Sierra Vista Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fresno, California.
- Location
- 1715 South Cedar, Fresno, California 93702
- CMS Provider Number
- 555866
- Inspections on file
- 21
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Sierra Vista Healthcare during CMS and state inspections, most recent first.
A resident with acute encephalopathy, severe cognitive impairment, and a history of wandering eloped from the facility after staff failed to respond promptly to a triggered security bracelet alarm at the front door. The resident, who was independently mobile and assessed as high risk for elopement and falls, was later found at a family member's home and returned to the facility with the security bracelet still in place. Facility leadership confirmed that the alarm was not answered immediately, and several other residents at high risk for elopement were also present in the facility.
A resident with a fractured ankle and suspected surgical site infection did not receive a prescribed antibiotic because the physician's order, received via fax, was not provided to clinical staff as required. The breakdown in communication led to the resident missing the ordered treatment.
A resident with cognitive and physical impairments fell and fractured his hip after attempting to self-transfer from a bed with unlocked wheels. The bed had been moved by a CNA to assist the resident's roommate, and the wheels were not locked afterward. Staff interviews confirmed that bed wheels should be locked when residents are in bed.
The facility did not post the most recent survey results in an accessible location for residents and their representatives. A binder labeled CDPH Survey Results was missing the last recertification survey results. Interviews with the DON and ADM revealed a misunderstanding about the requirement to include survey results from 2022. The facility's policy on Resident Rights states that residents have the right to examine survey results, which was not met.
The facility failed to properly store and label medications, with two medication carts found unlocked and unattended, posing a risk of unauthorized access. A bottle of polyethylene glycol 3350 was left unattended on a cart, and an expired bottle of Lactulose was found in another cart, indicating lapses in adherence to storage and expiration policies.
The facility failed to maintain an infection prevention and control program, with deficiencies in sharps storage and oxygen equipment maintenance. Sharps containers were improperly stored in an accessible room, posing a risk of injury. Oxygen concentrator filters for several residents were dirty, and there was confusion about cleaning responsibilities. Additionally, a resident's oxygen tubing was not labeled with the change date, risking infection. These issues indicate a lack of adherence to infection control policies and inadequate staff training.
Five residents experienced a delay of up to 30 minutes in receiving their lunch trays while watching others eat, due to a lack of communication between nursing and dietary staff. This affected their dining experience and violated their right to dignity. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
The facility failed to implement resident-centered care plans for three residents, leading to potential risks and unmet medical needs. A resident lacked a care plan for prescribed medication, another had exposed bedrail padding despite a seizure risk, and a third had no care plan for a change in condition related to diarrhea. Staff acknowledged these oversights, which were confirmed through observations and interviews.
A resident with a fluid restriction order was allowed to consume more fluids than prescribed during a meal, leading to a deficiency in care. Staff acknowledged the oversight, and the facility's policy to check trays for correct diets was not effectively followed.
The facility exceeded the acceptable medication error rate with two incidents involving improper administration. An LVN gave a resident glucophage and methenamine without food, against instructions, risking GI distress. Another LVN mixed Polyethylene Glycol with insufficient water, leading to potential discomfort. Both errors were acknowledged by staff and highlighted the need for adherence to medication instructions.
A dietary staff member failed to check the internal temperature of pork loins before serving, as observed during a survey. The staff member admitted to not knowing the required temperature, and both the Dietary Service Manager and Dietitian confirmed the importance of this step to prevent foodborne illness. Facility policies and professional guidelines emphasize the necessity of using a food thermometer for safety.
The facility failed to ensure sanitary food preparation and storage, affecting 87 residents. A serving cart was found with a white powdered substance and other items, while a kitchen storage room had dirt, debris, and a missing baseboard. The Dietary Manager Supervisor, Registered Dietitian, and Administrator acknowledged the importance of cleanliness to prevent contamination and pest attraction.
A resident's POLST form was not completed and signed by a physician for over eleven days after admission, contrary to facility policy. Staff interviews indicated the form should have been completed upon admission and signed within 72 hours. The resident, with multiple diagnoses and moderate cognitive impairment, was automatically considered full code due to the incomplete form.
A resident's personal information was exposed when an LVN left a computer screen open and unattended, violating privacy protocols. Facility staff confirmed that this action breached HIPAA regulations and contradicted the facility's policy on maintaining residents' confidentiality.
Two residents experienced an unclean and cluttered environment due to one resident's food hoarding habits. Despite being cognitively intact, the resident continued to store various food items improperly, leading to potential risks of pest infestation and foodborne illness. Facility staff attempted to manage the situation through education and alternative storage solutions, but the resident often refused assistance.
A facility failed to accurately complete the PASRR for a resident admitted with unspecified psychosis and depression, who was on psychotropic medications. The PASRR from the hospital inaccurately indicated no need for Level II screening and no mental illness diagnosis, which was not corrected by the facility. The DON acknowledged the oversight, which could affect the resident's psychiatric care.
A resident with diabetes and other conditions had long, thick, and crooked toenails due to the facility's failure to ensure proper foot care. Despite the resident's refusal of podiatry visits, staff did not take further action to address the issue, which was contrary to the facility's foot care policy.
A resident with no cognitive impairment did not have his meal preferences documented, leading to him not eating his lunch due to a dislike for Italian food. Despite the facility's policy to accommodate preferences, staff failed to ensure meal tickets were accurate, resulting in the resident not receiving a meal he would eat.
A resident with psychosis and muscle weakness was not provided with the necessary built-up utensils on her meal tray, as required by her care plan. Despite the facility's policy and staff responsibilities, the dietary aides failed to ensure the correct utensils were placed, leading to the deficiency.
A resident with dementia, known for wandering, exited a facility unsupervised and was found in a rose garden during extreme heat, resulting in second-degree burns and an acute kidney injury. The resident, who had severe cognitive impairment and was a fall risk, required hospitalization for treatment. Staff interviews confirmed the resident needed constant supervision, which was not provided, leading to the incident.
Failure to Respond to Elopement Alarm Results in Resident Leaving Facility
Penalty
Summary
A deficiency occurred when staff failed to respond promptly to a security elopement alarm, resulting in a resident eloping from the facility. The resident had been admitted with acute encephalopathy, severe impairment affecting judgment, and a history of wandering and elopement. Assessments indicated the resident was independently mobile, at high risk for both elopement and falls, and had a physician's order for a security bracelet to be worn on the right ankle. The care plan included interventions such as applying the security bracelet and checking its function and placement per protocol. On the day of the incident, the resident was last seen by staff outside his room during breakfast service. When the resident could not be located, a search was initiated inside and outside the facility. The security bracelet alarm at the front door was triggered, but staff did not respond to the alarm in a timely manner. The resident was eventually found at a family member's home approximately one mile away and was returned to the facility. At the time of his return, the security bracelet was still in place and functioning. Interviews with facility leadership confirmed that the alarm at the front door was sounding but was not answered immediately, as the receptionist who typically monitors the area was not on duty at the time. The facility had six other residents identified as high risk for elopement, all with physician's orders for security bracelets due to wandering or exit-seeking behaviors. Facility policies required adequate supervision and timely response to alarms for residents at risk of elopement, but these protocols were not followed during the incident.
Failure to Administer Prescribed Antibiotic Following Physician Order
Penalty
Summary
A deficiency occurred when a resident who was admitted for aftercare following a fractured left ankle did not receive a prescribed antibiotic for a suspected surgical site infection. The surgeon ordered Bactrim DS to be administered twice daily for ten days, starting on 3/3/25, after a follow-up visit raised concerns about infection. However, the antibiotic was not administered as ordered. The failure was traced to a breakdown in the facility's process for handling physician orders received via fax. The surgeon's progress note, which included the antibiotic order, was faxed to the facility and received by medical records staff, but it was not provided to the clinical staff as required. The Director of Nursing confirmed that the process in place to start antibiotics within four hours of receiving an order was not followed, resulting in the resident not receiving the medication as prescribed.
Resident Falls Due to Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident was free from injury when he attempted to self-transfer out of his bed with the bed's wheels unlocked, resulting in a fall and fracture to his left hip. The resident, who was cognitively intact but had impairments in both lower extremities and required substantial assistance for transfers, attempted to transfer himself to his wheelchair. During this attempt, the unlocked wheels caused the bed to move, leading to the fall. The resident had been admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies, bipolar disorder, and dementia. Despite being wheelchair-bound and needing maximal assistance for transfers, the resident attempted to transfer himself after a CNA had moved his bed to assist his roommate and forgot to lock the bed's wheels. This oversight was confirmed by the resident, who stated that the CNA had asked for permission to move the bed but did not lock the wheels afterward. Interviews with staff, including CNAs and nurses, confirmed that the bed's wheels should have been locked when the resident was in bed. The bed was found moved from its normal position, and the resident was discovered on the floor by a nurse. The staff acknowledged that the bed would not have moved if the brakes were locked, indicating a failure to follow safety protocols regarding bed wheel locks.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to all 91 residents, their families, and legal representatives. During an observation, a binder labeled CDPH Survey Results was found in a hallway near the main entrance, but it did not contain the results of the last recertification survey conducted on September 22. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the survey results were not included in the binder. The ADM mistakenly believed that only results from the previous year needed to be stored, and since the survey was conducted in 2022, it was not included. The facility's policy on Resident Rights, dated August 22, indicated that residents have the right to examine survey results, which was not upheld in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. Two of four medication carts were found unlocked and unattended by licensed nurses, which posed a risk of unauthorized access by residents, staff, and visitors. During observations, Licensed Vocational Nurses (LVNs) were seen leaving medication carts unlocked while attending to residents in their rooms, acknowledging that the carts should have been locked to prevent access to medications by unauthorized individuals. Additionally, a bottle of polyethylene glycol 3350 was left unattended on top of a medication cart, creating a potential risk for unauthorized access and misuse. The LVN responsible admitted to leaving the medication unattended and acknowledged the risk of it being accessed by residents, staff, or visitors. The Director of Nursing (DON) confirmed that leaving medications unattended on top of carts was against facility policy and posed a risk of unauthorized access and potential harm. Furthermore, an expired bottle of Lactulose was found in a medication cart, indicating a failure to adhere to the facility's policy of checking expiration dates before administering medications. The LVN and Assistant Director of Nurses (ADON) acknowledged that expired medications should not be present in the cart and could lead to ineffective treatment or harmful side effects. The facility's policies clearly stated that expired medications should be removed and destroyed, highlighting a lapse in adherence to these procedures.
Infection Control Deficiencies in Oxygen Equipment and Sharps Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper storage of sharps containers in a room accessible to residents. The room contained five full sharps containers, one of which was uncovered, posing a risk of injury and cross-contamination. The room was used by an outside lab company, but the facility staff did not monitor or report the unsafe condition, despite the potential for residents to access the room and harm themselves. Another deficiency involved the maintenance of oxygen concentrators for multiple residents. Resident 58's oxygen concentrator filter was found covered in dirt, dust, and lint, which could introduce contaminants into the oxygen supply. Similarly, the oxygen concentrator filters for Residents 61 and 3 were covered with grayish-white material, indicating they were not cleaned regularly. There was confusion among staff about who was responsible for cleaning these filters, leading to a lack of proper maintenance and increased risk of respiratory issues for the residents. Additionally, Resident 345's oxygen tubing was not labeled with the date it was changed, which is necessary to ensure timely replacement and prevent respiratory infections. The facility's policies required nasal cannula tubes to be changed weekly and labeled with the date, but this was not adhered to, putting the resident at risk. These deficiencies highlight a lack of adherence to infection control policies and procedures, as well as inadequate staff training and communication regarding responsibilities for maintaining medical equipment.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure a dignified dining experience for five residents, as they were made to wait up to 30 minutes for their lunch trays while observing other residents eat. This incident involved Residents 68, 81, 245, 246, and 350, who were left without their meals in the dining room on two separate occasions. The delay in serving these residents was attributed to a lack of communication between the nursing and dietary staff, as the lunch trays for these residents were mistakenly sent to their rooms instead of the dining room. Resident 68, who has a severe cognitive deficit, and Resident 81, with a moderate cognitive deficit, were among those affected. Resident 245, with no cognitive deficit, and Resident 246, with a severe cognitive deficit, also experienced the delay. Additionally, Resident 350, who has no cognitive deficit, was affected, and a family member expressed discomfort with the situation. The staff's failure to communicate effectively resulted in these residents being served significantly later than others, impacting their dining experience. Interviews with various staff members, including CNAs, the Dietary Service Manager, the MDS Coordinator, and the Director of Nursing, revealed that the standard practice was to serve one table at a time. However, due to a lack of communication, the dietary staff was not informed of the residents' presence in the dining room, leading to the delay. The facility's policy emphasizes treating residents with dignity and respect, which was not upheld in this instance.
Failure to Implement Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement a resident-centered care plan for three residents, leading to potential risks and unmet medical needs. For Resident 31, there was no care plan for the use of clotrimazole medication, which was prescribed for a fungal infection on the toenails. This oversight was identified during a review of the resident's order summary and confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that a care plan should have been initiated immediately upon receiving the order. Resident 1's care plan was not properly implemented, as the padding on the left bedrail was not intact, exposing a metal bar. This was observed during room inspections and interviews with Certified Nursing Assistants (CNAs) and a Registered Nurse (RN). The care plan indicated the need for padded side rails due to the resident's history of seizures, but the nursing staff failed to ensure the padding was maintained, potentially putting the resident at risk of injury during a seizure. For Resident 53, there was no care plan developed for a change in condition related to diarrhea, which was documented in the SBAR communication form and progress notes. Despite the physician ordering tests to rule out C-Diff, the DON and other staff members confirmed that a care plan should have been created to address this change in condition. The absence of a care plan meant that the resident's medical needs might not have been adequately met.
Failure to Follow Fluid Restriction Order
Penalty
Summary
The facility failed to adhere to professional standards of quality care for a resident by not following the physician's fluid restriction order. The resident, who was admitted with diagnoses including psychosis and muscle weakness, was observed consuming more fluids than the prescribed limit during a meal. Specifically, the resident was allowed to consume 28 ounces of fluid in one meal, exceeding the allowed 10 ounces per meal as per the physician's order. This oversight was confirmed by multiple staff members, including a CNA, the Assistant Dietary Service Manager, and the Dietary Service Manager, who acknowledged that the resident received more fluid than ordered. Interviews with staff revealed a lack of compliance with the fluid restriction order, which was crucial to prevent potential health issues such as fluid overload. The Director of Nursing noted that the resident was confused and frequently requested more coffee, indicating a need for staff to consistently explain the fluid restriction to the resident. The facility's policy required the Food Service Manager or designee to check trays for correct diets before distribution, but this protocol was not effectively followed, leading to the deficiency.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an error rate of 11.54%. This deficiency was observed in two separate incidents involving medication administration. In the first incident, an LVN administered glucophage and methenamine to a resident without food, contrary to the medication instructions that specified administration with food. The LVN acknowledged the error, noting that the resident had eaten breakfast earlier, but did not provide food at the time of medication administration. The Assistant Director of Nursing and the Director of Staff Development confirmed that the medication orders should have been followed to prevent gastrointestinal distress. In the second incident, another LVN did not adhere to the medication instructions for administering Polyethylene Glycol to a different resident. The LVN mixed the medication with only four ounces of water instead of the prescribed eight ounces, resulting in a more concentrated solution. This deviation from the prescribed method was acknowledged by the LVN and confirmed by the Director of Staff Development, who noted that the error could lead to gastrointestinal discomfort and inefficient absorption. The facility's policy on medication errors emphasizes the importance of following physician orders and manufacturer instructions to prevent adverse consequences.
Failure to Ensure Competency in Food Temperature Checks
Penalty
Summary
The facility failed to ensure that a dietary staff member was competent in carrying out the functions of the food and nutrition services safely and effectively. During an observation, the dietary staff member was seen removing a baking tray containing three pork loins from the oven without checking their internal temperature. The staff member then proceeded to the prep area to slice the pork loins for service without verifying if they were cooked to the required temperature. In an interview, the staff member admitted to not checking the internal temperature and was unsure of what it should have been, acknowledging that he should have checked it upon removal from the oven. Further interviews with the Dietary Service Manager and the Dietitian confirmed that the staff member should have checked the temperature to ensure the pork loins were properly reheated, as per the facility's policy. The Dietary Service Manager stated that the pork loins were precooked but emphasized the importance of verifying the temperature to prevent foodborne illness. The Dietitian reiterated the necessity of following the recipe's temperature requirements and indicated that the Dietary Service Manager was responsible for training the staff member. The facility's policy and professional references reviewed highlighted the importance of using a food thermometer to ensure food safety.
Sanitation Deficiencies in Food Preparation and Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices, affecting 87 of 91 residents. During an observation, a serving cart was found with a white powdered substance scattered across its surface, alongside items such as serving trays, gloves, aprons, garbage bags, and a utensil holder. The Dietary Manager Supervisor (DMS) acknowledged that the cart should be cleaned daily to prevent contamination and infection, and that it was the responsibility of the dietary aide to maintain its cleanliness. Additionally, a storage room in the kitchen was observed to have dirt and debris on the floor, with a missing baseboard on one wall. The DMS stated that maintenance was responsible for fixing the floors and baseboards, and acknowledged that the area was not clean. The Registered Dietitian (RD) and the Administrator (ADM) both confirmed the importance of maintaining cleanliness to prevent cross-contamination and pest attraction. The facility's policy and the USFDA Food Code emphasize the need for cleanliness in food-contact and non-food-contact surfaces, as well as proper storage of maintenance tools.
Failure to Timely Complete POLST Form
Penalty
Summary
The facility failed to ensure that a resident's code status was documented upon admission on the Physician Order for Life Sustaining Treatment (POLST) form. The POLST form for the resident was not completed and signed by the physician for more than eleven days after admission, which was not in accordance with the facility's policy and procedure. This oversight had the potential to result in the resident's wishes not being honored and unnecessary medical interventions being administered. Interviews with staff revealed that the POLST form should have been completed upon admission, with the physician or nurse practitioner required to sign it within 72 hours. The admission nurse was responsible for completing the POLST form and communicating the resident's wishes to the physician. However, the form was not signed by the physician until much later, and the resident was automatically considered a full code due to the incomplete POLST form. The resident involved was admitted with diagnoses including COVID-19, polyneuropathy, depression, hypertension, and constipation. The resident was moderately cognitively impaired but was her own responsible party. The facility's policy stated that the POLST form is not valid until signed by both the resident and a physician, and the failure to complete this process in a timely manner was a clear deficiency in the facility's adherence to its own procedures.
Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to protect the privacy of a resident's personal information when a Licensed Vocational Nurse (LVN) left her workstation computer open and unattended, exposing the resident's information to public view. This incident involved Resident 34, whose personal and medical information was left visible on the computer screen outside their room. The LVN acknowledged that leaving the computer screen open was inappropriate and that it allowed any passing residents, staff, or visitors to potentially view the resident's private information. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Director of Nursing (DON), confirmed that the facility's practice and expectation were to always close computer screens when not in use to protect residents' information. The DSD identified this incident as a violation of the Health Insurance Portability and Accountability Act (HIPAA), which mandates the protection of sensitive health information. The facility's policy and procedure document also emphasized the residents' rights to privacy and confidentiality, which were not upheld in this instance.
Failure to Maintain a Clean and Homelike Environment Due to Food Hoarding
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, Resident 16 and Resident 39, due to the improper storage of personal food items. Resident 16 had a collection of fresh produce, canned goods, and various food items stored in their room, including on the floor and shelves, which created clutter and an unclean environment. This situation was observed during multiple visits, and Resident 39, who shared the room, expressed that the clutter made it impossible to use the shared sink. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status (BIMS), Resident 16 continued to hoard food despite repeated discussions and education from facility staff, including the Infection Preventionist, Director of Staff Development, and Registered Dietitian. The staff explained the risks of food hoarding, such as pest infestation and foodborne illness, but Resident 16 and their family persisted in bringing food into the facility. The facility staff attempted to manage the situation by checking expiration dates and offering to store food in a refrigerator, but Resident 16 often refused these measures. Housekeeping staff were observed cleaning the room but stated that their responsibilities did not include managing the food clutter. The Director of Nursing and other staff members acknowledged the ongoing issue and the potential risks it posed to the facility. Despite efforts to educate and offer alternative solutions, Resident 16's preference to remain in the facility with friends and continue their habits contributed to the deficiency in maintaining a clean and homelike environment.
Inaccurate PASRR Completion for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the accurate completion of the Level I Preadmission Screening and Resident Review (PASRR) for a resident upon admission. The resident, who was admitted with diagnoses of unspecified psychosis and depression, was also on psychotropic medications. However, the PASRR completed at the general acute care hospital inaccurately indicated that the resident did not require a Level II screening and did not have a diagnosis of mental illness or prescriptions for psychotropic medications. This discrepancy was not identified or corrected by the facility upon the resident's admission. During a review, the Director of Nursing (DON) acknowledged that the PASRR assessment was not accurate and should have been reviewed and updated to reflect the resident's mental health diagnoses and medication needs. The facility's policy required confirmation and review of PASRR documentation from the hospital, which was not adequately followed in this case. This oversight had the potential to impact the resident's receipt of necessary psychiatric treatment and evaluation.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, identified as Resident 3, whose toenails were observed to be long, thick, and crooked. This condition was noted during an observation and interview with a registered nurse, who acknowledged that the toenails were not in an acceptable condition and should have been reported by certified nursing assistants (CNAs). Despite being aware of the condition, CNA 1 stated that Resident 3 had refused nail care, and no report was made to the nurse. The resident's refusal of podiatry visits was documented in the podiatry notes, and the Social Services Director indicated that if staff had alerted her, alternative arrangements could have been made. Interviews with various staff members, including a licensed vocational nurse, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing, revealed a consensus that the resident's refusal of nail care should have prompted further action. The staff acknowledged the potential risks associated with the resident's diabetic condition, which could lead to complications such as skin breakdown or infection. The facility's policy on foot care emphasized the importance of maintaining foot health, particularly for residents with medical conditions like diabetes, but the policy was not effectively implemented in this case.
Failure to Document and Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to document and accommodate a resident's meal preferences, resulting in the resident not eating his lunch. The resident, who had no cognitive impairment, expressed a dislike for Italian food, which was not documented on his meal ticket. On the day of the incident, the resident was served a meal consisting of spaghetti and zucchini, which he refused to eat due to his dislike for Italian food. Despite the availability of meal alternatives, the resident's appetite was ruined, and he did not request a different meal. Interviews with facility staff revealed a lack of communication and responsibility in ensuring meal preferences were documented and respected. The Certified Nursing Assistant (CNA) and Registered Nurse (RN) acknowledged their roles in checking meal tray accuracy and addressing resident meal preferences. The Dietary Services Manager and Assistant Dietary Services Manager stated that it was the dietary department's responsibility to document food preferences, and the Registered Dietitian emphasized the importance of providing alternate meals if a resident's meal was untouched. The facility's policy indicated that residents should receive meals according to their preferences, but this was not adhered to in this case.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for a resident, identified as Resident 68, who required built-up utensils to feed herself independently and safely. During an observation in the dining room, it was noted that Resident 68's meal tray contained regular utensils instead of the prescribed built-up utensils. The resident's admission record and order summary report indicated the need for adaptive equipment, including a divided plate and built-up utensils, due to her diagnoses of psychosis and muscle weakness. Interviews with various staff members, including a Certified Nurse Assistant, Assistant Dietary Service Manager, Dietary Aide, Dietary Service Manager, and Registered Dietitian, revealed that the dietary aides were responsible for ensuring the correct utensils were placed on meal trays. However, the dietary aides failed to perform a final check before sending out the tray cart, resulting in the omission of the necessary adaptive utensils. The facility's policy and procedure on self-feeding devices stated that such devices should be provided with each meal, but this was not adhered to in the case of Resident 68.
Resident with Dementia Sustains Burns Due to Lack of Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accident hazards for a resident with dementia, who was known to independently move around the facility in a wheelchair. The resident, who had severe cognitive impairment and was a fall risk, managed to exit the facility unsupervised and was found in the rose garden exposed to extreme heat. The temperature on that day reached up to 108 degrees Fahrenheit, and the resident was outside for an unknown amount of time. As a result of this lack of supervision, the resident sustained second-degree burns on multiple parts of the body, including the scalp, right ear, neck, left shoulder, and both knees. Additionally, the resident suffered an acute kidney injury, likely due to dehydration from prolonged sun exposure. The resident required treatment at an acute care hospital for these injuries. Interviews with facility staff revealed that the resident had a history of wandering and required constant supervision. Staff members acknowledged that the resident should not have been left unattended outside, especially given the high temperatures. The facility's policy emphasized the importance of making the environment free from accident hazards and providing adequate supervision based on individual resident needs, which was not adhered to in this case.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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