 was observed cleaning soiled food contact surfaces incorrectly by using a towel from a sanitizer bucket without first cleaning with soap and water, contrary to facility policy which mandates a two-step process of cleaning and then sanitizing. DA 2 also demonstrated improper technique in preparing and testing the sanitizer solution, including incorrect use of test strips and not adhering to the required solution temperature for accurate testing. The sanitizer solution was found to be below the recommended temperature range, and DA 2 did not have the required food handler's certificate, despite being listed as a cook in her employee file. Both DA 1 and DA 2 had documentation indicating competency in relevant procedures, and records showed they attended in-service trainings. However, there were no individualized lesson plans for the competency topics, and the Director of Food and Nutrition was responsible for training and ensuring compliance with infection control policies. These failures had the potential to place 88 out of 92 residents at risk for foodborne illness due to improper food handling and sanitation practices.
Infection Control Lapses: Tubing and Enteral Feeding Practices
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Oxygen tubing for three residents with respiratory conditions, including chronic obstructive pulmonary disease, acute respiratory failure, and asthma, was found lying on the floor while in use. Licensed nurses and the Director of Nursing confirmed during interviews that the tubing should not be in contact with the floor due to infection control and safety concerns. Facility policy requires respiratory therapy equipment to be free from all microorganisms, and staff acknowledged the tubing's improper placement. A resident with a Foley catheter for urinary drainage was seen wheeling herself in a wheelchair with the catheter tubing dragging on the floor. Both a licensed nurse and the Director of Nursing confirmed the tubing was in contact with the floor and stated this was against infection control expectations. The facility's policy on indwelling catheters specifies that catheter tubing and drainage bags must be kept off the floor, and the Infection Preventionist reiterated that floor contact increases the risk of contamination. Additionally, a resident receiving continuous enteral feeding via a feeding tube was observed returning from physical therapy with the feeding formula and tubing left uncapped and open to air while disconnected. A licensed nurse confirmed that the uncapped tubing could lead to contamination, especially for vulnerable residents. Facility policies on enteral feedings and cleaning of resident-care items require aseptic technique and prevention of contamination, which were not followed in this instance.
Call Light Not Within Reach for Resident Requiring Assistance
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including muscle weakness, difficulty walking, and a history of falls, did not have their call light within reach on multiple occasions. The resident required partial to moderate assistance with activities of daily living, as documented in their Minimum Data Set. During observations, the call light was found on the floor behind the bed and later dangling off the side of the bed, both times out of the resident's reach. The resident expressed frustration about not being able to use the call light to request assistance, such as lowering the television volume, and noted that the privacy curtain was usually drawn, making it difficult to see staff passing by. The resident also mentioned that their roommate kept the television volume high, making it unlikely that staff would hear them if they called out. Staff interviews confirmed the call light was not within reach during these observations. A licensed nurse and a certified nurse assistant both acknowledged the issue when it was pointed out. The Director of Nursing stated that the expectation was for all call lights to be within reach of residents. A review of the facility's policy on answering call lights indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide Appropriate Pain Management During Wound Care
Penalty
Summary
A resident with a history of chronic pain and a stage 4 sacral pressure ulcer was admitted to the facility and was under hospice care. The resident had physician orders for pain assessment every shift using a standardized pain scale and for administration of morphine or oxycodone as needed for moderate to severe pain. The resident's care plan specified that pain should be managed to a tolerable level, with relief expected after comfort measures or medication. During wound care, the resident expressed significant pain, stating her pain was 'a lot,' and was observed moaning and crying throughout the procedure. The nurse performing the wound care did not use a pain scale to assess the resident's pain, nor was there documentation of pain medication being administered prior to the treatment, despite the resident's clear expressions of discomfort. The nurse also prolonged the resident's pain episode by not having all necessary supplies at hand, resulting in multiple trips to the treatment cart and extending the time the resident had to remain in a painful position. The Director of Nursing confirmed that the facility's expectation was for nurses to pre-medicate residents for pain prior to wound care and to use a pain scale for assessment. Facility policies required pain assessment using a standardized approach and for wound care supplies to be prepared in advance and within reach. These protocols were not followed, resulting in unmanaged pain for the resident during wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident diagnosed with chronic osteomyelitis and bacteremia. The resident was under Enhanced Barrier Precautions (EBP) for activities such as wound care, which required the use of personal protective equipment (PPE) including gowns. However, during an observation, a licensed nurse performed wound care on the resident without donning a gown, which was confirmed by the nurse as a deviation from the required protocol. Interviews with the Infection Preventionist and the Director of Nursing further confirmed that gowns are mandatory during high-contact care activities like wound care under EBP. The facility's policy, effective April 2024, mandates the use of gowns and gloves during such activities to mitigate infection risks. The failure to follow these guidelines had the potential to increase the spread of infection, as noted in the report.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency and local law enforcement, and did not report the results of the investigation within the required five working days. The incident involved a resident who was admitted with medical diagnoses including hemiplegia and hemiparesis following a cerebral infarction. The resident, who had an intact cognitive status, reported that a Certified Nursing Assistant (CNA) disrespected him by pushing her fingers into his chest and making demeaning comments. This grievance was documented, but the facility did not follow through with the necessary reporting procedures. Interviews with various staff members revealed a lack of consensus on the severity of the incident. The Director of Staff Development acknowledged receiving the grievance but did not report it further, considering it a customer service issue rather than abuse. Similarly, other staff members, including a Licensed Nurse and the Social Services Director, did not perceive the incident as abuse and did not take further action. The facility's policy on abuse prevention requires investigation and reporting of all possible incidents of abuse, but this protocol was not followed in this case.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative (RR) of a change in condition and emergency hospital transfer for one of the sampled residents. The resident, who had a history of memory problems with agitation and aphasia, exhibited aggressive and combative behaviors, prompting a transfer to the emergency department. Despite the facility's policy requiring notification of the RR in such situations, the RR was not informed until contacted by the hospital the following day, leading to feelings of astonishment and upset. The clinical record indicated that the physician was notified and an order for hospital transfer was obtained, but the documentation showed discrepancies in the timing of the RR notification. The Licensed Nurse (LN) involved acknowledged these discrepancies and the lack of documentation regarding the RR's response. The Director of Nursing (DON) confirmed that the RR should have been notified after the physician, as per facility policy, and recognized the RR's reaction upon learning of the transfer from the hospital.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services according to professional standards of quality for three residents. Resident 39 and Resident 240 were administered oxygen at rates inconsistent with their physician's orders and care plans. Resident 39 was observed receiving four liters of oxygen per minute instead of the prescribed two liters, and Resident 240 was observed receiving five liters per minute instead of the prescribed two liters. Both discrepancies were confirmed by licensed nurses and the Director of Nursing, who acknowledged that the incorrect oxygen administration could lead to carbon dioxide retention due to their diagnoses of COPD and acute respiratory failure. The facility's policy on oxygen administration was not followed, as it requires verification of physician's orders for oxygen administration. Resident 5 was not provided with an incentive spirometer as ordered by the physician. Despite a physician's order for the use of an incentive spirometer three times a day to improve lung function, the device was not available in Resident 5's room, and the resident had never seen or used it. Licensed Nurse 3 confirmed the absence of the device and admitted to not instructing Resident 5 on its use. The Director of Nursing stated that nursing staff are expected to follow physician's orders accurately and ensure that residents receive the prescribed treatments. The facility's policies on carrying out physician orders and incentive spirometry were not adhered to in this case.
Failure to Ensure Accurate Accountability and Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability and effective storage of controlled medications for three out of four residents. Specifically, the controlled medications for Residents 6, 189, and 190 did not reconcile between the Controlled Drug Record (CDR) and the Medication Administration Record (MAR). For Resident 6, tramadol was signed out on the CDR but not documented on the MAR for specific dates in February and March 2024. Similarly, for Resident 189, hydrocodone/APAP was signed out on the CDR but not documented on the MAR for a specific date in March 2024. For Resident 190, oxycodone was signed out on the CDR but not documented on the MAR for multiple dates in March 2024. During an interview, the Director of Nursing (DON) confirmed that nursing staff were expected to document on both the MAR and CDR whenever a controlled medication was administered. The facility's policy and procedure for controlled medications, dated May 2022, also indicated that the licensed nurse administering the medication should immediately enter the date, time, amount administered, and their signature on both the accountability record and the MAR. The failure to follow these procedures resulted in inaccurate accountability of controlled medications and potential for abuse or misuse.
Medication Administration Errors
Penalty
Summary
The facility had a 10.42% medication error rate when five medication errors out of 48 opportunities were observed during a medication pass for two residents. Licensed Nurse 1 (LN 1) administered Trelegy Ellipta to Resident 5 without instructing the resident to rinse and spit after use, contrary to the manufacturer's specifications. LN 1 acknowledged that she normally instructs residents to rinse and spit to prevent fungal infections but failed to do so in this instance. Licensed Nurse 4 (LN 4) made several errors while administering medications to Resident 189. LN 4 did not prime the insulin glargine and insulin lispro pens before administration, did not swab the rubber cap of the heparin vial with an alcohol pad, and administered heparin with a large air bubble in the syringe. Additionally, LN 4 administered insulin lispro after Resident 189 had eaten breakfast, contrary to the physician's order to administer it before meals. LN 4 also prepared a multivitamin with minerals instead of the prescribed plain multivitamin. The Director of Nursing (DON) confirmed that the correct administration of injectable medications is expected and part of the nursing staff's competency. The facility's policies and procedures for administering medications and subcutaneous medication administration were reviewed, indicating that medications should be administered safely, timely, and as prescribed, including verifying the right dosage and expelling air from syringes.
Failure to Provide Adaptive Eating Utensil
Penalty
Summary
The facility failed to provide a special eating utensil, specifically a rocker knife, for a resident with left side hemiplegia, muscle weakness, and lack of coordination. Despite the resident's meal ticket indicating the need for a rocker knife, the resident was observed without it during meals. The resident was unable to cut her food using a regular knife, which led to her not eating her lunch. This was confirmed by multiple staff members, including a Restorative Nurse Assistant and Central Supply, who acknowledged the absence of the rocker knife and the resident's inability to cut her food with a regular knife. Further review of the resident's records, including the Minimum Data Set, Order Summary Report, and Nutrition Care Plan, indicated that the resident required a rocker knife as adaptive equipment to promote self-feeding independence. Interviews with the Kitchen Dietary Manager and the Director of Nursing revealed that the facility never had a rocker knife available, and staff failed to notify the appropriate personnel about the unavailability of the utensil. This oversight contributed to the resident's weight loss and increased dependence on staff for feeding assistance.
Failure to Maintain Sanitary Food Storage and Handling
Penalty
Summary
The facility failed to store food in a sanitary manner, as observed during a survey. Dietary staff were found not using hair nets and beard guards while in the kitchen, which is against the facility's dress code policy. Specifically, a Dietary Aid and the Kitchen Dietary Manager were observed without the required hair restraints. The Kitchen Dietary Manager confirmed that hair nets and beard guards are mandatory while in the kitchen. Additionally, several food items in the reach-in refrigerator and dry storage were not labeled with their open dates, and some were expired. This included two loaves of bread and heads of lettuce without date labels, expired left-over beef puree, and six opened bread bags without open date labeling. Furthermore, a Dietary Cook was about to reheat expired left-over roast beef, unaware of its expiration. The facility's policies on labeling, dating, and handling leftover foods were not followed, as confirmed by the Food Service Efficiency Consultant.
Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to follow proper infection control practices in two observed instances. First, a dietary cook did not perform proper hand hygiene while in the kitchen. The cook was observed washing her hands without using soap and scrubbing for less than 20 seconds, and pat drying her hands using her clothes. This was confirmed by the Food Service Efficiency Consultant, who stated that staff must perform hand washing before providing food services. The facility's policy on hand washing, dated 2023, indicated that hands need to be washed with soap and water for at least 20 seconds before starting work in the kitchen. Second, a licensed nurse did not change gloves and perform hand hygiene during wound care for a resident with diabetes and a stage 4 pressure ulcer. The nurse was observed removing the old dressing, cleaning the wound, and applying a new dressing without changing gloves or performing hand hygiene between these steps. This was confirmed by the Director of Nursing, who stated that staff are required to change gloves from dirty to clean during the wound care process. These failures had the potential to spread infection within the facility.
Failure to Ensure Physician Approval for Self-Administered Medications
Penalty
Summary
The facility failed to ensure that self-administered medications kept at the bedside for one resident were reviewed and approved by a physician. During an observation, a Licensed Nurse (LN) was seen administering medications to a resident who had an albuterol inhaler on their bedside table without a pharmacy label. The resident mentioned that the inhaler was brought from the hospital and was not providing relief. Upon review, it was confirmed that there was no physician's order for the albuterol inhaler or for the resident to self-administer medications. The LN acknowledged that a physician's order was necessary for safe self-administration and that the medication should have been stored in a lockbox. The Director of Nursing (DON) stated that medications brought in by residents should be given to family members or securely stored with the DON. A resident assessment and a physician's order are required to allow self-administration of medication, and the medication should be stored in the medication cart. The facility's policies and procedures were reviewed, indicating that medications brought in by residents must be identified and approved by a physician or pharmacist, and residents may self-administer medications only if deemed safe by the attending physician and the Interdisciplinary Care Planning Team.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident 62's respect and quality of care were maintained when the resident was unable to reach the call light. Resident 62, who was admitted in 2024 with diagnoses including asthma and a left lower limb infection, reported during an observation and interview that she could not reach the call light while in her wheelchair because it was located on the other side of her bed. The Director of Nursing confirmed that the call light should have been within reach of the resident. The facility's policy, dated December 2022, indicated that the call light should be within easy reach of residents when they are in bed or confined to a chair.
Failure to Provide a Homelike Environment for Resident
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for Resident 37, who had a history of urinary tract infection, major depressive disorder, and paraplegia. Upon readmission from the hospital, Resident 37's room was cluttered with multiple personal belongings, including bags and boxes, which had not been unpacked since her return. Despite Resident 37's requests for assistance, the Social Services Assistant (SSA) and other staff members did not help her unpack, leading to a disorderly and cluttered room. This clutter prevented housekeepers from properly cleaning the area and created an unsafe environment for Resident 37, who was unable to adjust her bed or use the call light due to the clutter. The Director of Staff Development (DSD) and Licensed Nurse 1 (LN 1) acknowledged Resident 37's requests but failed to communicate them to the appropriate personnel, resulting in the continued disarray of her room. Resident 37's care plan indicated a need for a safe environment free from clutter due to her risk of falls related to paraplegia and gait/balance problems. However, the facility did not adhere to this care plan, as evidenced by the cluttered state of her room and the lack of assistance provided to unpack her belongings. The Director of Nursing (DON) confirmed that the SSA should have filed a grievance form or resident concern form and followed up until the problem was resolved. The facility's policy on providing a homelike environment was not followed, leading to Resident 37's increased anxiety and discomfort due to the disorderly state of her room and the inability to access her personal items.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for three residents. Resident 70's most recent quarterly MDS assessment did not reflect his impaired vision, despite observations and interviews indicating he had vision issues and had requested to see an eye doctor. The Activities Director and Social Services Assistant confirmed that Resident 70 used eyeglasses and had been requesting an optometrist visit, which had not been arranged yet. The Director of Nursing acknowledged that the MDS assessment should accurately reflect the resident's condition to develop an appropriate care plan. Resident 64's MDS inaccurately indicated that she had no feeding tube, despite her being observed with a feeding tube and her medical records confirming the need for enteral feeding due to gastrointestinal dysfunction. The MDS Coordinator and Director of Nursing confirmed the inaccuracy, noting that it could impact data collection, billing, and the delivery of specific care areas. The facility's policy requires that any person completing a portion of the MDS must certify its accuracy, which was not adhered to in this case. Resident 88's MDS inaccurately indicated that he was discharged to a hospital, while records and interviews confirmed he was discharged home with his daughter. The MDS Coordinator and Director of Nursing verified the discrepancy, acknowledging that the discharge status in the MDS was incorrect. These inaccuracies in the MDS assessments had the potential to affect the residents' care and interventions, as the assessments guide the development of care plans and other critical aspects of resident management.
Failure to Develop and Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and provide a baseline care plan (BCP) and written summary for one of 23 sampled residents (Resident 240) within 48 hours after admission. Resident 240 was admitted to the facility on [DATE], but the BCP was not completed until 3/19/24, and a printed summary was not provided to the resident or her representative. During an interview on 3/26/24, the Director of Nursing (DON) confirmed that the BCP was not completed within the required timeframe and acknowledged that the summary was not provided in writing. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their representative.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a diagnosis of pulmonary dysfunction due to COPD exacerbation. The resident had physician's orders for the use of an incentive spirometer three times a day for 10 days and for the use of compression stockings for 10 hours daily. However, these orders were not included in the resident's care plan, which had the potential for the orders to be missed and not implemented. This was confirmed during interviews and record reviews with the licensed nurse, medical records director, and director of nursing, who all acknowledged the absence of the required care plans. The deficiency was identified during a review of the resident's medical records and order summary reports, which showed the specific orders for the incentive spirometer and compression stockings. Despite the facility's policy and procedure requiring comprehensive care plans to be developed and implemented for each resident within seven days, the care plans for these orders were not found. The director of nursing stated that she expects her staff to develop and revise care plans as necessary, but this was not done in this case.
Failure to Expel Air from Syringe Resulting in Incorrect Heparin Dose
Penalty
Summary
The facility failed to provide care and services in accordance with acceptable professional standards of quality for Resident 189 when nursing staff did not expel air from a syringe, resulting in an incorrect dose of heparin being administered. During a medication pass observation, Licensed Nurse 4 (LN 4) was seen preparing ten medications for Resident 189, including heparin 5000 units/milliliter. LN 4 withdrew the medication and pulled the plunger back to the 1 milliliter measurement marker, but a large bubble was observed in the syringe, causing the heparin to be at the 0.88 milliliter measurement marker. LN 4 confirmed she had finished preparing the dose and administered the heparin into Resident 189's left lower abdomen without expelling the air from the syringe. A review of Resident 189's medical record indicated a physician's order for heparin 5,000 units/milliliter, to be injected 1 milliliter subcutaneously every 24 hours for deep venous thrombosis. During an interview, LN 4 acknowledged that she was unable to remove the bubble from the syringe and agreed that Resident 189 did not receive the correct dosage of heparin. The Director of Nursing confirmed that correctly administering injectable medications was an expectation and part of nursing staff's competency. The facility's policy and procedure for administering medications and subcutaneous medication administration both indicated that air should be expelled from the syringe before administering the medication.
Failure to Arrange Eye Doctor Consultation for Resident
Penalty
Summary
The facility failed to assist Resident 70 with the arrangement of an eye doctor consultation, which had the potential to delay the delivery of care to improve the resident's vision. Resident 70, who was admitted in June 2023 with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was observed squinting while watching television and reported that the reading glasses provided by the Activities Director caused headaches. Despite requesting to see an eye doctor, no consultation had been arranged by the time of the survey in March 2024. The Social Services Assistant (SSA) acknowledged that the last follow-up on Resident 70's request was documented in August 2023, with no further updates. The Director of Nursing (DON) confirmed that staff are expected to assess and identify residents' needs, including vision impairments, and assist in obtaining necessary services promptly. The facility's policies and procedures stipulate that staff should refer visually impaired residents for vision evaluations and provide medically-related social services to maintain or improve residents' abilities to meet everyday physical needs.
Failure to Follow Physician's Treatment Order for Pressure Ulcer
Penalty
Summary
The facility failed to follow a physician's treatment order for a stage 4 pressure ulcer for one resident. The resident, who was admitted in 2024 with diagnoses including diabetes and a stage 4 pressure ulcer, had a specific treatment order for the ulcer on the left posterior leg. The order required cleansing with normal saline, patting dry, applying collagen, hydroferra blue, triad cream to the margin, and a silicone border foam dressing with skin prep every Monday, Wednesday, and Friday during the day shift. However, during an observation, a licensed nurse did not use skin prep and collagen as prescribed while performing the dressing change. This was confirmed by the nurse during the observation and later by the Director of Nursing, who stated that staff are expected to follow physician orders for wound care. The resident's care plan, dated 3/25/24, indicated the presence of a pressure ulcer on the left leg and required the administration of treatment as ordered. The facility's policy on pressure ulcers, dated 4/2022, also indicated that the physician or nurse practitioner would order pertinent wound treatment, including wound cleaning and the application of topical agents. The failure to follow the prescribed treatment order had the potential to worsen the resident's current pressure ulcers.
Improper Checking of Roam Signal Device
Penalty
Summary
The facility failed to properly check the functionality of a roam signal device for a resident diagnosed with paranoid schizophrenia and Alzheimer's disease. The resident, who exhibited exit-seeking behavior, was observed wearing the device and propelling himself towards the dining room. The order summary indicated that the device should be checked for placement every shift and functionality every afternoon shift. However, the Licensed Nurse interviewed was unsure how to check the functionality and which staff was responsible for this task. The Director of Nursing confirmed that the device was checked by taking the resident near the main door, but acknowledged the need for a proper method to ensure the resident's safety. The facility's policy on assistive devices and equipment indicated that the facility provides, maintains, trains, and supervises the use of such devices for residents. Despite this policy, the improper checking method placed the resident at an increased risk for elopement. The Director of Nursing admitted awareness of the current checking method and recognized the necessity for a safer procedure. The failure to implement a proper checking method for the roam signal device led to the deficiency noted in the report.
Failure to Ensure Routine Midline Catheter Care
Penalty
Summary
The facility failed to ensure the routine care and dressing change of a midline catheter for one resident. During an observation and interview, it was noted that the dressing on the resident's midline catheter was dated 21 days prior, indicating it had not been changed as required. The Licensed Nurse confirmed that the dressing should have been changed. A review of the resident's physician's orders and medical records revealed no orders for flushing and locking the midline catheter or for changing the dressing. The Director of Nursing acknowledged that the nurses failed to add preset orders to the active orders, leading to the omission of necessary midline catheter care until the catheter was removed. This failure increased the risk of central line-associated bloodstream infections for the resident. The facility's policies and procedures for central venous catheter care and dressing changes were reviewed and indicated specific guidelines for flushing, locking, and changing dressings. These guidelines were not followed, as evidenced by the lack of documentation in the resident's medical records regarding the midline catheter care. The Director of Nursing confirmed that the nurses did not follow the facility's policies, resulting in the missed care and increased risk of infection for the resident.
Unattended Medications on Med Cart
Penalty
Summary
The facility failed to ensure medications were not stored on top of medication carts when left unattended. During an observation, a Licensed Nurse (LN 7) was seen preparing medications at a med cart in the hallway. LN 7 left the med cart unattended to locate a missing medication, leaving a bubble pack containing six hyoscyamine 0.125 mg tablets on top of the cart. LN 7 confirmed that the bubble pack was left unattended and not securely stored. The facility's policy and procedure for administering medication, dated April 2023, explicitly stated that no medications are to be kept on top of the cart.
Failure to Ensure Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure the competency of Food and Nutrition Services staff, specifically Dietary Cook 1 (DC1), in two critical areas. First, DC1 did not correctly follow the cooling down process for turkey, as evidenced by the cooling log being documented as complete while the turkey was still cooking in the oven. This was confirmed by both the Kitchen Dietary Manager (KDM) and the Food Service Efficiency Consultant (FSEC). Additionally, there was no cooling down process training or in-service provided to DC1 in 2023, as confirmed by the KDM. Second, DC1 demonstrated a lack of knowledge and adherence to proper procedures for pureeing food. During observations, DC1 did not use recipes, measuring tools, or utensils while pureeing beef, vegetables, starch, and bread biscuits. DC1 confirmed not knowing the correct puree consistency and not using any measurable tools or recipes. This was further corroborated by the FSEC, who stated that dietary staff should use recipes and measuring utensils when pureeing food. The facility's policy requires Food and Nutrition Services employees to demonstrate competency in food safety principles and job skills, which was not adhered to in this case.
Failure to Use Recipes and Measuring Tools for Pureed Diets
Penalty
Summary
The facility failed to prepare food in a manner that conserves nutritive value when recipes were not followed, and measurable tools/utensils were not used for pureed beef, pureed vegetable, and pureed starch. This deficiency was observed during the preparation of lunch, where the dietary cook used unmeasured amounts of ingredients and did not follow any recipes for pureeing beef, vegetables, sweet potatoes, and bread biscuits. The dietary cook confirmed that no measuring tools or recipes were used during the preparation process. The Food Service Efficiency Consultant confirmed that dietary staff should have used recipes and measuring utensils to maintain the nutritive value of the food. The facility's policy on food preparation, dated May 2023, indicated that food should be prepared by methods that conserve nutritive value, flavor, and appearance. This failure had the potential to decrease the nutrients in the food served and decrease food intake for five residents who received a pureed diet out of a facility census of 90.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was complete and posted on a daily basis at the beginning of each shift for a census of 90 residents. The Staffing Coordinator (SC) posted staffing information in the afternoon without including the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was observed on multiple occasions, including when the staffing information for the current date was not posted in the morning. The SC confirmed that the Direct Care Service Hours Per Patient Day (DHPPD) forms for several dates did not include the required information and that staffing information was not posted on one of the dates. The facility's policy required daily posting of nurse staffing data for each shift, but this was not adhered to, as confirmed by the SC.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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