Sharp Chula Vista Med Ctr Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Chula Vista, California.
- Location
- 751 Medical Center Court, Chula Vista, California 91911
- CMS Provider Number
- 555216
- Inspections on file
- 21
- Latest survey
- October 15, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sharp Chula Vista Med Ctr Snf during CMS and state inspections, most recent first.
The facility failed to accommodate residents' preferences for bus outings, which were discontinued during the COVID-19 pandemic. Despite receiving a grant for outings, the facility was unable to secure suitable transportation for residents in wheelchairs. Residents expressed a strong desire for group outings to maintain their independence and experience the outside world, but the facility did not fulfill these needs.
The facility failed to monitor and document target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. A resident was not monitored for behaviors and side effects related to antidepressants and anti-anxiety medication, while two other residents lacked proper monitoring for antidepressant medications. Another resident's antidepressant use lacked appropriate target behavior monitoring, with discrepancies between care plans and physician orders.
The facility's kitchen was found to have multiple deficiencies, including dented and expired food items, improper labeling and storage, unsanitary conditions, and inadequate personal hygiene practices. These issues were acknowledged by the facility's management and pose a risk of foodborne illnesses to residents.
A resident with arteriosclerotic cardiovascular disease transitioned from skilled to custodial care without receiving an Advanced Beneficiary Notice (ABN), despite having remaining Medicare days. The facility issued a Notice of Medicare Non-Coverage (NOMNOC) instead, failing to inform the resident of private pay options or appeal rights. Interviews revealed staff were unaware of the ABN requirement, and the facility's policy was not followed.
A resident with a history of stroke was readmitted to an LTC facility with a new stroke diagnosis, resulting in a decline in ADLs and dependence on tube feeding. Despite these changes, the facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days, as required. Staff interviews confirmed the oversight, noting that the resident's condition had significantly declined and was not expected to return to baseline within two weeks.
The facility failed to implement care plans for three residents regarding RNA ROM exercises. A resident with a traumatic brain injury received fewer passive ROM exercises than prescribed, leading to contractures. Another resident with weakness and confusion did not receive the required active and passive ROM exercises, risking contractures and decline. A third resident with stroke-related hemiparesis received fewer ROM exercises than ordered, risking further decline. Staff interviews and observations confirmed these deficiencies.
A facility failed to provide ordered ROM exercises for three residents, leading to potential worsening of contractures. One resident with a traumatic brain injury received fewer passive ROM exercises than ordered due to staffing issues. Another resident with weakness and confusion did not receive any ROM exercises despite orders. A third resident with stroke-related hemiparesis received fewer exercises than prescribed. The facility's policy emphasized adherence to the written plan for maintaining residents' independence.
The facility failed to properly store and label insulin aspart, with bottles not labeled with open dates, leading to potential interchanging and compromised medication integrity. The DON confirmed that without proper labeling, LNs could not ensure the correct use of insulin, which has a 28-day expiration upon opening.
The facility did not address transportation concerns for outdoor activities raised by the resident council in their QAPI program. Although the DON acknowledged the issue and its potential impact on residents' quality of life, it was not documented or formalized in the QAPI plan. Efforts to restore transportation options post-pandemic were ongoing, but the issue remained unaddressed in the QAPI activities.
The facility failed to implement proper infection prevention and control practices for two residents. A CNA entered a resident's room on contact precautions without PPE, and an LN did not wear a gown or change gloves during high-contact care for a resident on enhanced barrier precautions. These actions violated the facility's infection control policies, posing a risk of infection spread.
The facility failed to implement an effective antibiotic stewardship program, as the Infection Preventionist and pharmacy staff did not adequately track and monitor antibiotic use. A resident was coded for antibiotic use on the MDS but not on the MAR, indicating a gap in oversight. Interviews revealed inconsistencies in tracking processes, and there was no documented evidence of a comprehensive tracking list, contrary to the facility's policy.
A resident reported to their Responsible Party that a CNA had pulled their arm and spoken hurtfully. The Social Worker informed management, but the DON and Clinical Lead were unaware of the abuse allegation. The Clinical Lead investigated other concerns but did not address the abuse allegation, thinking it was an old incident, contrary to the facility's policy requiring immediate investigation.
A resident with a potential malignancy diagnosis was not protected from unauthorized visitors despite an APS case indicating financial exploitation concerns. The facility failed to create a care plan or communicate restrictions to staff, allowing restricted individuals to visit the resident multiple times.
Failure to Provide Resident Outings
Penalty
Summary
The facility failed to accommodate the activity preferences of its residents, specifically regarding bus outings, which were previously available before the COVID-19 pandemic. During a confidential group meeting, six residents expressed dissatisfaction with the discontinuation of these outings, which included trips to stores, parks, and other recreational locations. The facility's bus and driver were no longer available, and efforts to find alternative transportation had been unsuccessful due to cost and capacity issues. The residents emphasized their desire for group outings to experience the outside world and maintain their independence. The facility's records from February to September 2024 indicated ongoing attempts to secure transportation, but no progress was made. Interviews with staff members revealed that the facility had received a grant for bus outings, but they were still unable to find suitable transportation for residents in wheelchairs. The Director of Nursing acknowledged the residents' rights to outings and the facility's failure to accommodate these needs. The facility's policy on activities emphasized the importance of community outings and accommodating residents' preferences, which was not fulfilled in this case.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to appropriately monitor and document the target behaviors and side effects for psychotropic medications for four residents, leading to potential unnecessary medication use and adverse effects. Resident 274 was not monitored for behaviors and side effects related to two antidepressants and one anti-anxiety medication. Interviews revealed that the monitoring was subjective and lacked objective measures, and side effects were not documented in the medication administration record (MAR). The facility's policy required monitoring for suspected adverse drug reactions, which was not adhered to in this case. Residents 35 and 58 also lacked proper monitoring for behaviors and side effects associated with their antidepressant medications. For Resident 35, there was no measurement of sleep hours to evaluate the effectiveness of Trazodone, and the MAR showed zeros for a month of use. Similarly, Resident 58's record did not include a way to measure the behavior for Trazodone, and the MAR also showed zeros for a month's use. The facility's policy emphasized the importance of monitoring for adverse drug reactions, which was not followed. Resident 51's use of antidepressant medication lacked appropriate target behavior monitoring. The care plan and physician's orders did not align, leading to confusion about the target behavior for monitoring. Interviews indicated that there was no clear method to measure depressive behavior, such as continuous crying or refusal of care. The facility's policy required documentation of the necessity for medication and monitoring of its effects, which was not adequately implemented for Resident 51.
Multiple Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its kitchen, leading to multiple deficiencies. Observations revealed dented cans of thyme and hoisin sauce, which were acknowledged by the Food Service Manager (FSM) and Food Operations Manager (FOM) as potentially hazardous due to the risk of botulism. Additionally, expired food items such as wonton chips, split peas, corn starch, barley, beans, dried red chili peppers, mango mousse, parmesan cheese, and shredded zucchini were found, which the FSM and FOM agreed should be discarded to ensure food safety. Further deficiencies were noted in the labeling and storage of food items. Unlabeled and improperly sealed food items, including pasta, graham crumbs, chili peppers, bread, hash browns, and various vegetables, were observed. The FSM and FOM acknowledged the importance of labeling to ensure freshness and prevent contamination. The facility's policy on food storage was not adhered to, as evidenced by cracked and loose container lids, dust, and spilled food on container lids, which could lead to contamination. Additional unsanitary conditions included the presence of moldy strawberries, wilted produce, dirty rugs, trash in storage areas, and improper storage of ready-to-eat food above raw meat. Kitchen utensils were found with crusted food debris, and personal items such as employee drinks and belongings were improperly stored in food preparation areas. A Nutrition Assistant was observed preparing food without a hair covering, increasing the risk of contamination. These findings indicate a failure to comply with professional standards and the facility's own policies, potentially exposing residents to foodborne illnesses.
Failure to Provide Advanced Beneficiary Notice for Custodial Care Transition
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 282, who transitioned from skilled services to custodial care. Resident 282 was admitted with a history of arteriosclerotic cardiovascular disease and had remaining Medicare days when skilled services were discontinued. The facility's Assistant Director (AD 1) acknowledged that a Notice of Medicare Non-Coverage (NOMNOC) was issued instead of an ABN, despite the resident not exhausting Medicare skilled days. This oversight resulted in Resident 282 not being informed of the option to continue services under private pay or the associated costs, nor having the opportunity to appeal the decision. Interviews with facility staff, including AD 1, AD 2, and the Director of Nursing (DON), revealed a lack of awareness and proper procedure regarding the issuance of the ABN. AD 2 confirmed that the ABN provided was unsigned and that the business office had not issued an ABN document before September 2024. The DON expressed that it was crucial for the resident and their responsible party to be notified about the transition to custodial care and the implications of non-coverage. The facility's policy required an ABN to be completed and signed when services were believed to be non-covered, which was not adhered to in this case.
Failure to Complete SCSA for Resident with Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) within 14 days for a resident who experienced a significant change in condition. The resident, who had a history of stroke, was readmitted to the facility with a new stroke diagnosis and exhibited a decline in activities of daily living (ADLs), becoming dependent on tube feeding and unable to participate in the Brief Interview for Mental Status (BIMS). Despite these changes, the facility did not conduct the required SCSA, which is necessary to update the resident's plan of care based on their current health status. Interviews with facility staff, including MDS Coordinators and the Director of Nursing (DON), confirmed that the resident's condition had significantly declined in multiple areas, including mental status, nutrition, and ADLs. The staff acknowledged that an SCSA should have been completed as the resident was not expected to return to their prior levels of function within two weeks. The failure to conduct the SCSA was attributed to the completion of another comprehensive admission MDS instead, which did not adequately reflect the resident's current health status and needs.
Failure to Implement ROM Exercises as per Care Plans
Penalty
Summary
The facility failed to implement care plans for three residents concerning Restorative Nursing Assistant (RNA) range of motion (ROM) exercises. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises daily to prevent further contractures. However, the RNA weekly summary indicated that Resident 1 only received these exercises five times a week instead of the prescribed seven times. Observations showed that Resident 1's hands were contracted, and interviews with staff confirmed the lack of adherence to the care plan. Resident 45, who was admitted with weakness and confusion, required assistance with activities of daily living and was supposed to receive both active and passive ROM exercises five times a week. However, interviews with staff revealed that these exercises were not being provided as per the care plan. The care plan aimed to prevent contractures and decline in ROM, but it was not implemented, as confirmed by the staff and the Director of Nursing (DON). Resident 51, who had a stroke with right-sided hemiparesis, was dependent on staff for most activities and was supposed to receive daily ROM exercises. The RNA weekly summary showed that Resident 51 received these exercises only five times a week instead of daily. Interviews with staff and the DON confirmed that the care plan was not followed, which was necessary to prevent contractures and decline in performing activities of daily living. The facility's policies did not clearly indicate the implementation of care plans, contributing to the deficiency.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
The facility failed to consistently provide Restorative Nursing Assistant (RNA) services for range of motion (ROM) exercises as per physician's orders for three residents with limited ROM. Resident 1, who had a traumatic brain injury and was in a vegetative state, was supposed to receive passive ROM exercises seven times a week to prevent worsening of contractures. However, due to insufficient RNA staffing, Resident 1 only received these exercises five times a week, which was not in compliance with the physician's orders. Resident 45, who was admitted with weakness and confusion, was ordered to receive both active and passive ROM exercises five times a week. Despite this, there were no records of ROM exercises being provided to Resident 45 since the order was given. This oversight was confirmed by the staff, who acknowledged that Resident 45 was not enrolled in the RNA program and did not receive the necessary exercises to prevent the development of contractures. Resident 51, who had a stroke with right-sided hemiparesis, was ordered to receive daily ROM exercises. However, the facility only provided these exercises five times a week, contrary to the physician's orders. The staff confirmed the discrepancy, acknowledging that the exercises were not provided as frequently as required. The facility's policy on the Restorative Nursing Program emphasized the importance of following the written plan to help residents achieve and maintain the highest possible levels of independence, which was not adhered to in these cases.
Improper Storage and Labeling of Insulin Aspart
Penalty
Summary
The facility failed to properly store and label house supply/stock medications, specifically insulin aspart, with open dates. During an observation and interview, it was found that two boxes of insulin aspart were stored in a medication refrigerator, each containing one bottle. One box was labeled with an open date, but the bottle inside was not labeled. The other box was labeled with an expiration date, but again, the bottle inside was not labeled with an open date. This lack of labeling could lead to the interchanging of bottles, compromising the integrity of the medication. The Director of Nursing (DON) confirmed that insulin has a 28-day expiration upon opening and acknowledged that without proper labeling, Licensed Nurses (LNs) would not be able to determine which bottle corresponded to the correct box with the open date. This oversight could result in the use of ineffective medication. The facility's policy on drug storage and security requires all medications to be accurately labeled with expiration dates and stored in a manner that reduces the likelihood of error.
Failure to Address Resident Council Concerns in QAPI
Penalty
Summary
The facility failed to identify and address concerns raised in the residents council minutes regarding transportation for outdoor activities within their Quality Assurance and Performance Improvement (QAPI) program. During an interview with the QAPI program members, it was revealed that the team utilized various sources of information, including family and resident feedback, to track performance and make necessary changes to policies and procedures. However, the Director of Nursing (DON) admitted that while concerns from the resident council were discussed, they were not documented or formalized into the QAPI plan. The DON further explained that transportation for activities had been halted during the pandemic, and efforts were being made to restore these options. Despite recognizing that the lack of transportation could affect residents' quality of life, the facility did not formally address the issue in their QAPI activities. A review of the facility's QAPI policy indicated that the program should encompass all segments of care and services impacting clinical care, quality of life, and resident choice, yet the transportation issue was not included.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, leading to deficiencies in care. For Resident 52, who was on contact precautions due to a history of methicillin-resistant Staphylococcus aureus (MRSA), a CNA entered the resident's room without performing hand hygiene or wearing the required personal protective equipment (PPE), such as a gown and gloves. The CNA admitted to not knowing why the resident was on contact precautions and acknowledged the importance of following these precautions to prevent the spread of infection. Additionally, the Infection Prevention nurse did not have a complete list of residents on infection control precautions, which contributed to the oversight. For Resident 1, who was in a vegetative state and on enhanced barrier precautions (EBP) due to the use of a gastrostomy tube, a licensed nurse (LN) failed to wear a gown and did not change gloves between procedures while administering tube feeding. The LN incorrectly believed that wearing a gown was discretionary and admitted to not changing gloves after touching a potentially contaminated curtain. The Director of Nursing (DON) confirmed that the expectation was for staff to wear a gown and gloves during high-contact activities with residents on EBP to prevent infection spread. The facility's policies on standard and transmission-based precautions, as well as enhanced barrier precautions, were not followed by the staff, leading to potential risks of infection spread among residents, staff, and visitors. The lack of adherence to these protocols highlights a significant deficiency in the facility's infection control practices.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as per its own policy and procedure. During an interview and record review, the Infection Preventionist (IP) acknowledged that while the pharmacy assisted with logging and tracking antibiotics, there was no comprehensive tracking system in place. The IP was responsible for tracking urinary tract infections (UTIs), but there was no documented evidence of a line tracking list for antibiotics. This lack of documentation and oversight was further highlighted by the fact that a resident was coded for antibiotic use on the Minimum Data Set (MDS) but was not listed on the medication administration record (MAR), indicating a gap in tracking and monitoring antibiotic use. Interviews with pharmacy staff revealed further inconsistencies in the antibiotic tracking process. Pharm 1 stated that he did not track the antibiotic line list and suggested that another pharmacist might be responsible. Pharm 2 mentioned the use of antibiotic escalation but emphasized the need for a collaborative process to ensure all information is available and accessible to the healthcare team. The facility's long-term care policy on antimicrobial stewardship indicated the need for a designated committee to monitor antimicrobial use, but this was not effectively implemented, leading to a deficiency in the facility's antibiotic stewardship program.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse for one of the sampled residents, leading to an increased risk of abuse for the resident. The resident was admitted to the facility and later reported to their Responsible Party (RP) that a Certified Nursing Assistant (CNA) had pulled their arm and spoken to them in a hurtful manner. The RP communicated these concerns to the facility's Social Worker (SW), who then informed the facility's management. However, the Director of Nursing (DON) and the Clinical Lead (CL) were not aware of the abuse allegation. The CL conducted an investigation into the RP's concerns but did not investigate the abuse allegation, mistakenly believing it was related to an old incident. This oversight was contrary to the facility's policy, which mandates immediate investigation of any abuse charges.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to develop a care plan to ensure the safety of a resident who was at risk due to financial exploitation concerns. The resident was admitted with a diagnosis that included an ill-defined liver mass concerning for malignancy. An Adult Protective Services (APS) case was opened after a family member expressed concerns about the resident's financial transactions with neighbors. Despite the APS report and a psychiatrist's determination that the resident lacked the capacity for financial decision-making, the facility did not create a care plan to restrict certain visitors, leading to unauthorized visits by individuals suspected of exploiting the resident. Interviews with facility staff, including the Director of Nursing (DON), Licensed Nurses (LN), and Certified Nurse Assistants (CNA), revealed a lack of awareness and communication regarding the restricted visitors. The visitor logs showed that the restricted individuals visited the resident multiple times after the APS report was filed. The facility's policy required care plans to be reviewed and revised as needed, but no such plan was created for the resident, and there was no documentation of restricted visitors in the resident's records.
Latest citations in California
The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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