Fallbrook Rehabiliation And Care Center

Penalty

Fine: $12,460

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

Summary

The deficiency involves the facility’s failure to ensure that nursing staff, including CNAs and nursing leadership, possessed and demonstrated the competencies and skills necessary to safely perform mechanical lift transfers. A cognitively intact female resident with cerebral palsy, significant mobility limitations, muscle weakness, contractures, and a high fall risk score required two-person assistance with a mechanical lift for transfers per her care plan. Her care plan also directed staff to ensure mechanical lift straps were secure, intact, and that all straps were in place before transfer. Despite these requirements, the resident was transferred in the early morning hours by a CNA who did not follow proper sling attachment procedures. During a mechanical lift transfer from bed to chair, the CNA attached the lift sling to the handling strap instead of the designated sling attachment loop. The resident fell from the lift during this transfer and was found on the floor on her back. She initially denied pain, and no immediate skin discoloration was observed, but later developed bruising and pain in the left shoulder. X‑ray and CT imaging confirmed a fractured clavicle. The resident reported that usually two staff assisted with mechanical lift transfers, but on the day of the fall she believed only one CNA performed the transfer and that the CNA was attempting to get her out of bed early without obtaining a second staff member. She also reported that after the incident, a new sling used for transfers caused her significant pain in her right leg during each transfer, and she did not feel safe when that sling was used, although she had not reported this concern to the facility. Interviews and observations revealed broader competency failures beyond the single incident. The Administrator identified the root cause of the fall as staff error related to improper sling attachment. The DON was unable to demonstrate proper mechanical lift use, did not lock the lift wheels, did not correctly position the sling, and could not clearly explain required safety measures or the system to ensure proper lift use, sling inspection, or frequency of equipment checks. The DOR, who provided an in‑service on mechanical lifts after the incident, stated he had not been trained on the specific lifts and slings used in the facility, was unfamiliar with manufacturer models and sling compatibility, and had not used the facility’s mechanical lift competency and evaluation checklist. Multiple CNAs and nurses reported they had been in‑serviced on mechanical lift transfers but denied completing any competency validation and were unable to clearly explain or demonstrate proper mechanical lift and sling use during surveyor observation. Record review showed no documentation that CNAs or other direct care staff, including the DON, had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no structured system to verify staff competency or to identify which residents required mechanical lift transfers. During an observed transfer of the same resident by two CNAs, staff again failed to demonstrate proper mechanical lift technique. They did not ensure the lift wheels were unlocked prior to sling attachment and did not center the sling under the resident before transferring her from chair to bed. The resident reported pain associated with improper positioning during this transfer. Staff interviewed during the survey could not clearly explain required safety measures for mechanical lift use. These findings, combined with the lack of documented competencies, unclear responsibility for sling and lift inspection, and leadership’s inability to describe or demonstrate safe transfer procedures, showed that the facility failed to ensure nursing staff had the appropriate competencies and skill sets to safely perform mechanical lift transfers, resulting in a resident fall with a fractured clavicle and placing other residents who required mechanical lift transfers at risk for serious injury. An Immediate Jeopardy was identified related to this deficiency, based on the lack of competency validation and improper sling attachment that led to the resident’s fall and injury. The facility did not have documentation verifying that direct care staff or supervising nursing staff had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no record identifying the number of residents requiring mechanical lift transfers. Leadership interviews showed that the Administrator, DON, and DOR were unclear about training systems, competency tracking, and responsibility for equipment inspection. These conditions contributed to the improper use of the mechanical lift and sling that caused the resident’s fractured clavicle and placed other residents requiring mechanical lift transfers at risk for serious injury, including fractures, head trauma, internal injury, or death, as stated in the report.

Removal Plan

• Administrator/DON/Corporate Nurse reviewed the Safe Handling of Resident Transfers policy.
• Assess resident; notify appropriate parties; send resident to hospital for further evaluation as indicated; schedule follow-up appointment as indicated; continue monitoring for injuries/changes in condition.
• Corporate Nurse to re-educate nursing staff directly involved in the resident’s fall before performing direct care on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
• Place manufacturer instructions for mechanical lift sling inspection on each mechanical lift for employee reference.
• Corporate Nurse to re-educate the DON and DOR on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
• DON/designee to review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in the care plan.
• IDT to review new admissions in morning clinical meeting to identify transfer needs and care plan these needs.
• IDT to discuss residents with change in condition affecting mobility status and update transfer status and care plan as appropriate.
• Place care planned interventions including transfer status on the resident Kardex so direct care staff can view resident-specific needs.
• Educate nursing and therapy staff before performing direct care to review the Kardex to identify resident-specific needs.
• Corporate Nurse/Consultant Nurse to educate DON/ADON/Administrator on the facility orientation checklist for nursing staff; validate via facility mechanical lift competency checklist.
• Include mechanical lift/sling training at orientation for new nurses and nurse aides; complete training prior to staff transferring a resident using the lift/sling.
• Corporate Nurse, DON, DOR or designee to re-educate nursing staff and therapy staff before performing direct care on appropriate transfer and safe handling during mechanical lift transfers, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
• Administrator or DON to sign off that new nursing staff have completed the orientation checklist including validation of competencies prior to being moved from orientation status.
• DON/designee to audit mechanical lift transfers twice weekly for a specified period, then weekly for a specified period, then monthly for a specified period.
• Administrator to implement a QAPI PIP to gather/process information from monitoring rounds and report findings at the monthly QAA meeting.

Penalty

Fine: $12,460

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

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistance devices during a mechanical lift transfer, resulting in a fall and injury to a resident. The resident was an adult female with cerebral palsy, abnormalities of gait and mobility, muscle wasting and atrophy, generalized muscle weakness, and joint contractures. Her MDS showed a BIMS score of 14, indicating no cognitive impairment, and a fall risk assessment score of 22, indicating high risk for falls. Her care plan identified her as at risk for falls related to limited mobility, weakness, and altered mental status, with a goal to remain free of falls and injuries. Interventions included use of a mechanical lift with two-person staff assistance for transfers and ensuring mechanical lift straps were secure, intact, and that the lift was charged before transfer. On the date of the incident, the resident was being transferred from bed using a mechanical lift by CNA G, with conflicting accounts about whether a second staff member was present at the time of the transfer. The resident reported that only one staff member was performing the transfer initially and that a second CNA arrived after the fall to get the nurse. During the transfer, CNA G attached the mechanical lift sling to the handling strap instead of the designated sling attachment loop. The sling strap then broke during the transfer, causing the resident to fall from the lift to the floor. The resident immediately experienced pain and reported it to the nurse. The facility’s Administrator later determined through investigation that the root cause of the incident was staff error in attaching the sling to the wrong part of the lift. Following the fall, the nurse on duty assessed the resident, who at first denied pain and showed no immediate discomfort or visible skin discoloration. The resident was found on her back on the floor with the sling under her body. The nurse was informed that the sling strap had broken during the transfer and that another sling was used to transfer the resident back to bed after the incident. Later that morning, the resident reported pain, and bruising was observed near the left shoulder. An X-ray performed at the facility revealed a fractured clavicle, which was confirmed by hospital imaging as a fracture of the distal end of the left clavicle. Interviews with the Administrator and DON showed they could not clearly explain how staff training on mechanical lift use was tracked, how competencies were validated, or who was responsible for inspecting slings and straps for safety or how often such inspections occurred. These actions and inactions led to the unsafe transfer, fall, and resulting clavicle fracture. In addition, after the incident, the resident reported that the facility replaced the sling and that the new sling caused significant pain, described as a knife-stabbing sensation to her right leg during each transfer. She stated she did not feel safe when the new sling was used and had not notified the facility of this concern. The report notes that the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically citing the improper attachment of the sling by CNA G and the lack of clear systems for training, competency validation, and equipment inspection by facility leadership. An Immediate Jeopardy was identified related to this failure, and the facility remained out of compliance at a level of potential for more than minimal harm. The DON stated he was responsible for ensuring nursing staff were skilled and knowledgeable about mechanical lift safety but was not aware if the DOR had been informed of the fall incident. He could not explain who was responsible for inspecting slings and straps or how often mechanical lifts and slings were inspected for safety. The Administrator stated that all direct care staff were responsible for ensuring mechanical lift slings were safe and used properly, and that the DON was responsible for ensuring all direct care staff were trained by the DOR, but he was not aware how the DON tracked training and compliance. These gaps in oversight and unclear responsibilities contributed to the failure to ensure safe mechanical lift transfers and adequate supervision for the resident.

Removal Plan

• Corporate Nurse will provide re-education to nursing staff directly involved in the resident's fall on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• Manufacturer instructions for mechanical lift sling inspection will be placed on each mechanical lift for employee reference.
• Corporate Nurse will provide re-education to the DON and DOR on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• DON/Designee will review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in their care plan.
• IDT will review new admissions in the morning clinical meeting to identify transfer needs and care plan these needs.
• IDT will discuss residents with a change in condition affecting mobility status and update transfer status and care plan as appropriate.
• Care planned interventions, including transfer status, will be placed on the resident Kardex so direct care staff can view resident-specific needs.
• Corporate Nurse/Consultant Nurse will educate the DON/ADON on the facility orientation checklist for nursing staff; education validated via facility mechanical lift competency checklist.
• Corporate Nurse, DON, DOR or designee will re-educate nursing staff and therapy staff on appropriate transfer and safe handling of residents during mechanical lift transfers, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• DON or designee will audit mechanical lift transfers.
• A QAPI PIP will be initiated to report on the monitoring and auditing procedures.
• All findings from the PIP will be presented at the monthly QAA meeting.
• Monitoring/auditing and reporting will continue.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident’s need for an escort to off-site medical appointments. The resident was an older male with multiple significant diagnoses, including unspecified dementia with agitation, hypertension, dysphagia, hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, depression, HIV disease, cognitive communication deficit, and blindness in one eye. His Annual MDS showed he was rarely or never understood, had short- and long-term memory problems, was severely impaired in daily decision-making, and was totally dependent on staff for toileting, showering, footwear, and bed mobility. Despite these documented cognitive and functional impairments, his care plan did not include an intervention or measurable objective related to the need for an escort to accompany him to medical appointments. The resident’s care plan, dated in early January, addressed ADL self-care deficits, impaired cognitive function/dementia, and seizure disorder, with interventions such as total staff assistance for bathing and transfers, cuing and reorientation, consistent routines and caregivers, and seizure management steps. However, there was no care plan problem, goal, or intervention addressing the resident’s inability to communicate effectively or manage his own medical information during off-site visits, nor any directive that he required an escort. A care plan meeting held shortly before the survey documented that the responsible party (RP) attended and that no concerns, issues, or changes from the last care plan were recorded, despite the resident’s significant cognitive and communication deficits. The medical record also lacked documentation of the resident’s clinic visit that occurred at the end of December, with no progress notes, assessments, or uploaded records related to that appointment. Interviews and observations further demonstrated that the resident’s need for an escort was not incorporated into his care plan or consistently implemented. Clinic staff reported that when the resident arrived for his appointment, he seemed “out of it” and did not have his health information with him, and that the NP had to call the RP, who stated that facility staff should have gone with him. The RP stated she was aware of the appointment and that the facility told her they would get him to the appointment, but did not tell her she needed to attend; she also stated the resident was unable to talk about what was going on with him and that she had brought this to the facility’s attention during a care plan meeting. Facility staff, including an LVN, the SW, the MDS nurse, the DON, and the Administrator, gave varying accounts about who usually accompanied the resident and acknowledged there was no specific policy and no documentation in the record indicating that an escort was required. The SW admitted she forgot to update the record to indicate the need for an escort, and the MDS nurse acknowledged that, given the resident’s BIMS of 00 and that he was rarely or never understood, he should have been accompanied. The Administrator stated there was a communication breakdown and that having an escort should have been documented in the resident’s record, but it was not, and no notes from the clinic visit were available in the record as of survey exit. The facility’s failure to include the need for an escort in the resident’s comprehensive care plan, despite his severe cognitive and communication deficits and total dependence on staff, and the absence of documentation of the off-site clinic visit, constituted a failure to ensure a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the resident’s identified medical, nursing, and psychosocial needs. The report states that this failure could place residents at risk of not receiving appropriate care and interventions to meet their needs.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and that the resident received adequate supervision and assistance devices to prevent accidents during an off-site clinic visit. The resident was an elderly male with multiple significant diagnoses, including unspecified dementia with agitation, hypertension, dysphagia, left-sided hemiplegia and hemiparesis following a cerebral infarction, depression, HIV disease, cognitive communication deficit, and blindness in one eye. His Annual MDS showed he was rarely or never understood, had short- and long-term memory problems, was severely impaired in daily decision-making, and required total assistance for toileting, showering, footwear, and bed mobility. His care plan documented an ADL self-care performance deficit requiring a mechanical lift with two staff for transfers, impaired cognitive function/dementia requiring cueing, reorientation, and supervision, and a seizure disorder with specific post-seizure interventions. On the date of the clinic visit, there was no documentation in the resident’s medical record regarding the off-site appointment, including in progress notes, assessments, or uploads. At the clinic, the NP who saw the resident reported that he arrived not responsive, not oriented, and unaccompanied. The NP stated the resident was only able to answer a little, and another NP had to call the resident’s responsible party (RP) because the resident could not provide necessary information. The NP also reported the resident was soiled upon arrival, and clinic medical assistants were unable to assist him into a standing position to change him. Clinic staff confirmed the appointment date and reported that the resident did not have his health information with him when he arrived. The resident’s RP stated she was aware of the appointment but was not told by the facility that she needed to attend with the resident; she reported the facility told her they would get him to the appointment. She further stated the clinic called her during the visit because the resident could not recite his birthday and social security number and that the clinic told her they tried to call the facility but were unable to reach anyone. Facility staff interviews showed inconsistent understanding and lack of clear responsibility for arranging an escort: an LVN recalled seeing the resident leave for the appointment and assumed the RP would be there; the SW stated the facility typically sent someone with this resident and that he should have been accompanied, but she acknowledged she had forgotten to enter the escort information in the record, describing this as an oversight. The Administrator and MDS nurse both acknowledged that some residents required escorts and that this resident, with a BIMS of 0 and being rarely or never understood, should have been accompanied, yet there was no policy in place on accompanying residents to appointments and no documentation of an escort for this visit. A requested supervision policy and documentation of the resident’s 12/31 appointment notes were not provided by the time of survey exit. Interviews with leadership further confirmed that there was no specific written policy on escorts to off-site appointments and that the process relied on communication among staff and with the RP. The Administrator stated that some residents could go alone and some had an aide, and that if residents needed an escort, the facility would coordinate it, sometimes based on family-made appointments and BIMS scores. The MDS nurse reported that an aide was supposed to go with the resident but did not know who, and she did not believe escort needs had to be care-planned because staff were presumed to know which residents required escorts. The DON stated that if the resident was going to a clinic, he would have been supervised by the van driver and clinic staff, indicating reliance on external personnel rather than a designated facility escort. Overall, the resident, who had severe cognitive and functional impairments and was dependent on staff for mobility and ADLs, was sent to an off-site clinic visit without an escort, without his health information, and without facility documentation of the visit, constituting the cited failure to ensure adequate supervision and a hazard-free environment during the off-site appointment.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident who was totally dependent on staff for activities of daily living, including bathing, and who had multiple significant diagnoses such as dementia with agitation, hypertension, dysphagia, post-stroke hemiplegia, depression, HIV disease, cognitive communication deficit, and blindness in one eye. The resident’s Annual MDS documented that he was rarely or never understood, had severe cognitive impairment, and required total assistance for toileting, showering, footwear, and bed mobility. His care plan called for 2–3 baths weekly and as necessary, with total assistance from 1–2 staff and use of a mechanical lift with 2 staff for transfers, as well as consistent routines and caregivers due to impaired cognition. Record review of the resident’s bathing schedule for the last 30 days showed that on multiple dates (12/30/2025, 1/1/2026, 1/3/2026, 1/6/2026, 1/6/2026, 1/10/2026, and 1/13/2026), his bath did not occur or was documented as being provided 100% of the time by family and/or non-facility staff. The responsible party later stated she never gave the resident a shower and considered bathing to be the facility’s responsibility. Staff interviews revealed that a CNA had not yet given the resident a shower, and an LVN could not locate shower sheets for the resident for December, with the last available shower sheet dated 11/20/2025 and showing no skin conditions. The ADON explained that aides were expected to document showers on physical shower sheets and in the medical record, and acknowledged there were no reports of the resident refusing showers. The DON and ADON stated that showers or bed baths were being provided but not documented, and the DON attributed missing documentation to staff being busy and high staff turnover. In addition, the facility failed to maintain documentation related to the resident’s clinic visit on 12/31/2025. The resident’s medical record contained no progress notes, assessments, or uploaded documents regarding that appointment. Clinic staff confirmed that the resident had an appointment on that date and reported that he arrived “out of it” and without his health information; attempts to call the facility were unsuccessful. The responsible party also confirmed that the resident had a clinic visit on that date. The SW was unsure of the exact appointment date and stated she would request records from the clinic, but no documentation of the visit was received by the time of survey exit. These omissions occurred despite a facility policy stating that residents unable to carry out ADLs will receive necessary services to maintain grooming and hygiene, and that refusals of care should be documented after efforts to inform and educate the resident or representative.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide timely and necessary ADL care, including repositioning, incontinence care, and a scheduled bed bath, to a dependent resident. The resident was a 57-year-old female with acute respiratory failure with hypoxia, morbid obesity, and paralytic syndrome following cerebral infarction. Her MDS showed intact cognition (BIMS 14), total dependence on staff for all ADLs, and always-incontinent bladder and bowel status, with identified risk for pressure ulcers. Her care plan required that she remain clean, dry, odor-free, and well-groomed, with total assistance of two staff for toileting and personal hygiene, extensive assistance of two staff for bed mobility and dressing, and routine sponge baths when a full bath could not be tolerated. The shower/bathing schedule showed she was to receive a bed bath on the day shift, and facility policies required assistance with bathing, ADLs, and turning/repositioning every 2–4 hours. On the cited date during the 6:00 AM–2:00 PM shift, CNA documentation did not show that the resident received repositioning, incontinence care, or her scheduled bed bath. The resident reported that she had requested assistance earlier in the morning to have her soiled brief changed and to receive a bed bath, but the care was not provided. She stated she later informed another CNA of her need for a brief change and continued to wait, and that there were days when she called for assistance and no staff came, and days when no one checked on her until approximately 6:00 PM. She further stated she had not been repositioned even once during the morning shift, that staff including a nurse, the DON, and CNAs had checked in on her but did not reposition her, and that she was supposed to receive a bed bath that morning but was not offered one. She denied skin breakdown related to the delayed care. Nursing staff interviews confirmed that the ordered care was not provided during the morning shift. A nurse stated he reminded the assigned CNA multiple times during the shift to provide the bed bath and that the CNA assured him it would be completed before shift end; later, the CNA told him she had arranged for another CNA to help with the bed bath. The CNA assigned to the resident admitted that during her 6:00 AM–2:00 PM shift she did not reposition the resident, did not provide incontinence care, and did not provide the scheduled bed bath, despite the resident informing her of the need for a change. She acknowledged the resident required 2–3 staff for care, stated she did not ask for assistance during the shift, and said she planned to provide care after lunch during the following shift. The DON stated that dependent residents were expected to be repositioned at least every two hours and that staff had been trained on incontinence care, repositioning, and ADLs, and confirmed he was not informed that the required care had not been provided. Later observation of care showed removal of a wet brief and a bed bath with intact skin and no pressure injuries noted.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medication carts were properly secured and locked, as required by policy and professional standards. During observations, three out of five medication carts were found unlocked and unattended in areas accessible to residents, staff, and visitors. On one occasion, a nurse left two medication carts unlocked and unattended while she entered a resident's room, leaving blister packs of medication on top of one cart with a resident sitting nearby. Another medication cart was observed unlocked while the responsible nurse was at the nurse's station, unaware that the surveyor was able to open drawers and take photographs. These carts contained prescription drugs, over-the-counter medications, vitamins, and, in some cases, narcotics stored in a locked box within the cart. Interviews with nursing staff, the DON, and the ADM confirmed that all had been trained on medication storage policies, which require medication carts to be locked whenever unattended. Staff acknowledged their responsibility for securing the carts and recognized the risks of leaving them unlocked. Despite this, the medication carts were left unsecured, and staff could not provide explanations for these lapses. Review of the facility's Medication Storage Policy further confirmed the requirement for secure storage of all medications.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple complex medical conditions, including type 2 diabetes, chronic kidney disease, chronic pancreatitis, depression, and muscle weakness, experienced a significant change in condition that was not promptly assessed or addressed by nursing staff. On the evening in question, a CNA observed the resident doubled over in pain, grayish in color, and vomiting, with a fever of 103°F and a self-reported pain level of 10 out of 10. The CNA reported the resident's condition to the nurse on duty, but the nurse did not assess or provide medical care for approximately two hours after the initial notification. During this time, the resident continued to deteriorate, and multiple staff and residents reported the resident's distress to the nurse, but no timely intervention occurred. The resident's condition escalated to the point where the CNA, after observing continued vomiting and severe pain, called 911 from her personal phone. Emergency medical services arrived and transported the resident to the hospital, where he was diagnosed with fever, a left heel wound infection, a complicated urinary tract infection (UTI), and acute kidney injury (AKI). Interviews with staff and residents revealed inconsistent accounts regarding the communication of the resident's symptoms to the nurse, but it was confirmed that the nurse did not enter the resident's room or assess him until emergency services had already been called and were arriving at the facility. Documentation and interviews further indicated that the nurse did not notify the resident's family or responsible party of the hospitalization, and there was a lack of clear, timely communication and follow-up regarding the resident's change in condition. The facility's own policies required prompt assessment and notification of significant changes in a resident's health status, but these procedures were not followed in this instance, resulting in a delay in care and failure to provide treatment in accordance with professional standards of practice.

Penalty

No penalty information released

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

Summary

The facility failed to immediately notify a resident's physician and responsible party when the resident experienced a significant change in condition. The resident, a male with diagnoses including type 2 diabetes mellitus, chronic kidney disease, degenerative nervous system disease, chronic pancreatitis, depression, and muscle weakness, began experiencing severe symptoms such as vomiting, chest pain, and a high fever. Multiple staff and residents reported the resident's deteriorating condition to the assigned nurse, but the nurse did not promptly assess the resident or notify the physician or the resident's representative. The certified nurse aide (CNA) observed the resident doubled over, with grayish skin and severe pain, and after waiting over an hour for the nurse to respond, called 911 herself. The nurse only entered the resident's room shortly before emergency medical services arrived. Documentation showed that the nurse recorded the resident's symptoms and transport to the hospital but did not document any notification to the physician or the resident's representative. The nurse later stated she may have left a message for the physician after the resident was taken to the hospital but did not contact the resident's representative and had no reason for not doing so. Interviews with the nurse practitioner and the resident's family confirmed that neither the physician nor the resident's emergency contact were notified at the time of the incident. The nurse practitioner indicated that earlier notification could have allowed for intervention. The facility's own policy required prompt notification of significant changes to both the physician and the resident's representative, but this was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely and adequate incontinent care for two residents, resulting in a lack of dignity and compromised grooming. For one resident, who had morbid obesity, diabetes, hypertension, and required assistance with personal care, observations revealed that her incontinent brief was saturated with urine and brown in color, indicating it had not been changed for an extended period. The resident reported that she had only been changed once that day and that her requests for care were not promptly addressed. Staff interviews confirmed that the resident was not checked or changed every two hours as required by her care plan, and the responsible aide did not communicate the lack of care to the nursing staff. Another resident, also with morbid obesity, diabetes, hypertension, and a history of cerebral infarction, required total assistance with activities of daily living. This resident reported not being changed by the morning aide and feeling dirty and upset due to the delay. Upon assessment, her incontinent brief, draw sheets, and air mattress were found to be soaked with urine, and the brief was brown inside, indicating prolonged exposure. Staff interviews corroborated that the resident had not been changed for hours, and aides acknowledged the expectation to provide care every two hours, which was not met in this instance. Facility policy and staff statements confirmed that incontinent care should be provided at least every two hours and as needed, regardless of the resident's size or condition. Both residents expressed negative feelings about being left in soiled briefs, and staff recognized that such lapses in care were unacceptable. The documentation and interviews consistently showed that the facility did not adhere to its own policies or the residents' care plans, resulting in a failure to honor the residents' rights to dignity and timely personal care.

Penalty

No penalty information released

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

Summary

Two residents with significant medical needs did not receive timely assistance with activities of daily living, specifically incontinent care. One resident, a female with morbid obesity, diabetes, hypertension, and a need for personal care assistance, was found with a saturated and soiled incontinent brief during a head-to-toe skin assessment. She reported that she had only been changed once that day, despite requesting assistance before lunch, and expressed feeling uncared for due to being left in a dirty brief for hours. Staff interviews confirmed that the resident had not been checked or changed according to the facility's policy of every two hours, and that this lapse was not communicated between shifts. Another resident, also a female with morbid obesity, diabetes, hypertension, and a history of cerebral infarction, required total care with two staff for assistance. She reported not being changed by the morning aide and having to request help from the nurse, which was not provided in a timely manner. Upon observation, her incontinent brief, draw sheets, and air mattress were found to be soaked with urine, indicating she had not been changed for an extended period. Staff interviews corroborated that rounds for incontinent care were not performed as required, and that the resident was left in a soiled state for hours. Facility staff, including CNAs, nurses, the DON, and the administrator, acknowledged that residents should be checked and changed every two hours and as needed, regardless of their size or care needs. The facility's policy and care plans for both residents specified the need for frequent monitoring and prompt changing to maintain hygiene and prevent complications. However, direct observations, resident interviews, and staff statements revealed that these protocols were not followed, resulting in residents being left in wet and soiled briefs for prolonged periods.

Penalty

No penalty information released

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

Summary

Certified Nursing Assistants (CNAs) failed to provide appropriate perineal care to a female resident who was frequently incontinent of bladder and bowel and required total assistance with activities of daily living. During an observed episode of incontinent care, a CNA did not separate the resident's labia while cleaning, instead wiping between the closed peri area multiple times without visualizing the area. The resident expressed pain during the process, and bright red blood was noted on the wipes. The CNA did not stop care or notify the nurse as required when the resident reported pain and bleeding. Interviews with staff confirmed that the expected procedure was to separate the labia and clean each side and the middle with separate wipes, and to notify the nurse if there was pain or bleeding. The resident had a history of morbid obesity, diabetes, hypertension, and cerebral infarction, and was assessed as having moderately impaired cognition. The care plan specified prompt changing and application of a protective barrier to the skin. The facility's policy required separating the labia and cleaning from front to back to prevent infection. Staff interviews revealed knowledge of the correct procedure, but it was not followed during the observed care, resulting in inadequate cleaning and failure to assess the source of bleeding.

Penalty

No penalty information released

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

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and personal protective equipment (PPE) practices during incontinent care for a resident. Two CNAs provided care without washing their hands and donned gloves taken from their uniform pockets, rather than from a clean supply. Throughout the care process, the CNAs used the same gloves for multiple tasks, including cleaning the resident and applying a clean incontinent brief, which resulted in cross-contamination. Additionally, one CNA used peri wipes instead of disinfectant wipes to clean urine from the resident's air mattress, failing to properly disinfect the surface. The resident involved was a female with significant medical conditions, including morbid obesity, diabetes mellitus, hypertension, and a history of cerebral infarction. She required total assistance with activities of daily living and was frequently incontinent of bladder and bowel. Her care plan specified prompt changing and the use of protective barriers, but the observed care did not adhere to infection control protocols outlined in facility policy. Interviews with the CNAs, LVN, DON, and Administrator confirmed that the staff did not follow established procedures for hand hygiene and glove use, and acknowledged the risk of cross-contamination from their actions. Facility policies required hand hygiene before donning gloves and after glove removal, and specified the use of disinfectant wipes for cleaning contaminated surfaces, but these protocols were not followed during the observed incident.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident's call light system was found to be non-functional, preventing the resident from reliably calling for staff assistance. The resident, who required total care with assistance from two staff members and had moderately impaired cognition, reported that her call light worked intermittently. During an observation, the resident demonstrated that pressing the call light did not activate the indicator in the room or above the door. The resident stated that staff were aware of the issue, but she was unsure how long the problem had persisted. A nurse (LVN) confirmed the malfunction during an interview and attempted to troubleshoot the device by replacing the call light cord, which restored functionality. The LVN admitted she had not checked the call light before handing it to the resident and stated she would notify maintenance. The Director of Nursing (DON) and the facility Administrator both acknowledged that staff were responsible for ensuring call lights were operational before providing them to residents, and that maintenance was responsible for repairs. However, the maintenance director indicated that while monthly checks of call lights were performed, they were not documented, and only annual checks were recorded. There was no documentation in the maintenance log regarding the reported malfunction for the relevant period. The facility's policy required staff to report call light problems immediately and to provide alternative solutions until repairs could be made. Despite this, there was no evidence that the malfunction had been reported or that alternative measures were implemented prior to the surveyor's observation. The lack of documentation and failure to verify the call light's functionality resulted in the resident being unable to reliably summon assistance, as confirmed by multiple staff interviews and record reviews.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently. One resident, a male with a history of cerebral infarction, hypertension, atrial fibrillation, and diabetes mellitus, required extensive ADL care with one staff assist and had a care plan that included nail care. Despite this, observations revealed that his fingernails were dirty with a dark brown substance, and he reported that staff had not cleaned his nails even when he requested it. Multiple staff members, including CNAs and LVNs, acknowledged the resident's dirty fingernails and recognized the importance of nail care in preventing infection, but also indicated a lack of recent in-service training or skills check-offs related to ADL or nail care. Another resident, a male with end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, was dependent on staff for ADL care. Observations showed that this resident had ashy, dry patches of skin and was seen scratching his skin, which he reported was not being moisturized by staff after bed baths. Staff interviews confirmed that aides were responsible for applying lotion as part of daily ADL care, but the resident stated this was not being done. Staff also indicated that there was no recent training or skills check-off on skin care, and the resident's care plan did not include completed ADL care instructions. Record reviews and staff interviews further revealed that there was no documentation of recent training, skills check-offs, or in-service education for staff regarding nail and skin care. The facility's own policy required nail care to prevent infection, but staff relied on prior school training rather than facility-provided competency checks. The lack of adherence to care plans and absence of ongoing staff training contributed to the residents not receiving necessary personal hygiene and grooming services.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program for two of four residents observed. For one resident with end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, who was admitted with a wound on his left heel and required assistance with activities of daily living, there was no Enhanced Barrier Precaution (EBP) sign posted on the door and no personal protective equipment (PPE) set up at the resident's door, despite the resident being on EBP. Multiple staff interviews confirmed that the sign and PPE should have been present to prevent the spread of infection, and staff were unclear about who was responsible for posting the sign and setting up PPE. Some staff also reported not having received in-service training on infection control procedures. Additionally, a clean, uncovered linen cart with linens was observed stored in another resident's room. Staff interviews revealed that the linen cart should not have been stored in a resident's room due to the risk of cross-contamination. While some staff had received in-service training on infection control and linen storage, others had not. The facility's policy requires clean linens to be stored in a designated space with a closed door to reduce accidental contamination. The facility's policies on clean laundry storage and enhanced barrier precautions were not followed, as evidenced by the lack of signage, PPE availability, and improper linen storage. Staff interviews indicated inconsistent knowledge and training regarding infection control practices, and monitoring systems for ensuring compliance were not effectively implemented.

Penalty

No penalty information released

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

Summary

Surveyors observed that a resident's call light was not within reach while the resident was in bed. The call light was found under the dresser on the right side of the bed, and the resident was unaware of its existence. When prompted by the surveyor to use the call light for assistance, the resident stated he did not know he had one. The call light was only located after a search by surveyors, and it was then attached to the resident's blanket to ensure accessibility. The resident involved had a history of facial weakness following cerebrovascular disease and attention and concentration deficits following cerebral infarction, with a moderate cognitive impairment as indicated by a BIM score of 12 out of 15. He required substantial to maximum assistance for activities of daily living and had lower extremity impairment. The facility's policy required that call lights be accessible to residents at all times, but this was not followed in this instance, resulting in the resident being unable to request assistance when needed.

Penalty

No penalty information released

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

Summary

A deficiency occurred when LVN F failed to secure a computer during a medication pass, leaving a resident's medical records visible and accessible in the hallway. The incident was observed as LVN F retrieved IV medication from the medication cart and entered the resident's room without locking or closing the computer screen, which displayed the resident's medical information. The nurse later acknowledged forgetting to close the record and recognized this as a violation of privacy and HIPAA regulations. The resident involved was a female with diagnoses including staphylococcal arthritis, chronic pain, anemia, hypertension, heart failure, and stage 3 kidney disease. She was receiving IV antibiotics as ordered, and her cognitive status was intact according to her BIMS score. Facility policies reviewed indicated requirements for staff to maintain privacy and confidentiality of resident records, which were not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to develop a person-centered baseline admission care plan within 48 hours for two residents following their admission. For one resident, who had a history of hemiplegia, hemiparesis following a stroke, and a brief psychotic disorder, there was no baseline care plan documented in the medical record. The comprehensive care plan that was present addressed some care needs but was undated, and the Director of Nursing (DON) confirmed that a baseline care plan should have been in place to ensure the resident received appropriate care. For another resident, who had end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, there was also no baseline care plan found in the medical record. This resident was dependent on staff for activities of daily living (ADLs) and had intact cognition. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Nursing (ADON), and the admitting nurse, revealed confusion and lack of clarity regarding responsibility and procedures for initiating and completing the baseline care plan within the required timeframe. The facility's policy required a baseline plan of care to be developed within 48 hours of admission to address immediate health and safety needs. However, staff interviews indicated inconsistent understanding of this process, with some staff unaware of their responsibilities or lacking training on baseline care plan development. As a result, the two residents did not have individualized baseline care plans in place to guide their care during the initial period following admission.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the lack of measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. For one resident with severe cognitive impairment and a diagnosis of dementia, the facility did not include the resident's hospice status as a focus area in the comprehensive care plan, despite documentation indicating coordination with hospice services and selection of hospice care in the MDS assessment. There was no care plan intervention in place to address the resident's hospice needs, and physician orders for hospice services were not reflected in the resident's records at the time of review. Another resident, who was cognitively intact but dependent on staff for activities of daily living (ADL) due to multiple chronic conditions including end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, did not have ADL care addressed in the comprehensive care plan. The care plan was not completed to include the resident's ADL needs, despite the resident requiring one to two staff for assistance. Interviews with facility staff confirmed that the care plans were incomplete and not in accordance with facility policy, which requires comprehensive, person-centered care plans to be developed within a specified timeframe after admission or completion of the MDS assessment. The facility's policy states that care plans must include measurable objectives, timeframes, and describe the services to be furnished to attain or maintain the resident's highest practicable well-being. However, the care plans for both residents lacked these essential components, and staff acknowledged that the absence of complete care plans could result in residents not receiving all appropriate care from staff. The findings were based on record reviews and staff interviews, which confirmed the deficiencies in care planning for the affected residents.

Penalty

No penalty information released

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

Summary

A resident with a history of quadriplegia, bipolar disorder, and seizures, and who was assessed as having severely impaired cognition and limited range of motion (ROM) in both upper and lower extremities, did not receive appropriate preventive care measures to maintain or improve ROM and prevent further contractures of the hands. Physician orders and occupational therapy recommendations specified the use of resting hand splints and palmar guards for set periods to reduce pain and improve passive ROM, and the care plan included the use of pressure-reducing products such as hand rolls. However, multiple observations over two days revealed that the resident consistently did not have any hand contracture devices in place, and the resident's fingernails were noted to be long and dirty. Interviews with nursing and rehabilitation staff confirmed that the resident was not provided with the recommended hand devices, and there was a lack of clarity and follow-through regarding responsibility for ensuring these interventions were implemented. The Director of Rehab Services stated that the facility did not have a restorative care program at the time, and both the LVN and DON acknowledged that it was the responsibility of nursing staff and CNAs to ensure the use of hand rolls and proper nail care. Facility policy required residents with limited ROM to receive treatment and services to prevent further decline, but these measures were not provided for this resident.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a housekeeper left a container of micro-kill germicidal wipes unattended on top of her cart in a hallway, rather than securing it in the cart's locked compartment as required. During this time, a male resident with hemiplegia, hypertension, atrial fibrillation, and diabetes, who had a BIMS score indicating intact cognition but was noted to have impaired decision-making skills and safety awareness at intervals, accessed the wipes. The resident took approximately ten wipes from the container, used them to wipe his hands, both sides of his mouth, and his mattress, and then disposed of them in his trash can. The housekeeper was inside a resident's room and out of sight when this occurred. Interviews with staff revealed that the housekeeper was aware of the requirement to lock up chemicals but failed to do so, and could not recall details from her training on hazardous materials. Other staff, including a CNA and the housekeeping supervisor, confirmed that the wipes should have been secured to prevent resident access, as they could cause harm such as skin or eye irritation. The resident reported that he regularly took wipes from the cart. The facility's in-service documentation indicated that housekeepers were instructed to leave all chemicals in locked carts, and the housekeeper involved had signed this training. The facility's policy on accident/hazard prevention was requested but not provided.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections. Specifically, two residents with indwelling catheters did not have a Statlock catheter securement device in place during observations, despite physician orders and care plans indicating the need for such a device. For one resident, the care plan included an intervention to change the Foley tubing securement device weekly and as needed if loose or soiled, but observation revealed the absence of a Statlock. Similarly, another resident's care plan required monitoring for catheter migration and providing catheter care every shift, yet the Statlock was not in place during observation. Interviews with nursing staff and the DON confirmed that it was the responsibility of nurses to ensure the Statlock was in place to prevent accidental dislodgement of the Foley catheter. The CNA interviewed stated that while CNAs provide catheter care and report if the Statlock comes off, only nurses are responsible for placing the device. The facility's policy on catheter care also required securing the catheter with a securement device. These findings were based on direct observation, record review, and staff interviews.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that drugs and biologicals were stored properly in accordance with professional standards of practice in one of two medication rooms. During an observation of the Hall 100 medication storage room, three expired hydrocortisone acetate 25mg suppositories with an expiration date of 03/2025 were found. Interviews with an LVN and the DON revealed that the DON was responsible for checking the medication rooms for expired medications, and both acknowledged the risks associated with administering expired medications. The DON stated that he checked the medication storage rooms every morning and suggested that someone must have placed the expired medication in the storage room fridge. The facility's Regional Nurse was asked for the policy on expired medications and drug destruction.

Penalty

No penalty information released

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

Summary

A deficiency was identified when one of the facility's dumpsters, located behind the dietary department, was observed without a lid attached or covering it. The lid was found detached and placed on the side next to the dumpster, which was about a quarter full. On a subsequent observation, the right lid of the same dumpster was open and marked with white chalk. Staff interviews revealed that the reason for the open dumpster was unknown, but it was acknowledged that leaving the dumpster uncovered could attract rodents, especially given its proximity to a sewage line. The dietary manager stated that the trash company was scheduled to deliver a new dumpster due to a broken metal rod that connects the lids, and also noted that the facility had two other dumpsters available for use. The administrator confirmed that the trash company had been contacted and a replacement was expected. Facility policy requires that outside dumpsters be kept closed and free of surrounding litter, in accordance with state laws. The failure to keep the dumpster covered and in proper working order constituted a violation of this policy, as observed and documented by the surveyors.

Penalty

No penalty information released

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

Summary

The facility failed to establish and maintain an adequate system for the receipt, storage, and disposition of controlled drugs, specifically Norco (Hydrocodone-Acetaminophen), for a resident with multiple complex medical conditions including lung cancer, COPD, and chronic pain. After the resident was discharged to the hospital and subsequently returned, it was discovered that the Norco medication, which had been delivered and signed for, was missing. The medication was not appropriately stored under double lock in the DON's office as required when the resident was transferred, and the absence was only identified when the resident requested pain medication upon return. Review of the controlled drug count records for the relevant period revealed multiple instances of incomplete or missing signatures from both oncoming and off-going nursing staff, indicating that the required shift-to-shift narcotic counts were not consistently performed or documented. Interviews with nursing staff and management confirmed that the protocol for handling controlled substances during resident transfers was not followed. The medication was not removed from the cart and secured by the DON, and there was confusion among staff regarding the proper procedures for narcotic handling during resident absences. Further, statements from staff indicated lapses in communication and accountability, with some staff unsure of who was responsible for the narcotics at various times. The facility's own policies required controlled medications to be counted at each shift change and secured by the DON when a resident was transferred, but these procedures were not adhered to, resulting in the loss of the controlled medication and incomplete documentation of its handling.