Rialto Post Acute Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to identify signs of a developing pressure ulcer in a timely manner for one resident. The resident was admitted with significant medical conditions including quadriplegia, multiple sclerosis, acute respiratory failure, and lymphocytosis. On a documented change in condition evaluation dated March 3, 2026, the Wound Treatment Nurse (WTN) recorded that a CNA reported a pressure injury on the resident’s right hip. Upon assessment, the WTN identified a stage 3 pressure injury on the right hip, measuring 3.7 x 3 x 0.3 cm, with 90% granulation tissue and 10% slough, and obtained treatment orders from the MD. The WTN stated that the resident’s right hip area had been clear with no prior skin breakdown before this finding. CNA 1 reported that staff perform daily skin checks during care and report any skin changes to charge nurses, and that residents are repositioned every two hours to prevent skin breakdown and pressure ulcers. The DON stated that staff are supposed to conduct daily skin inspections during personal care to identify and report any skin changes, and acknowledged being informed of the new stage 3 pressure injury on the resident’s right hip on March 3, 2026. Review of the facility’s “Prevention of Pressure Injuries” policy, revised April 2020, showed that staff are required to inspect the skin daily during personal care or ADLs and identify any signs of developing pressure injuries, such as non-blanchable erythema. The DON acknowledged the policy and stated she expected staff to have provided care sooner.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to ensure adequate supervision and a safe environment to prevent elopement for one resident who had Parkinson’s disease, sequelae of cerebral infarction, lack of coordination, and a high fall risk. The resident’s records showed moderate cognitive impairment, disorientation, multiple recent falls, and need for assistance with mobility. The admission and therapy records also described weakness, impaired balance, and the need for contact guard assistance due to instability and right-sided weakness. On the morning of the incident, the resident told staff he wanted to go outside for fresh air. An out-on-pass order was obtained after the resident had already left the building, and the order was entered approximately three hours after he exited. Facility video showed the resident walking from his room toward the rear emergency exit while two nursing staff stood near the nurses’ station. The resident passed them without being approached, redirected, or accompanied, removed an elastic band placed across the emergency exit door, and exited through the alarmed door without staff assistance or supervision. The video further showed the resident walking outside with an unsteady gait and continuing away from the facility. The surveillance review and staff interviews showed no staff response to the alarm, no attempt to stop the resident, no staff member turning off the alarm, and no staff following the resident. The resident was later found by law enforcement approximately one mile from the facility in a wash, with blood on his clothing, lacerations to his feet and knees, and a large bruise on his left hip. Hospital records documented abrasions to both knees and feet and bruising to the left hip, and the resident was confused and unable to clearly explain what happened.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to ensure a dignified dining experience for two sampled residents when CNAs stood over them while assisting with meals. Resident 94 was admitted with dysphagia and hemiplegia/hemiparesis following cerebrovascular disease affecting the left non-dominant side. During observation in the resident's room, CNA 4 brought the lunch tray to the bedside table and fed Resident 94 while standing over the resident. CNA 4 stated there was no chair available and did not go out of the room to look for one. Resident 185 was admitted with epilepsy and cerebral infarction. During observation, CNA 1 raised the bed to waist level, positioned himself next to the resident, and fed the resident while standing. CNA 1 stated he normally stands while feeding residents but that it is not right and he is not supposed to be standing while feeding. On another observation, CNA 2 was standing next to Resident 185 while feeding her, and CNA 2 acknowledged she should not be standing while feeding residents. LVN 4 also observed this and stated CNA 2 should not be standing when feeding a resident and should be sitting to promote respect and dignity. The DON later reviewed the facility's resident rights policy and acknowledged the policy was not followed and that it should have been.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to keep a resident’s electronic health record confidential when an LVN left Resident 96’s information visible on a computer screen in the hallway. During observation on January 7, 2026, at 5:36 AM, LVN 7 went into Resident 96’s room to administer medication and left the computer screen open and unattended on the medication cart in Wing A. The screen displayed Resident 96’s name, picture, medication administration record, vital signs, and weight, all visible to anyone in the hallway. LVN 7 acknowledged and verified the private health information shown on the unattended screen. Resident 96’s admission record showed diagnoses including peripheral venous insufficiency, congestive heart failure, and urinary tract infection. During interview, when asked who is responsible for keeping resident information confidential, LVN 7 stated that it is not my responsibility for something, someone else sees. Later that day, the DON reviewed the facility’s Computer Privacy Screen Policy, dated January 14, 2025, which stated that staff must log off or lock computers when unattended. The DON stated that the policy was not followed and that the expectation is for staff to maintain resident privacy.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to develop and implement care plans for two residents. Resident 161’s admission record showed diagnoses including COPD, hypertensive heart disease, and acute kidney failure. During observation on January 5, 2026, Resident 161 was sitting on his bed with a bottle of Tums Oral Tablet Chewable at bedside. The LVN stated the Tums should not be kept at bedside and later stated there was no care plan developed to keep medication at bedside for Resident 161. Resident 161’s physician order dated December 18, 2024, directed Tums 500 mg by mouth every 12 hours as needed for GERD, give 2 tablets. The DON reviewed the facility’s Medication Storage and Labeling Policy & Procedure and acknowledged the policy was not followed and a care plan should have been created. Resident 23’s admission record showed diagnoses including T2DM, chronic kidney disease, and hypertension. During an interview on January 5, 2026, Resident 23 stated he smokes outside in the designated area and gets his cigarette from nurses on duty. On January 6, 2026, Resident 23 was observed outside the Activities room smoking unsupervised, and the Activities Specialist confirmed he had been smoking outside unsupervised. The Activity Director stated she was not aware there was no care plan for Resident 23 for unsupervised smoking. The MDS Director stated that during the admission assessment Resident 23 denied being a smoker, but he should have been re-assessed and a care plan should have been created. The DON reviewed the facility’s smoking and tobacco use policy, which stated smoking status and safety assessments are documented and supervision requirements and restrictions are included in the resident’s care plan, and acknowledged the policy was not followed and a care plan should have been created.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to maintain accurate records of controlled medications for one of six sampled medication carts, Medication Cart A-1, when the Narcotic Count Sheet for January 2026 had one missing signature for the outgoing licensed nurse on January 2, 2026, night shift. During a concurrent observation and interview on January 6, 2026, at 9:58 AM, an LVN reviewed the narcotic log in Wing A at Medication Cart A-1 and verified that the outgoing nurse’s signature was missing. The LVN stated that the log should have been signed by two LVNs verifying the correct number of narcotics in the medication cart. During a concurrent interview and record review, the facility’s policy titled Controlled Substances (Narcotic) Signing Policy & Procedure, dated January 14, 2025, was reviewed and stated that controlled substances are counted and reconciled at every shift change and that two licensed nurses perform the count and verify accuracy. The DSD stated the policy was not followed and that the counts should have been verified by both nurses, with a missing signature potentially indicating an incorrect count or missing narcotic that should have been reported to the DON. The DON also stated that the policy was not followed.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to ensure medication storage was properly secured when one LVN left the keys to Medication Cart A-1 unattended on top of the cart in the hallway in Wing A. During a concurrent observation and interview, the LVN was preparing medication and then went into Resident 96's room to discuss medication, leaving the cart keys outside the room on top of the cart. The LVN confirmed the keys were the ones used to open the medication cart and stated they should not be left unattended, although they were kept inside the binder on the cart so other LVNs could open the cart if needed. Resident 96's admission record showed diagnoses including peripheral venous insufficiency, congestive heart failure, and urinary tract infection. During interview and record review, the DON reviewed the facility's Medication Cart Key Control Policy, dated January 14, 2025, which stated each medication cart key must remain with the assigned staff member at all times and must never be left unattended, including on carts, desks, or in drawers. The DON stated the policy was not followed and explained that keys should be stored on staff to prevent unassigned personnel from gaining access to medications.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to ensure a physician-ordered therapeutic diet was provided for one sampled resident, Resident 7, when nutritional supplements listed on the meal ticket were omitted from the lunch tray. Resident 7’s admission record showed diagnoses including type 2 diabetes mellitus with hyperglycemia, essential hypertension, and anemia. A physician order dated November 14, 2025, directed Health Shake three times a day for weight management, 4 oz with meals, and Sherbert BID at lunch and dinner. During a concurrent observation and interview on January 5, 2026, at 12:30 PM, CNA 3 served Resident 7’s lunch tray, and the meal ticket for that tray instructed 4 oz Health shake and sherbert ice cream. CNA 3 stated the health shake and ice cream were not served and did not come from the kitchen, and Resident 7 stated she did not receive the health shake or ice cream. CNA 3 later stated she did not know the resident gets it every day. During a later interview, the DD and DC reviewed the facility’s physician order policy and stated staff should have followed what was on the meal ticket and served what was ordered by the doctor.

Penalty

Inspection fine: $15,340

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

Summary

Proper infection prevention and control practices were not followed when a CNA entered Resident 184's room after emptying Resident 67's urinal and used the same gloves to turn off the call light and open the privacy curtain without performing hand hygiene. Resident 67 had been admitted with diagnoses including UTI and ESBL resistance, and the CNA acknowledged she should have returned the urinal, removed her gloves, and performed hand hygiene before answering the other resident's call light. The DON later stated the facility policy was not followed and that the CNA should have disinfected her hands before helping other residents. Resident 184, who had diagnoses including SIRS of non-infectious origin without acute organ dysfunction and abnormalities of gait and mobility, was observed with an IV catheter on the left wrist that was not labeled. During the observation, LVN 1 verified there was no date, time of insertion, or staff initials on the dressing, and RN 2 also verified the IV dressing was unlabeled. The DON reviewed the facility's IV care and maintenance policy and stated that IV dressings are to be clean, dry, intact, and dated, and that all IVs should be labeled with no exceptions. Resident 89, who had diagnoses including hemiplegia, hemiparesis, T2 DM, and a G-tube, was observed with a water bag hanging for enteral hydration that was dated more than 24 hours earlier. The resident was receiving tube feeding and hourly water flushes via pump, and LVN 5 verified the water bag had been hung beyond the 24-hour limit stated in the manufacturer's instructions. The DON stated the facility did not have a policy specifying hang time for G-tube water bags, but nurses should follow the doctor's orders and the manufacturer's instructions, and acknowledged the instruction was not followed.

Penalty

Inspection fine: $15,340

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

Summary

The facility failed to ensure call lights were within reach for two sampled residents, Resident 120 and Resident 24. Resident 120 was admitted with diagnoses including end stage renal disease and a history of falling. During observation in Resident 120’s room, the resident was lying in bed awake and stated she did not know where the call light was. The CNA at bedside also could not find it at first, then located it on top of the roommate’s oxygen tank and placed it on Resident 120’s bed. The DON reviewed the facility’s Call Light Policy and Procedure and acknowledged that the policy was not followed. Resident 24 was admitted with diagnoses including bilateral primary osteoarthritis, hypertension, and depression. During observation in Resident 24’s room, the resident was sitting at the edge of the foot of the bed, crying, and stated she needed assistance to go out of the room but could not find her call light. The call light was found at the head of the bed under a pillow. An LVN stated the call light must be within the resident’s reach and accessible to them. The DON later reviewed the facility’s Call Light Policy and Procedure and acknowledged the policy was not followed and should have been.

Penalty

No penalty information released

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

Summary

A Licensed Vocational Nurse (LVN) failed to properly cross-check and reconcile discharge medications according to facility policy, resulting in the transfer of two medications—Atorvastatin and Eliquis—prescribed for one resident to the caregiver of another resident who was not prescribed these medications. The error occurred during the discharge process, when the LVN inadvertently provided two medication carts belonging to the first resident to the caregiver of the second resident. The facility’s policy required nurses to reconcile all pre-discharge medications with the resident’s post-discharge medications and document the reconciliation, but this step was not completed. The resident who was supposed to receive the medications had a history of hypertensive heart disease with heart failure and no mental impairment, while the resident who mistakenly received the medications had diagnoses of encephalopathy and cirrhosis of the liver, with moderate cognitive impairment. The error was discovered after the family of the second resident reported receiving medications not prescribed to their family member, prompting notification of facility leadership. Review of medical records confirmed that the medications in question were not prescribed to the second resident, but were prescribed to the first.

Penalty

No penalty information released

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

Summary

Two Certified Nursing Assistants (CNAs) failed to maintain the dignity and privacy of a resident diagnosed with Alzheimer's dementia during a transfer in bed. The surveyor observed that the resident's abdomen and diaper were exposed because the privacy curtain was not drawn and the door to the room was left open, allowing potential exposure to anyone passing by. Both CNAs acknowledged during interviews that the resident's privacy was not upheld and that the situation was inappropriate. The Director of Nursing confirmed that this was a violation of facility guidelines regarding resident privacy and dignity. Facility policy reviewed indicated that residents are to be treated with dignity and respect at all times.

Penalty

Inspection fine: $8,28125 days payment denial

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

Summary

A deficiency occurred when the facility failed to provide required one-on-one supervision and did not apply a wander guard for a newly admitted resident with dementia and a history of elopement. The resident, who had recently been released from jail and was on parole, was admitted with diagnoses including dementia with agitation and a major cognitive disorder. Documentation from the hospital and admission records indicated the need for a wander guard to prevent the resident from leaving the facility unassisted, and active orders were in place for its application and monitoring every shift. Despite these orders, the wander guard was not available at the time of admission, and the facility did not provide documented evidence that one-on-one supervision was implemented as required. Nursing notes indicated that the wander guard was not applied, and interviews with the DON revealed that no staff member was assigned to monitor the resident at the time he left the facility. The elopement risk assessment for the resident was completed only after the resident had already eloped, and it incorrectly indicated that the resident was not at risk for elopement or wandering. The resident was last seen in the facility in the morning and was later found to be missing. Police were notified, and the resident was subsequently found deceased at a bus stop several miles from the facility. The facility's policies required supervision based on assessed needs and completion of elopement risk assessments upon admission, but these procedures were not followed for this resident, resulting in the resident's elopement and death.

Removal Plan

• The DON provided a 1:1 in service to RN regarding 1:1 monitoring intervention to ensure it is followed.
• The DON/ADON provided in service to the nursing staff regarding 1:1 monitoring intervention to ensure it is followed.
• Ensure all new admissions have a completed elopement risk assessment.
• The NHA/CEO conducted an inspection of current residents with wander guard to check for placement and function.
• The NHA/CEO provided in service training to Maintenance Staff regarding wander guard alarm.
• Return demonstration of Maintenance by Nursing Home Administrator/CEO was conducted and performed well.
• Licensed Nursing staff along with the Maintenance, checked all residents with wander guard with the alarm door, all functioning well.
• Wander guard will be checked by the licensed nurses for placement attached to the resident every shift and for wander guard to be functioning daily.
• The licensed nurses re-evaluated the Wander/Elopement Risk of the residents at high risk for Wandering/Elopement.
• Licensed Nurses will conduct visual check of high-risk resident for wandering/elopement every 2 hours indicating location of the resident.
• A designated RN conducted inspection of current residents on 1:1 monitoring to ensure proper implementation.
• Resident started on 1:1 monitoring every hour by assigned CNA to determine resident's activity and provide supervision.
• RN Supervisor conducting actual physical head count of residents during shift to shift endorsements.
• RN Supervisor prints the facility census indicating resident's name, room number and bed assignment.
• Outgoing RN Supervisor together with the incoming RN Supervisor will conduct actual physical head count during room rounds.
• Both RN Supervisors will confirm number of actual physical head count by writing the final count in the census print out. Both RNs will sign to confirm actual head count.
• Completed census with actual head count will be filed in the RN Supervisor binder.

Penalty

No penalty information released

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

Summary

The facility failed to report allegations of abuse involving two residents in accordance with its own policy and regulatory requirements. In the first incident, a resident with a history of hemiplegia, hypertensive heart disease, COPD, and depression alleged that a Licensed Vocational Nurse (LVN) twisted her right wrist while attempting to turn off her phone, which had inadvertently connected to the facility's overhead speaker. The resident reported the incident to the Charge Nurse and complained of a burning sensation in her wrist. The LVN denied any physical contact, stating he was only trying to help with the phone, and the incident was reported to the Administrator and Director of Nursing (DON). However, the facility did not report the allegation to the California Department of Public Health (CDPH) or other required authorities as outlined in their policy. In the second incident, another resident with diagnoses including COPD, peptic ulcer, esophagitis, and type 2 diabetes alleged that a Certified Nurse Assistant (CNA) pushed her left leg forcibly while using a mechanical lift, resulting in ongoing pain and the need for continuous pain medication. The CNA stated she only lightly touched the resident's leg to reposition it and stopped when the resident expressed pain. The incident was brought to the attention of the LVN and DON, but again, the facility did not report the allegation to CDPH or other mandated agencies. Interviews with facility leadership revealed a lack of familiarity with the reporting policy and a failure to recognize the obligation to report all allegations of abuse, regardless of staff denial or the resident's history. The Administrator acknowledged that neither incident was reported as required, citing disbelief in the allegations and lack of awareness of one of the incidents. Review of the facility's abuse investigation and reporting policy confirmed that all alleged violations must be reported immediately to appropriate authorities, which was not done in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a resident's right to access personal and medical records was upheld when a law firm requested medical records for a legal matter. The request was made for a resident who was admitted with multiple sclerosis and had a BIMS score indicating cognitive intactness. The request for records was sent via fax on January 16, 2025, but was not received by the Director of Health Information (DHI) until January 24, 2025, due to it being sent to the Business office fax number. The records were not delivered within the facility's policy timeframe of two working days, as the DHI was awaiting approval from the facility's legal team and had not contacted the law office representing the resident. The facility's Policy and Procedure for the release of information, dated November 2009, states that residents may access their records within 48 hours of a request, excluding weekends and holidays. However, the DHI acknowledged a delay in dispatching the documents, which was not in compliance with the policy. During a review and interview, the Director of Nursing and the administrator agreed with the acknowledgment of the delay, confirming the failure to meet the specified timeframe for providing the requested records.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident from physical abuse by another resident, resulting in an altercation between two residents. Resident #88, who had moderate cognitive impairment, hit Resident #216 with a plastic water pitcher after a verbal disagreement. Resident #216, who had intact cognition and a recent hip surgery, was admitted to the facility just two days prior to the incident. The altercation occurred after Resident #88 complained about Resident #216's coughing, leading to a physical confrontation where Resident #88 hit Resident #216, and Resident #216 bit Resident #88's thumb during the struggle. The facility's policy on abuse prevention was not effectively implemented, as Resident #88 had a history of changing rooms due to noise issues but no documented history of physical abuse. The staff did not anticipate or prevent the altercation, despite Resident #88's known behavioral issues. The incident resulted in Resident #216 experiencing increased pain and requiring hospital evaluation for potential complications related to their recent hip surgery. Interviews with staff and residents revealed that the facility did not adequately assess the compatibility of roommates, leading to the altercation. The staff's response to the incident included separating the residents and notifying the appropriate authorities, but the initial failure to prevent the altercation highlights a deficiency in the facility's abuse prevention measures.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their medical conditions. Resident #22, who was admitted with a diagnosis of schizophrenia, had a significant change MDS that did not reflect a completed Level II Preadmission Screening and Resident Review (PASRR), despite a letter confirming its completion. Interviews with the MDS Assistant, Director of Nursing (DON), and Administrator confirmed that the Level II PASRR should have been included in the MDS. Resident #119, admitted with hemiplegia, had a quarterly MDS that failed to indicate a diagnosis of diabetes mellitus, despite receiving insulin injections and having a care plan that acknowledged the condition. Similarly, Resident #97, admitted with multiple psychiatric diagnoses, had an MDS that did not reflect a Level II PASRR evaluation indicating a serious mental illness, despite documentation confirming its completion. Interviews with facility staff, including the MDS Assistant, DON, and Administrator, revealed that the MDS should have accurately captured the PASRR information and the residents' medical conditions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that potentially hazardous medications were secured to prevent potential accidents for two residents. Resident #104, who had severe cognitive impairment and was not assessed for self-administration of medications, was found with a cup of pills on their over-bed table. The medications were within reach, and the resident stated they had forgotten to take them. Despite multiple staff members, including LVNs and CNAs, being involved in the resident's care, none could confirm who left the medications at the bedside. The facility's policy clearly stated that medications should not be left at the bedside unless the resident was assessed and authorized for self-administration, which was not the case for Resident #104. Resident #75, who had intact cognition, was found with a roll-on applicator and a pump bottle of Pain Wizard Natural Relief at their bedside. The resident stated that the nurses were aware of the medication's presence. However, there was no order for the resident to self-administer this over-the-counter medication, nor was there an assessment completed for self-administration. Staff members, including CNAs and LVNs, were unaware of the medication's presence or mistook it for deodorant, indicating a lack of awareness and adherence to the facility's policy regarding medication storage and administration. Interviews with the facility's nursing staff, including the ADON and DON, revealed a lack of compliance with the facility's policy on medication administration and storage. The staff acknowledged that medications should not be left at the bedside without proper assessment and orders. The DON and Administrator confirmed that neither resident was appropriate for self-administration of medications, and the presence of medications at the bedside posed a risk, especially for residents with cognitive impairments or those who wander. The facility's failure to adhere to its policies resulted in a deficiency in ensuring a safe environment free from accident hazards.

Penalty

No penalty information released

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

Summary

The facility failed to provide proper urinary catheter care for a resident, leading to a potential risk of urinary tract infection or other complications. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had an indwelling urinary catheter due to a neurogenic bladder. During an observation, a CNA was seen performing catheter care without following the facility's policy. The CNA used a single towel to clean multiple areas without changing to a clean section, did not rinse the soap from the resident's skin, and failed to dry the skin before applying a clean brief. Additionally, the CNA improperly positioned the urinary catheter drainage bag by allowing it to lie flat inside a basin on the floor, which could prevent proper drainage. The CNA admitted to forgetting the correct procedure due to nervousness. The Director of Nursing and the Administrator both confirmed that the facility's policy was not followed, which included using a clean area of the cloth for each stroke, rinsing off soap, and ensuring the drainage bag was positioned correctly to facilitate gravity drainage.