Stonebrook Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, California.
- Location
- 4367 Concord Boulevard, Concord, California 94521
- CMS Provider Number
- 555421
- Inspections on file
- 22
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Stonebrook Post Acute during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiparesis, and total dependence for toileting and bed mobility was care planned for two-person assistance, low bed position, and floor mats on both sides of the bed. During incontinence care, a CNA elevated the bed, turned the resident to assess for soiling, then left the room to obtain supplies and assistance, leaving the resident alone with the bed not fully lowered and with uncertainty about floor mat use. The resident fell from the bed to the floor and was later found with facial bruising, abrasions, and right leg deformity; hospital evaluation identified a frontal/perinasal hematoma and a comminuted distal femur fracture. The DON stated the CNA should not have left the dependent resident alone with the bed elevated and that required fall-prevention measures, including floor mats and two-person assist, were not in place at the time of the incident.
A resident with documented capacity and an active DNR order did not have a completed POLST form on file. During a medical emergency, staff initiated CPR and emergency responders used a defibrillator, despite the DNR order. The facility's policy required honoring DNR orders and completing state-specific forms, but these were not followed, resulting in unwanted resuscitative interventions.
A resident reported that a CNA was rough during care, resulting in pain and difficulty urinating. Although the incident was reported to authorities and the CNA was suspended, the facility failed to retain or provide the investigation summary and could not confirm if the required report was sent to the State Agency. The investigation documents were missing following a change in facility ownership, and the relevant policy for reporting was not available.
Three resident rooms were found to have privacy curtains that were worn, frayed, and torn, with loose threads and exposed linings, detracting from the homelike appearance of the rooms. The Housekeeping Supervisor confirmed the lack of a routine inspection schedule for curtains and acknowledged that many rooms required curtain replacement, but no new curtains had been ordered.
The facility did not ensure accurate MDS assessments for three residents. One resident's code status was incorrectly recorded, another's issues with ill-fitting dentures were not reflected in the MDS despite documentation and resident report, and a third resident's discharge location was inaccurately documented. Staff interviews confirmed these errors and a lack of familiarity with the MDS process.
A resident with a history of bipolar disorder was diagnosed with major depressive disorder with psychotic symptoms, but the facility did not refer the resident for a required Level II PASARR evaluation as outlined in facility policy. Staff interviews revealed a lack of awareness about the need for a new PASARR screening following a new mental illness diagnosis, resulting in the deficiency.
Two residents with severe cognitive impairment and significant physical limitations were observed using bed rails or bed canes without the required assessments being completed. Staff interviews confirmed that the facility did not follow its policy to evaluate residents for bed rail use, resulting in the use of these devices without proper assessment or documentation.
A resident with moderate cognitive impairment and a history of chronic kidney disease experienced ongoing issues with ill-fitting dentures. Despite a dentist's recommendation for new dentures and a denial of coverage by state insurance, the DSS did not provide timely or documented follow-up to assist the resident in obtaining needed dental care or alternative solutions. Staff interviews confirmed the lack of follow-up and absence of a dental care policy.
Staff did not follow enhanced barrier precautions or perform required hand hygiene during care for two residents with invasive devices and wounds, and failed to properly store respiratory equipment for another resident. Gowns were not worn during high-contact care, hand hygiene was omitted between glove changes, and CPAP/nebulizer masks were left out instead of being bagged, contrary to facility expectations and policies.
A resident with intact cognitive status alleged that a CNA bumped his foot into a wall while being pushed in a wheelchair. Despite the complaint being reported to the DON, no thorough investigation was conducted, and the grievance was not documented or resolved according to the facility's policy. The incident was observed by an OT, who noted the wheelchair's footrest hitting the wall, but the resident's foot was not seen making contact. The failure to address the grievance could have caused emotional distress to the resident.
A medication administration error occurred when an LVN in a long-term care facility mistakenly provided Bengay cream instead of a prescribed skin barrier cream to a CNA for application on a resident with severe cognitive impairment. This resulted in the resident experiencing pain and a burning sensation. The facility's policy requiring licensed nurses to administer medications as ordered was not followed.
A resident developed Moisture-Associated Skin Damage (MASD) and a Stage 3 pressure injury due to the facility's failure to initiate and implement appropriate care plans. Despite being at high risk for pressure injuries, the resident did not receive necessary interventions such as turning, repositioning, and the use of a low air-loss mattress. The facility also did not create care plans for the MASD and Stage 3 pressure injury, as confirmed by the Wound Nurse (WN) and Director of Nursing (DON).
The facility failed to meet professional standards of care for a resident by not weighing the resident per physician's orders, not mobilizing the resident out of bed as ordered, and not implementing care plans for the resident's worsening wound. The resident developed a Stage 3 pressure injury, and there was no oversight of the wound's progression.
Failure to Provide Safe, Supervised Incontinence Care Resulting in Fall and Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision during incontinence care, resulting in a fall from bed and multiple injuries. The resident was admitted in December 2025 and had a Minimum Data Set (MDS) dated 12/17/25 showing a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severely impaired cognition. The MDS Section GG documented that the resident was dependent for toileting hygiene. The baseline care plan dated 12/12/25 specified that the resident required two-person physical assistance for personal hygiene and bed mobility. A fall risk care plan initiated on 12/12/25 included interventions such as floor mats on both sides of the bed, keeping the bed in a low position, and frequent monitoring when the resident was in bed or a chair, with a goal of no falls over a 90-day period. Skilled charting dated 12/31/25 documented that the resident did not bear weight, had an unsteady gait requiring supervision, impaired balance, weakness, and paralysis, and required assistance with transfers and toilet use. The resident was incontinent of urine. On 1/2/26, a change of condition note indicated the resident had fallen out of bed, with impaired balance identified as a fall risk factor. A post-fall evaluation on 1/2/26 recorded that the fall occurred at noon in the resident’s room, with poor balance noted as a factor. The incident summary described the resident, a 77-year-old female with hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, as confused but able to move herself toward her left side and fall from the bed to the floor. The resident sustained a skin tear on the forehead and right facial area below the periorbital region and complained of left arm pain rated 6/10, and was transported to a hospital for evaluation. A rehab post-fall review dated 1/8/26 stated that the event occurred in the resident’s bedroom from the bed and that a CNA had begun to change the resident, then left the room to obtain supplies and assistance while the bed was at working height and not lowered. The air mattress was described as having adjusted and slid the resident out of bed, and the resident was found on the floor when the CNA returned. In an interview, the CNA reported being informed by the family that the resident needed incontinence care, entering the room alone to confirm incontinence and obtain consent for a shower, elevating the bed, and turning the resident to assess the brief, confirming stool incontinence. The CNA stated the bed was lowered “a little” before leaving the room to gather gloves and request assistance, and that moments later the resident was found on the floor; the CNA was unsure if floor mats were in place. The CNA acknowledged knowing the resident required two-person assistance for incontinence care but wanted to confirm soiling and consent first, and stated that two-person assistance was important so dependent residents were not left alone. During a concurrent interview and record review with the ADON and DON, the fall care plan and rehab post-fall review were examined. The DON stated that, based on documentation listing floor mats as a post-fall intervention, it could be assumed there were no floor mats in place at the time of the fall. The DON further stated that the CNA should not have left the resident with side rails down and the bed elevated before exiting the room, and should have gathered necessary supplies and requested assistance before entering the room for incontinence care. The DON explained that due to the resident’s limited cognition and one-sided partial mobility, the resident was able to shift herself off the bed onto the floor, and that dependent, total-care residents warranted two-person assistance for incontinence care and should not be left alone mid-care. Hospital emergency department documentation described the fall as unwitnessed, with the resident found on the floor about 15 minutes after last being seen, and noted lacerations and abrasions, shortening of the right leg, and a reported “pop” in the right lower extremity. Imaging showed a frontal/perinasal hematoma and a comminuted distal right femoral fracture. Facility policies on falls and resident quality of care required identification of fall risk factors, implementation of interventions to prevent falls, and provision of a safe environment free of accident hazards with adequate supervision.
Failure to Honor DNR Order and Complete POLST During Medical Emergency
Penalty
Summary
The facility failed to ensure that a Physician's Orders for Life Sustaining Treatment (POLST) was completed and that an existing Do Not Resuscitate (DNR) physician order was followed for one resident during a medical emergency. The resident, who was self-responsible and had documented capacity to make medical decisions, had an active DNR order in place. During a medical emergency, the resident was found unresponsive, with no vital signs, and CPR was initiated by a registered nurse. Emergency responders arrived and used a defibrillator, successfully obtaining a pulse before suspending CPR. The emergency team was informed of the DNR order but noted that no POLST was on file, and the facility was asked to contact the family to clarify the code status. Record review and staff interviews confirmed that although the resident had a DNR order, there was no completed POLST form in the resident's file. The facility's policy required that DNR orders be honored and specified that no resuscitative measures should be used when such orders are in effect. Despite this, CPR and defibrillation were performed. Documentation showed that the resident's wishes regarding resuscitation had been discussed and verbally consented to, but the required POLST form was not completed or available at the time of the emergency.
Failure to Timely Report and Retain Abuse Investigation Results
Penalty
Summary
The facility failed to ensure that the results of an investigation into an abuse allegation were reported in a timely manner to the State Agency, as required. A resident, who had no cognitive impairment, reported to social services that a CNA was rough with him during care, causing pain and subsequent difficulty urinating. The incident was reported to the appropriate authorities, and the CNA was suspended and reassigned. However, when surveyors requested the investigation summary, the current Director of Nursing and Administrator were unable to locate the investigation documents, stating that the facility had transitioned to a new company and the records were left by the previous administration. Interviews with former administrative staff confirmed that the investigation was conducted and the abuse allegation was reported, but the specific investigation notes and summary could not be found. The current administration searched for the documents without success and could not confirm if the required 5-day investigation report was sent to the State Agency. The facility's policy required the use of an abuse investigation process as mandated by law, but the relevant policy and procedure for reporting investigation notes or summaries was not available in the provided documentation.
Failure to Maintain Homelike Environment Due to Worn Privacy Curtains
Penalty
Summary
The facility failed to maintain a homelike environment for residents when three out of four sampled rooms were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the appearance of the resident rooms. During observation and interview, the Housekeeping Supervisor confirmed that the curtains in these rooms were torn, with loose threads and exposed linings, and acknowledged that there was no routine schedule for inspecting the condition of privacy curtains; inspections were only conducted on an as-needed basis. A review of purchase orders revealed that no new privacy curtains had been ordered, despite the Housekeeping Supervisor's belief to the contrary. Further, it was stated that 28 out of 69 resident rooms required replacement of privacy curtains. The facility's policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for three residents. For one resident with a history of spinal stenosis, COPD, dementia, and major depressive disorder, the MDS indicated a code status of CPR, while the resident's active orders reflected a DNR status. The MDS nurse responsible for the assessment was unavailable for interview, and both the Director of Nursing and the Administrator stated they were unfamiliar with the MDS process but expected accuracy. Another resident with hypertensive chronic kidney disease had ill-fitting dentures documented in dental and social services records, and the resident reported issues with denture fit. However, the MDS did not reflect the presence of broken or loosely fitting dentures. The MDS nurse acknowledged the oversight. In a third case, a resident who was discharged home was incorrectly documented in the MDS as having been discharged to a hospital. The MDS nurse admitted to the error, and both the DON and Administrator confirmed the MDS should accurately reflect the discharge location.
Failure to Refer Resident for Level II PASARR Evaluation After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASARR) evaluation after the resident was identified with a new diagnosis of major depressive disorder with psychotic symptoms. The resident, who had a history of bipolar disorder and was admitted to the facility several years prior, received the new diagnosis, which was documented in the medical record. The facility's policy required referral for a Level II PASARR evaluation upon identification of a new or possible serious mental disorder, but there was no evidence in the resident's record that such a referral was made following the new diagnosis. The resident's care plan and medication orders reflected the new diagnosis, including the administration of antidepressant medication. Interviews with facility staff revealed a lack of awareness regarding the need for a new PASARR screening when a resident receives a new mental illness diagnosis. The receptionist, responsible for the PASARR process, was unaware of the requirement, and the administrator confirmed that a new PASARR should be completed in such cases. This failure to coordinate and refer for the required PASARR evaluation constituted the deficiency.
Failure to Assess Residents for Bed Rail Use
Penalty
Summary
The facility failed to assess two residents for the use of bed rails, as required by their policy and regulatory standards. Both residents had significant medical histories and severe cognitive impairment, requiring substantial or maximal assistance with bed mobility and transfers. Despite these needs, there was no documented assessment for the use of bed rails for either resident, and both were observed with bed rails or bed canes in use during the survey. For the first resident, who had a history of polymyalgia rheumatica and falls, and was totally dependent on staff for activities of daily living, quarter rails were observed in the up position on both sides of the bed. Interviews with facility staff, including the Administrator, Director of Rehabilitation, and DON, confirmed that no assessment had been completed for the use of bed rails for this resident. The facility's policy required an assessment at admission, readmission, quarterly, and with changes in condition, but this was not followed. The second resident, with hemiplegia, hemiparesis, and epilepsy, also had severe cognitive impairment and required total assistance from two staff for bed mobility and transfers. This resident was observed with bed canes (rails) on both sides of the bed and was unable to communicate their use. Staff interviews revealed that therapy was responsible for assessments, but no evaluation had been completed. Multiple staff, including the Administrator, DOR, and DON, acknowledged the lack of required assessments and indicated a breakdown in the facility's system for ensuring proper evaluation before bed rail use.
Failure to Provide Timely Social Services Follow-Up for Dental Care
Penalty
Summary
The facility failed to provide timely follow-up of medically related social services to assist a resident in obtaining dental services for the replacement of ill-fitting dentures. The resident, who had a history of hypertensive chronic kidney disease and moderate cognitive impairment, was identified as having ill-fitting upper and lower dentures during a dental evaluation. Despite the dentist's recommendation for new dentures and subsequent denial of coverage by the state insurance, there was a lack of documented follow-up by the Director of Social Services (DSS) to assist the resident in finding alternative dental care or resolving the coverage issue. The resident repeatedly expressed concerns about the unresolved denture situation, and the DSS acknowledged being aware of the problem but did not document any follow-up actions or communication with the resident regarding the denial or next steps. Interviews with facility staff, including the DSS, dental hygienist, dental office manager, and administrator, confirmed that the resident's need for new dentures was known, the insurance denial was communicated to the DSS, and there was an expectation for follow-up that did not occur. The DSS also stated there was no dental care policy or procedure in place at the facility. The lack of timely and documented follow-up resulted in the resident continuing to experience issues with ill-fitting dentures, impacting their ability to wear them.
Failure to Implement Infection Control Precautions and Proper Equipment Storage
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper infection control measures for multiple residents. For one resident with a gastrostomy tube and severe cognitive impairment, staff did not wear gowns during high-contact care activities such as incontinence care and gastrostomy tube dressing changes, despite facility policy requiring gown and glove use for residents with invasive devices. Additionally, during a gastrostomy tube dressing change, a nurse changed gloves without performing hand hygiene, contrary to facility policy and staff knowledge. Another resident with a deep tissue pressure injury and moderate cognitive impairment received wound care from a nurse who failed to perform hand hygiene after removing gloves and before donning new gloves. The nurse acknowledged the lapse, and both the DON and Administrator confirmed that hand hygiene should occur before and after glove changes, as well as between glove changes, in accordance with facility policy. The facility also did not ensure proper storage of respiratory equipment for a resident using a CPAP and nebulizer. Observations revealed that the CPAP and nebulizer masks were left out in the open and not stored in bags when not in use, as required to prevent infection. Staff interviews confirmed the expectation that such equipment should be stored in bags, but the facility lacked a written policy on respiratory equipment storage. The Administrator was unaware of the procedure but agreed that masks should be cleaned and stored in bags after use if that was the expectation.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address and resolve a grievance made by a resident, identified as Resident 1, who alleged that a Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while being pushed in a wheelchair. The incident was reported to the Director of Nursing (DON) by the resident's daughter, who is also the responsible party. Despite the complaint, the DON did not conduct a thorough investigation or interview witnesses, as he believed CNA1's account that the resident's foot did not hit the wall due to the presence of a footrest on the wheelchair. Resident 1, who had a BIMS score of 15 indicating intact cognitive status, was able to clearly express his concerns. The resident had limitations in the range of motion in the lower extremity and was diagnosed with heart failure and muscle wasting. The Occupational Therapist (OT) observed the wheelchair's footrest bumping into the wall but did not see the resident's actual foot make contact. Despite this, the resident complained that his foot was hit, and the incident was discussed in a daily stand-up meeting. The facility's grievance policy, which mandates prompt and fair resolution of complaints, was not followed. The DON admitted to not documenting the complaint in the resident's medical records and failing to follow up with the resident or the responsible party. This oversight had the potential to cause emotional distress to the resident, as the grievance was not addressed in a timely or thorough manner.
Medication Administration Error Leads to Resident Discomfort
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) administered medication accurately and safely to a resident, resulting in pain and discomfort. The incident involved the administration of Bengay cream, which is used for treating minor aches and pains, instead of a prescribed skin barrier cream for moisture-associated skin damage. This error occurred when the LVN handed the wrong cream to a certified nursing assistant (CNA) to apply on the resident's skin during a change. The resident, who had severe cognitive impairment and was diagnosed with conditions including dementia and osteoarthritis, experienced a burning sensation in the affected area due to the application of the incorrect cream. The error was confirmed by the LVN during an interview, where it was revealed that the Bengay cream was mistakenly given instead of the Coloplast Critic-Aid barrier cream. The facility's policy and procedure for medication administration, which requires medications to be administered by licensed nurses as ordered by the resident's physician, was not followed. The medication error was documented in a report, indicating that the Bengay cream was applied instead of the barrier cream, causing the resident pain and a burning sensation.
Failure to Implement Care Plans for Skin Damage and Pressure Injuries
Penalty
Summary
The facility failed to initiate and implement person-centered care plans for a resident who developed Moisture-Associated Skin Damage (MASD) and a Stage 3 pressure injury. The resident, who was admitted with multiple diagnoses including rheumatic tricuspid insufficiency, chronic heart failure, and pulmonary hypertension, was identified as being at high risk for pressure injuries based on a Braden Scale score of 11. Despite this, the facility did not create a care plan for the MASD that was discovered on the resident's sacrococcygeal area, as confirmed by the Wound Nurse (WN) during an interview and record review. The facility also failed to implement necessary interventions to prevent the resident from developing a pressure injury. The resident's care plan included instructions for turning and repositioning every two hours and the use of a pressure-relieving mattress, but these interventions were not followed. The resident was documented as staying in bed without being turned or repositioned 178 times between July and October. Additionally, the resident did not have a low air-loss (LAL) mattress, which was only ordered upon discharge. The Director of Nursing (DON) confirmed these lapses during an interview and record review. Furthermore, the facility did not initiate a care plan when the resident developed a Stage 3 pressure injury on the sacrococcygeal region. Progress notes indicated the presence of an open wound that progressed to a Stage 3 injury, but no care plan was created to address this condition. Both the WN and the DON confirmed the absence of a care plan for the Stage 3 pressure injury during interviews. The facility's policies on the prevention and treatment of pressure injuries were not followed, as care plans were not initiated for each skin concern as required.
Failure to Meet Professional Standards of Care
Penalty
Summary
The facility failed to ensure care provided met professional standards of care for one resident when nursing staff did not weigh the resident per physician's orders. The resident had multiple physician orders for weekly weights on specific days, but the records indicated that the resident was not weighed on numerous occasions as ordered. The Director of Nursing (DON) confirmed that the resident was not weighed according to the physician's orders during a telephone interview and record review. Additionally, the nursing staff did not get the resident out of bed as ordered by the physician. The resident's care plan and physician's orders indicated that the resident should be out of bed to a chair for meals every shift and up in a wheelchair for at least four hours a day. However, progress notes showed that the resident stayed in bed for extended periods, and there was no documented evidence that the resident was mobilized out of bed for meals. The DON confirmed that the nursing progress notes did not indicate the resident was mobilized out of bed as expected. Furthermore, the facility failed to implement or initiate care plans as the resident's wound continued to worsen. The resident developed a facility-acquired Stage 3 pressure injury on the sacrococcygeal region. Despite having a care plan for potential skin breakdown, there was no care plan initiated for the resident's Moisture-Associated Skin Damage (MASD) or the subsequent Stage 3 pressure injury. The Wound Nurse (WN) and DON confirmed that there was no care plan for the resident's MASD or Stage 3 wound, and the resident did not have a low air-loss mattress as required. The facility also lacked oversight of the resident's worsening wound, with no additional Braden Scale assessments documented after a certain date, and no specialized wound consultant overseeing the WN's work.
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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