Ashley Rehabilitation And Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rogers, Arkansas.
- Location
- 2600 N 22nd Street, Rogers, Arkansas 72756
- CMS Provider Number
- 045421
- Inspections on file
- 29
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Ashley Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
A registered nurse left a medication cart unattended with a computer screen displaying residents' electronic medication administration records, allowing staff and residents passing by to view protected health information. Interviews confirmed staff are trained to lock screens, and facility policies require confidentiality of medical records.
Staff failed to perform hand hygiene after resident care and before and after medication administration for three residents. An RN was observed exiting a resident room without sanitizing hands, then handling and administering medications to other residents, including pouring a pill into an ungloved hand. Interviews confirmed that these actions were not in line with facility infection control policies.
A resident with moderate cognitive impairment experienced emotional abuse when a CNA made inappropriate comments and showed an inappropriate picture during a shower. The facility delayed investigating the incident, leading to the resident's distress, including nightmares and self-harm. The facility's inadequate staff training and improper rehiring practices contributed to the deficiency.
A resident, who was a full code, was found pulseless and breathless, but staff failed to administer CPR as required by the care plan and POLST. Despite the presence of staff at the bedside, CPR was not initiated, and there was no documentation of vital signs being taken. The DON confirmed the resident's full code status, but confusion arose due to a claimed physician order to withhold CPR, which the physician did not recall giving. The facility lacked a policy on when to withhold CPR, contributing to the inaction.
The facility experienced staffing deficiencies, resulting in residents not receiving scheduled showers. Interviews and records indicated that several shifts in September 2024 were understaffed, with some having only two staff members or none at all. Staff expressed concerns about insufficient time to complete duties, and grievance logs showed multiple complaints about missed showers. The facility's assessment lacked a contingency plan for staffing shortages.
The facility did not post the required daily nurse staffing information, including the facility name, date, staff hours, and resident census, potentially affecting all 60 residents. The DON believed these postings were no longer required.
The facility failed to maintain proper food storage and sanitation standards. Observations revealed uncovered and expired food items in storage areas, a dirty ice machine, and dietary staff not adhering to hand hygiene protocols. The facility's handwashing policy was not followed, compromising food safety.
The facility did not have a policy for the governing body, and the governing body was not involved in the development and implementation of the facility assessment. The Administrator confirmed that no governing body member assisted with the assessment and that the facility lacked a documented policy for the governing body.
The facility's assessment was incomplete, missing critical components such as resident population details, facility resources, risk assessments, staffing needs, and staff training. The Administrator, responsible for the assessment, admitted it was his first time completing it and that neither the governing body member nor the medical director contributed. This deficiency potentially affected all 60 residents.
The facility did not ensure that the arbitration agreement included the right for residents to rescind within 30 days, instead allowing only 21 days. The administrator confirmed the discrepancy and the lack of a policy on arbitration agreements, potentially affecting all residents who signed.
The facility's arbitration documentation failed to include details on selecting a neutral arbitrator and a convenient location, affecting all 47 residents. Interviews with the Administrator and Admission Director revealed the absence of such language in the admission agreement, and the Administrator confirmed there was no policy for arbitration agreements.
The facility failed to consistently implement infection surveillance and lacked a water management plan for Legionella. Incomplete Infection Control Log analysis forms and the absence of a Legionella management plan were noted. The Infection Control Nurse confirmed no infection surveillance was being conducted, contrary to the facility's policy requiring facility-wide surveillance to prevent infections.
The facility failed to maintain a consistent antibiotic stewardship program, as infection control assessments were not completed for several months. A resident with a cutaneous abscess was prescribed an intravenous antibiotic, but there was no evidence to confirm the necessity or adjustments of the treatment. The Infection Control Nurse admitted to not conducting necessary investigations, and the DON was not involved in the process. The facility's policy aimed to optimize antimicrobial use and control resistance, but these goals were not achieved due to inadequate assessments and documentation.
The facility did not conduct required annual in-service training on communication for direct care staff. A review of records showed no communication training was completed between late 2023 and late 2024. The Administrator could only provide documentation of an in-service on resident rights. The DON, unaware of the incomplete trainings, had been working on them since her arrival and provided a recent in-service covering other topics.
The facility did not conduct required annual in-service trainings on compliance and ethics for staff from late 2023 to late 2024. The Administrator could not provide documentation of these trainings, except for one on resident rights. The DON stated that the Administrator was responsible for these in-services and was unaware of their omission, although she had been working on completing them since her arrival.
The facility did not conduct required annual in-service trainings for staff in behavioral health services. The Facility Assessment lacked information on staff preparation for residents needing behavioral health care. In-service records from the past year showed no completed trainings in this area. The Administrator could only provide evidence of an in-service on resident rights, and the DON was unaware of the incomplete trainings, although she had been working on them since her arrival.
The facility did not conduct required annual in-service trainings for staff, particularly in dementia care and abuse prevention. A review of records showed no in-services for dementia care were completed over a year. The Administrator could only provide documentation for an in-service on resident rights, and the DON was unaware of the reason for the missing trainings.
The facility failed to maintain lint-free dryer traps, posing a fire hazard. A surveyor found excessive lint build-up in all three dryers, with the last documented cleaning entry made the previous morning. The Housekeeping Supervisor confirmed lint should be removed after every three loads, but the evening shift employee admitted to not doing so. The facility's Fire Policy did not address this issue.
A facility failed to implement its abuse prevention policies after a resident reported inappropriate behavior by a CNA. The resident, with moderate cognitive impairment, was shown an inappropriate picture by the CNA, leading to distress and self-harm. Despite the administrator's awareness, the CNA continued to work near the resident due to staffing issues, and no new background checks were conducted upon her return.
A resident's discharge summary was incomplete, missing details on medications and discharge status, and lacked a physician's signature. The facility's policy required these elements, but they were not included, leading to a deficiency.
A resident did not receive scheduled showers due to understaffing, with only one CNA available on the hall. The resident, who required substantial assistance due to medical conditions, reported the issue. Grievance logs showed multiple complaints about missed showers, and the DON acknowledged the problem, despite in-service training for staff.
A resident with Alzheimer's and frequent incontinence did not receive timely and proper incontinence care. CNAs failed to clean all areas exposed to urine, risking skin breakdown and infection. The facility's policy emphasizes thorough cleaning to prevent such issues.
A facility failed to assess the risk of entrapment before using bed rails for a resident with Alzheimer's and dementia. Despite the care plan requiring an unobstructed path to the bathroom, a CNA was observed lowering a side rail that blocked the resident's path. The DON confirmed that the side rail restrained the resident and that no entrapment assessment was conducted.
A resident did not receive prescribed Lactulose due to unavailability during medication administration. On two occasions, staff could not find the medication in the cart, and progress notes indicated it was out of supply. The DON stated nurses were responsible for ordering refills, but the medication was not delivered in time, leading to missed doses.
The facility exceeded the acceptable medication error rate, reaching 7.41%. One resident missed doses of Lactulose due to supply issues, while another received an incorrect dosage of a probiotic. Staff failed to adhere to medication administration guidelines.
The facility did not follow the planned menu during a meal service, serving incorrect portions and types of food to residents on specific diets. Residents on Minced Moist Soft diets received less chicken spaghetti and the wrong type of vegetables, while those on pureed diets received less chicken spaghetti than prescribed.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Failure to Protect Resident PHI Due to Unattended Computer Screens
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' protected health information (PHI) on the 200 hall. During observations, a registered nurse left a medication cart unattended with a computer screen open to the electronic medication administration record of a resident. On a separate occasion, the same nurse prepared medication for another resident, locked the medication cart, but left the computer screen open to that resident's medication administration record while entering a resident's room. During these times, both residents and staff were observed walking past the unattended cart and visible computer screen. Interviews with the registered nurse, Director of Nursing, and Administrator confirmed that staff are trained to lock computer screens when unattended to protect resident information, and that leaving screens open constitutes a breach of confidentiality. Facility documents reviewed also emphasized the importance of maintaining the confidentiality and privacy of resident records and information.
Failure to Perform Hand Hygiene During Resident Care and Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during resident care and medication administration, as observed with three residents. Specifically, a registered nurse was seen exiting a resident's room without performing hand hygiene and then proceeded to handle medications and administer them to other residents without sanitizing hands between residents. The nurse also poured a vitamin D pill into their ungloved hand before placing it into a medication cup, contrary to infection control protocols. These actions were directly observed during medication passes and resident care activities. Interviews with the nurse, Director of Nursing, Administrator, and Infection Preventionist confirmed that facility policy requires hand hygiene before and after resident contact, as well as before and after medication administration. The nurse acknowledged awareness of these requirements but did not follow them during the observed incidents. Facility policies reviewed also emphasized the importance of hand hygiene and outlined specific procedures for staff to follow, which were not adhered to in these instances.
Failure to Protect Resident from Emotional Abuse
Penalty
Summary
The facility failed to protect a resident from emotional abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who made inappropriate comments and showed an inappropriate picture to the resident while they were in the shower. The incident occurred when CNA #4 entered the shower room and made comments about the resident's body, which was followed by showing a picture on her phone. This incident was not investigated by the facility until a week later, despite the resident showing signs of distress, such as having nightmares and self-harming behavior. The resident involved had a moderate cognitive impairment and required assistance with activities of daily living. The resident's care plan indicated that they could perform most functions with supervision and limited assistance. Following the incident, the resident exhibited signs of trauma, including being upset, having nightmares, and self-harming by biting their wrist until it bled. The facility's delay in addressing the incident and the lack of immediate investigation contributed to the resident's continued distress. The facility's policies on abuse and neglect were not effectively implemented, as evidenced by the failure to train staff adequately and the inappropriate rehiring of CNA #4 without conducting new background checks. The administrator's decision to allow CNA #4 to work on the same hall as the resident due to staffing shortages further compromised the resident's safety. The facility lacked a clear policy on rehiring employees, which contributed to the oversight in handling the situation appropriately.
Removal Plan
- Resident was interviewed by social services director and requested to talk to a psychiatrist and have a psychiatric evaluation. Evaluation is scheduled.
- Resident currently attends a day group program at Ozark Community Hospital with a psychiatric Advanced Nurse Practitioner 2 times a week.
- All current and future admitted residents will have a safety provided at all times.
- CNA has been terminated.
- DON/Designee will in-service all staff on abuse and neglect as well as psychosocial well-being and will continue to in-service all employees prior to next start of shift.
- This in-service will be done with all new hires and at least annually.
- Any behaviors documented on resident will be reviewed daily in stand-up ensuring that resident feels safe, and needs are being met.
- QA committee will monitor in morning meeting to ensure new hire education on Abuse, neglect and psychosocial well-being will be reviewed, to ensure employees received education. All staff will be reviewed annually.
Failure to Administer CPR to Full Code Resident
Penalty
Summary
The facility failed to administer Cardiopulmonary Resuscitation (CPR) to a resident who was a full code, as per their care plan and Physician Order for Life Sustaining Treatment (POLST). The resident, who was cognitively intact and had diagnoses of heart failure and morbid obesity, was found pulseless and breathless. Despite the resident's full code status, CPR was not initiated by the staff upon discovery. The last recorded vital signs were taken prior to the incident, and there was no documentation of CPR being administered when the resident was found in distress. Interviews revealed that the Director of Nursing (DON) acknowledged the resident's full code status and the lack of documentation regarding CPR administration. The EMS dispatcher reported that upon arrival, two staff members were present at the resident's bedside without administering CPR, and one staff member claimed to have received an order to withhold CPR from a physician. However, the physician later stated he did not recall giving such an order. An LPN who arrived during the incident confirmed that no CPR was being performed and that the resident was cold to touch. The facility lacked a policy on when to withhold CPR, contributing to the confusion and inaction during the emergency situation.
Removal Plan
- A cardiopulmonary (CPR) in-service was initiated by the Director of Nursing (DON).
- DON reviewed all physician orders, care plans, and signed Do Not Resuscitate (DNR) documents for code status.
- Color coded name plates were placed outside resident doors, green for full code and red for DNR.
- An in-service was provided to staff and new hires regarding color coded name plates.
- Quality Assurance and Performance Improvement (QAPI) is to ensure continued employee education.
- Staff interviews were conducted with staff from all positions to verify training had been completed.
- Staff interviewed verified they had been trained on CPR initiation and how to identify DNR or full code residents.
- A review of in-service sheets provided indicated staff had been provided training.
- Those staff who were not physically present to receive the in-services were messaged via telephone by the Administrator, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
Staffing Deficiency Leads to Missed Resident Showers
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the residents' needs over several shifts in September 2024. Interviews and record reviews revealed that residents, including one who was scheduled for showers on specific days, did not receive showers as planned due to understaffing. The grievance logs showed multiple complaints about missed showers in August, September, and October 2024. Staffing schedules and timecards indicated that on several occasions, there were insufficient CNAs and nurses on duty, with some shifts having only two staff members or none at all. Interviews with staff members confirmed the understaffing issues, with CNAs and LPNs expressing concerns about not having enough time to complete their duties, including scheduled showers. The facility's assessment did not include a contingency plan for staffing shortages. The administrator acknowledged the staffing issues and mentioned efforts to hire more CNAs but did not provide details on retention strategies.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information, which is required to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. This deficiency was identified through observation, interview, and record review, and had the potential to affect all 60 residents in the facility. Specifically, the shift staffing schedule for the 7:00 AM to 3:00 PM shift on 10/28/2024 was missing the facility's name, the number and actual hours worked by staff, the resident census, and the licensed staff scheduled to work. Additionally, the staffing schedule for the 11:00 PM to 7:00 AM shift on the same date only listed one Certified Nursing Assistant's (CNA's) name. During an interview on 11/01/2024, the Director of Nursing (DON) stated that the staffing sheets, which should include the facility name, date, census, and total and actual number of hours worked per shift for nursing staff, were no longer required and therefore were not completed.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards, as observed during a survey. In the walk-in freezer, several opened boxes of food items such as cookie dough, garlic bread sticks, and Salisbury steak were not covered or sealed. Additionally, containers of sugar and flour were left uncovered under the food preparation counter. The spice rack contained expired items, including cinnamon, ground ginger, and poultry seasoning. In the nourishment room refrigerator, various food items lacked labels indicating when they were received or opened, and some were expired or discolored. The ice machine was found to have wet black residue on its plastic panels, indicating inadequate cleaning. The Dietary Manager confirmed that the machine is used by CNAs for residents' water pitchers and acknowledged the residue. Furthermore, dietary staff failed to adhere to hand hygiene protocols. Instances were observed where staff handled clean dishes, food preparation equipment, and meal trays without washing their hands after performing tasks that could lead to contamination. The facility's handwashing policy, initiated in 2018, was not followed by dietary staff, as evidenced by multiple observations of staff failing to wash hands between tasks. This included handling clean and dirty items without proper hand hygiene, which could compromise the safety and quality of food served to residents. The Dietary Manager confirmed the lapses in hand hygiene and food storage practices during interviews.
Lack of Governing Body Involvement in Facility Assessment
Penalty
Summary
The facility failed to establish and implement a policy for the governing body responsible for managing and operating the facility. The governing body was not active in the development and implementation of the facility assessment. During an interview, the Administrator admitted that no member of the governing body assisted with the completion of the facility assessment. Additionally, the facility did not have a documented policy for the governing body, as confirmed by the Administrator when asked to provide one.
Incomplete Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment contained essential information to allocate necessary care and resources to meet the needs of its residents. The assessment, approved on 08/08/2024 and reviewed on 10/28/2024, was missing critical components such as details about the resident population, facility resources, a facility-based and community risk assessment with an all-hazards approach, and the staff responsible for completing the assessment. Additionally, it lacked information on staffing needs, staff training and competencies, policies and procedures for care provision, physical environment and building information, contracts and third-party agreements, and health information technology resources. The Administrator, who was interviewed on 11/01/2024, acknowledged responsibility for completing the assessment and stated that this was his first time doing so. He admitted that neither the governing body member nor the medical director had input in the completion of the facility assessment. This deficiency had the potential to affect all 60 residents of the facility.
Arbitration Agreement Deficiency
Penalty
Summary
The facility failed to ensure that the arbitration agreement included all necessary components, specifically the right for residents or their representatives to rescind the agreement within the first 30 days of admission. During a review of the facility's admission agreement, it was found that the arbitration provision allowed revocation within 21 days of signing, rather than the required 30 days. The facility's administrator confirmed this discrepancy and acknowledged that there was no existing policy regarding arbitration agreements. This oversight had the potential to affect all residents who had signed the arbitration agreement.
Arbitration Agreement Lacks Neutral Arbitrator and Location Details
Penalty
Summary
The facility failed to ensure that its arbitration documentation included the selection of a neutral arbitrator and a convenient location for arbitration, potentially affecting all 47 residents. During interviews, both the Administrator and the Admission Director were unable to identify language in the admission agreement that described the process for selecting an arbitrator and a neutral location. The Administrator acknowledged the absence of a policy for arbitration agreements. A review of the facility's arbitration agreement confirmed that section f of the admission agreement, which pertains to arbitration, did not contain the necessary information regarding the selection of an arbitrator and location.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to implement consistent infection surveillance to prevent the spread of possible communicable diseases and did not develop a water management plan to prevent the growth and spread of waterborne pathogens. During a review on 10/30/2024, it was found that the Infection Control Log analysis forms were incomplete, lacking trends and root cause analysis, and the facility diagrams were blank for each month. Additionally, the facility did not have any policy, procedures, or management plan for Legionella, as confirmed by the Administrator and the Infection Control Nurse. The Infection Control Nurse admitted to not conducting an infection surveillance process at the time, despite the facility's policy stating that a facility-wide surveillance should be performed to identify opportunities to prevent or reduce infection rates among residents, employees, and visitors.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure a consistent antibiotic stewardship program to determine if antibiotics were indicated or if adjustments to therapy should be made. This deficiency was identified through interviews, record reviews, and facility policy reviews. A resident, who was cognitively intact with a BIMS score of 15, had a diagnosis of a cutaneous abscess on the right foot and was prescribed an intravenous antibiotic every 24 hours. However, infection control assessment tools were not completed for August, September, and October, as confirmed by the Infection Control Nurse. The nurse admitted to having no paper evidence to verify whether the antibiotic was necessary or if adjustments were needed, and stated that without conducting investigations, it was impossible to confirm if the resident had a true infection. The Director of Nursing also indicated a lack of involvement in the process, stating they were told not to interfere. The facility's policy on antibiotic stewardship aimed to optimize antimicrobial use, improve clinical outcomes, and control antimicrobial resistance, but these objectives were not met due to the lack of proper assessments and documentation.
Failure to Conduct Required Communication Training
Penalty
Summary
The facility failed to ensure that required annual in-service trainings were conducted, specifically in the area of communication, for direct care staff members. During a review of in-service records from September 30, 2023, to October 27, 2024, it was found that no communication training had been completed. The Administrator was only able to provide documentation of an in-service on resident rights. The Director of Nursing (DON) stated that the Administrator was responsible for conducting mandatory in-services and was unaware of why some had not been completed. The DON had been working on completing the in-services since her tenure began and provided a monthly all-staff in-service dated October 16, 2024, which covered resident rights/abuse and neglect and enhanced barrier precautions.
Failure to Conduct Compliance and Ethics In-Services
Penalty
Summary
The facility failed to conduct the required annual in-service trainings on compliance and ethics for staff over a period from September 30, 2023, to October 27, 2024. During a review on November 1, 2024, the Administrator was unable to provide documentation of these in-services, except for one related to resident rights. The Director of Nursing (DON) indicated that the Administrator was responsible for conducting these mandatory in-services and expressed unawareness of why they had not been completed. The DON mentioned efforts to complete the in-services since her tenure began, but the deficiency remained unaddressed at the time of the survey.
Failure to Conduct Behavioral Health In-Service Trainings
Penalty
Summary
The facility failed to conduct required annual in-service trainings for staff, specifically in the area of behavioral health services. The Facility Assessment, dated August 8, 2024, lacked information on how staff were prepared to care for residents requiring behavioral health services. Upon review of the in-service records from September 30, 2023, to October 27, 2024, it was found that no in-services were completed for behavioral health. The Administrator could only provide evidence of an in-service on resident rights. During an interview, the Director of Nursing stated that the Administrator was responsible for conducting mandatory in-services and was unaware of why some had not been completed, although she had been working on completing them since her tenure began.
Deficiency in Staff Training on Dementia Care
Penalty
Summary
The facility failed to ensure that required annual in-service trainings were conducted, specifically in the areas of dementia care and abuse prevention. During a review of in-service records from September 30, 2023, to October 27, 2024, it was found that no in-services were completed for dementia care. The Administrator was only able to provide documentation of an in-service on resident rights. The Director of Nursing, when interviewed, stated that the Administrator was responsible for conducting these mandatory in-services and was unaware of the reason for their incompletion. She mentioned that she had been working on completing the in-services since her tenure began.
Failure to Maintain Lint-Free Dryer Traps
Penalty
Summary
The facility failed to ensure that lint traps in the laundry area were free from excessive lint build-up, which could pose a fire hazard. During an inspection, the Surveyor observed that all three clothes dryers had excessive lint accumulation. The clipboard used for documenting lint removal showed the last entry was made on the previous morning, indicating that the lint traps had not been cleaned since then. The Housekeeping Supervisor confirmed that lint was supposed to be removed after every three loads of laundry and documented accordingly. However, the employee responsible for the evening shift on the previous day admitted to not removing the lint or making an entry. The facility's Fire Policy and Procedure did not address this specific issue.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its established abuse policies and procedures following an allegation of abuse involving a resident. The facility's Abuse & Neglect Policy and Procedure, revised in 2017, mandates the protection, response, reporting, and investigation of any abuse allegations. However, after an incident involving a Certified Nursing Assistant (CNA) showing inappropriate pictures to a resident, the facility did not adequately protect the resident from further contact with the alleged abuser. The CNA involved in the incident was not immediately suspended or removed from the resident's vicinity, as she continued to work on the same hall where the resident resided, despite the administrator's initial intention to suspend her. The resident involved, who has a moderate cognitive impairment and other medical conditions, expressed distress over the incident, which led to self-harm. The resident reported being shown an inappropriate picture by the CNA, which caused significant agitation and led to the resident biting himself. Despite the administrator's awareness of the situation, the CNA was allowed to work in proximity to the resident due to staffing issues, and no new background checks were conducted upon her return. The facility lacked a policy on rehiring employees, which contributed to the oversight in handling the situation appropriately.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a written discharge summary for a resident included a comprehensive summary of the stay, a reconciliation of medications, and the resident's status at discharge. The discharge summary for the resident, who was admitted and later discharged home with family, noted participation in physical, occupational, and speech therapy, as well as wound care. However, it lacked details on the resident's pre- and post-discharge medications and the resident's status at discharge. Additionally, the discharge summary was not signed by a physician. During an interview, the Director of Nursing acknowledged that the discharge summary was incomplete and should have included information on the disposition of the resident's medications and belongings. The facility's policy on discharge/transfer of residents, which was undated, required that the discharge summary include a list of medications with instructions, post-discharge care instructions, and signatures from the resident or their representative. The policy also stated that the signed original form should be placed in the medical record, which was not adhered to in this case.
Failure to Provide Scheduled Showers Due to Understaffing
Penalty
Summary
The facility failed to ensure that a resident received scheduled baths/showers, which compromised personal hygiene and grooming. The deficiency was identified for a resident who was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. On one occasion, the resident did not receive a shower due to understaffing, with only one CNA available to assist on the resident's hall. The resident, who was cognitively intact and required substantial assistance with bathing due to chronic obstructive pulmonary disease and spastic hemiplegia, reported the issue during an interview. The facility's grievance logs revealed multiple complaints about missed baths/showers over several months. The staffing schedule confirmed inadequate CNA coverage on the day in question, and the DON acknowledged the issue, noting that grievances had been filed. Despite in-service training provided to staff, the facility's records showed inconsistencies in documenting completed baths/showers, further highlighting the deficiency in maintaining scheduled personal hygiene care for residents.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide proper and timely incontinence care for a resident with memory problems and frequent incontinence of bowel and bladder. The resident, diagnosed with Alzheimer's disease and non-Alzheimer's dementia, was observed multiple times throughout the day sitting in a wheelchair in the hallway common area and dining room. Despite the resident's care plan, which included ensuring an unobstructed path to the bathroom, the resident was not provided with timely incontinence care. During an observation, Certified Nursing Assistants (CNAs) #4 and #7 provided incontinence care to the resident, who had been incontinent of bowel and bladder. CNA #7 failed to clean all areas of the perineal and buttock regions exposed to urine. CNA #7 admitted that the resident's pants were wet when removed and acknowledged not cleaning certain parts of the perineal area. The Director of Nursing confirmed that staff should clean every surface of the perineal area to prevent skin breakdown, bacteria buildup, and urinary tract infections. The facility's incontinence care policy emphasizes keeping the skin clean, dry, and free of irritation to prevent infections.
Failure to Assess Bed Rail Entrapment Risk
Penalty
Summary
The facility failed to ensure that bed rails were used only after a proper assessment for the risk of entrapment was completed for a resident. The resident in question had memory problems, frequent incontinence, and diagnoses of Alzheimer's disease and non-Alzheimer's dementia. Despite the care plan indicating that the resident should have an unobstructed path to the bathroom, a surveyor observed a Certified Nursing Assistant lowering a side rail that obstructed the resident's path. The Director of Nursing acknowledged that the side rail restrained the resident's movement and confirmed that no assessment for entrapment had been completed prior to its use.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that medication was available for a resident during a medication administration observation. On two separate occasions, staff members were unable to locate Lactulose, a medication prescribed for constipation, for a specific resident. On the first occasion, an LPN discovered the absence of Lactulose in the medication cart and indicated the need to contact the pharmacy. On the second occasion, an RN confirmed that the available Lactulose was intended for another resident, and there was none available for the resident in question. The resident's order summary and electronic medication administration record both indicated the need for Lactulose to be administered twice daily. Progress notes revealed that the medication was out of supply on two consecutive days, and staff were awaiting delivery from the pharmacy. The Director of Nursing stated that nurses were responsible for ordering medication refills, while the Administrator handled over-the-counter medication orders. The facility's Medication Administration Guidelines policy outlined the process for medication administration, which includes verifying the medication with the physician's orders and recording the information promptly. However, the failure to have the medication available resulted in the resident missing scheduled doses.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during an observation of medication administration. This deficiency involved two residents and was observed during the administration of medications by two RNs and three LPNs. Specifically, Resident #46 did not receive their prescribed Lactulose medication on two consecutive days due to it being out of supply, as noted in the progress notes. The medication was not available in the medication cart, and staff were waiting for delivery from the pharmacy, which led to missed doses. Additionally, Resident #7 received an incorrect dosage of a probiotic medication. An LPN prepared and administered only one capsule of Saccharomyces Boulardii instead of the prescribed two capsules. The error was confirmed upon review of the resident's electronic medication administration record. The facility's policy requires that medications be administered timely and according to established guidelines, which was not adhered to in these instances.
Failure to Adhere to Planned Menu During Meal Service
Penalty
Summary
The facility failed to ensure that food items were prepared and served according to the planned written menu during the noon meal service on 10/28/2024. Specifically, residents on Minced Moist Soft diets were supposed to receive 1 cup of chicken spaghetti using 2 #8 scoops, but instead, they were served 3/4 cup using a 6-ounce ladle. Additionally, these residents were served pureed vegetable blend instead of the prescribed soft mash vegetables. Furthermore, residents on pureed diets were supposed to receive 1 cup of pureed chicken spaghetti using 2 #8 scoops, but they were served 2/3 cup using a #6 scoop. These discrepancies were observed during the meal service and indicate a failure to adhere to the planned menu, which was not followed as required.
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A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
Surveyors found that a nurse responsible for wound care and infection prevention failed to follow basic infection control practices while treating two residents with pressure ulcers and one with a suprapubic catheter. The nurse repeatedly handled keys, a phone, and a computer, then accessed and prepared wound supplies without performing hand hygiene, touched gauze with ungloved hands before using it on a wound, and set up supplies on non‑impervious paper towels next to personal items instead of on a properly disinfected, protected surface. During one observation, the nurse cleaned a hip pressure ulcer and then a suprapubic catheter site using separate gauze cups but without changing gloves or performing hand hygiene between dirty and clean tasks, and then applied dressings after glove removal without washing hands. Facility policies required clean technique, use of an impervious barrier, handwashing between dirty and clean steps, and labeling dressings, but these were not followed, and the nurse and leadership acknowledged that the nurse had not received formal wound care training from the facility.
Two residents with complex medical conditions and extensive medication regimens experienced significant medication errors when new LPNs, inadequately oriented and not fully competency-checked, misadministered drugs during med pass. In one case, a new LPN on her first day, unfamiliar with residents and the electronic system, gave another resident’s medications—including a hypoglycemic and an antihypertensive—to a cognitively intact resident with multiple cardiopulmonary and renal diagnoses, leading to hypotension, hypoglycemia, and hospital transfer. In the other case, an LPN in training and her preceptor pulled medications simultaneously from the same cart, and a resident requesting pain medication received an excessive dose of a controlled sleeping pill instead, a drug the pharmacist stated would definitely increase sedation and could depress CNS and breathing. Facility policy required verification of resident identity, triple-checking medication labels, and at least three days of accompanied med rounds for new personnel, but interviews showed these requirements were not fully implemented before the new nurses participated in or conducted medication administration alone or in a hurried, shared-cart process.
The facility failed to implement and complete its nurse orientation and competency validation process for new LPNs, resulting in two separate medication errors. One LPN, new to LTC and unfamiliar with the facility’s computer system, was left alone on the med cart after only partial observation-based training and without a completed competency checklist, and a resident received another resident’s medications. Another new LPN, also without documented competency sign-offs, was in joint med-pass with an untrained preceptor when a resident requesting pain medication was given sleeping pills after the preceptor pulled the wrong controlled medication and the trainee administered it. Preceptors were selected informally from floor nurses without preceptor training, and leadership interviews confirmed that required competency checklists and the facility’s own med-pass orientation policy were not consistently followed or documented.
Two residents who required substantial/maximal assistance with ADLs did not receive consistent nail care, use of protective geri-sleeves, and shaving as outlined in their care plans. One resident with Parkinson’s disease, severe cognitive impairment, and a history of arm skin tears was repeatedly observed with overgrown fingernails and exposed arms without geri-sleeves, despite ADL records indicating weekly nail checks and encouragement of geri-sleeves. Staff interviews revealed uncertainty about who was responsible for applying geri-sleeves and providing nail care, and ADL documentation lacked staff initials. Another resident with tremors and moderate cognitive impairment was observed multiple times with visible chin hair and reported not being offered shaving, even though ADL records showed facial hair checks and shaving as needed were documented as completed without initials. A CNA acknowledged seeing the facial hair earlier and intending to shave the resident later, and the DON confirmed CNAs were responsible for checking and removing facial hair and that documentation should not indicate tasks were done when they were not.
A resident with respiratory failure, heart failure, type 2 diabetes, and COPD was approved to self-administer inhaled medications, but surveyors observed the resident’s corticosteroid and beta2-agonist inhalers left unattended on the over-bed table on multiple occasions, and a medication lockbox kept on the over-bed table with the key left in the lock. The resident reported being told they could use their own inhalers. An LPN stated the resident was approved for unsupervised self-administration but admitted not being familiar with the self-administration policy, while also acknowledging that medications should not be left on the over-bed table and that the lockbox should not have the key in it. The DON and another LPN described that the facility’s process and expectations required assessment of the resident’s ability to self-administer, demonstration of correct use, and secure locked storage out of reach of other residents, and CNAs stated that medications should not be left out in resident rooms.
A resident with terminal Parkinson’s disease and severe cognitive impairment was enrolled in hospice, with hospice aides providing baths and an updated care plan specifying hospice CNA, RN, social services, and chaplain visits. However, no hospice physician order was present in the EHR at the time, no hospice notes appeared in progress notes, and the MDS still reflected that the resident was not on hospice. The MDS Coordinator reported she did not complete a Significant Change in Status Assessment because there was no hospice order in the system to trigger it, later finding that the hospice admission order had been dated earlier but not entered until much later. The DON stated that the nurse on duty at hospice admission should have entered the hospice order and believed nurses knew they were responsible for doing so.
A nonverbal resident with a history of brain stem hemorrhage and intact cognition was admitted with documented unclear speech, rare ability to make themself understood, and reliance on nodding, head shaking, and sign language for communication, yet no communication deficit with individualized interventions was initiated on the comprehensive care plan. Multiple assessments and progress notes by nursing, social services, APRN, and SLP consistently described the resident as nonverbal and using alternative communication methods, but these findings were not incorporated into a person-centered care plan. CNAs, an RNA, and an LPN reported using yes/no questions, body language, facial cues, and the resident’s hand signals to communicate, while also stating they did not know sign language and had not seen communication boards or structured tools, and leadership acknowledged that a communication deficit should have been care planned and that there were no facility policies guiding communication care planning for nonverbal residents.
A resident with neuropathy, non‑weight‑bearing status on one leg, multiple comorbidities, and a known history of falls was care planned as high fall risk and required two‑person assistance with a gait belt for all transfers. After prior incidents where the resident’s legs had given out during transfers, two staff attempted a wheelchair‑to‑toilet transfer by standing and pivoting the resident using the stronger leg while the resident held grab bars, but they did so without a gait belt. The resident’s legs collapsed, the resident went down to the knees, and an abrasion to the knee occurred. Staff and leadership interviews, along with policies and job descriptions, confirmed that a gait belt was required for all assisted transfers and that staff were expected to follow this procedure, but the involved staff admitted they forgot to use the gait belt during this transfer.
A resident with respiratory failure and other comorbidities received O2 via nasal cannula under an order that lacked a start date and was not set up as a scheduled order in the electronic record, even though oxygen use was documented on multiple days. Over several days, the resident’s humidifier bottle was repeatedly observed to be undated or dated but empty while the resident was on 2 L O2, and the resident reported persistent nasal dryness and that the bottle had been empty despite asking staff to change it. An LPN confirmed the order issue and acknowledged the empty, dated humidifier bottle, and leadership reported expectations for changing tubing and humidifier bottles but had no policy addressing oxygen equipment or humidified water.
Failure to Follow Wound Clinic Orders for Lower Extremity Wounds
Penalty
Summary
The deficiency involves the facility’s failure to complete and follow wound care provider orders for one resident with multiple lower extremity wounds. The resident was admitted with diagnoses including peripheral vascular disease, acquired absence of a right toe, and malnutrition, and was documented as alert, oriented, and cognitively intact. The resident received wound care at an external Wound Care Clinic, which issued detailed written orders on two separate dates for multiple wounds on both lower legs, specifying cleansing with normal saline, use of transfer foam or autolytic debridement gel, specific secondary dressings, soft cloth surgical tape, sterile roll gauze, gauze sponges, and, for one right lower leg wound, a compression stocking. Review of the facility’s Treatment Administration Record (TAR) for the same period showed that the treatments documented did not match the clinic’s orders. The TAR listed generalized treatments for the left and right lower legs, including cleansing with normal saline, gauze to the wound bed, and application of self-adherent wrap from toes to bend of leg on a Tuesday, Thursday, Saturday schedule, rather than every other day as ordered. Later TAR entries for bilateral extremities referenced autolytic debridement gel, auto debridement dressing, and elasticated tubular bandage, but still did not clearly distinguish between the multiple wounds on the right lower leg or document all ordered components. There was no distinction on the TAR to ensure both right lower leg wounds were treated, no documentation that transfer foam was applied as ordered, and no documentation that the ordered compression stocking was applied to the specified right lower leg wound. Interviews and record review confirmed these discrepancies and the lack of supporting documentation. The Treatment Nurse described a process in which Wound Care Clinic orders were faxed to the facility, compiled, and then entered onto the TAR by the Treatment Nurse after leadership meetings or by the end of the business day. The DON stated that it was the Treatment Nurse’s responsibility to ensure clinic orders were completed and acknowledged that wounds could deteriorate if not treated per provider orders. During a joint interview, the DON, Administrator, and Nurse Consultant were unable to provide any documentation that the transfer foam treatment was given as ordered or any explanation for why every-other-day orders were carried out on a fixed Tuesday, Thursday, Saturday schedule. Facility policy on Medication and Treatment Orders required that medications be administered per the written order of a licensed provider, which was not followed in this case.
Inadequate Hand Hygiene and Aseptic Technique During Wound and Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented infection for two residents receiving wound treatments. For the first resident, who had cellulitis, type 2 diabetes mellitus, protein-calorie malnutrition, venous insufficiency of both lower extremities, chronic venous hypertension with inflammation, candidiasis of the skin and nails, and a stage 2 pressure ulcer to the sacrum, the Treatment Nurse (TN), who was also the Infection Preventionist (IP), did not consistently perform hand hygiene or maintain a clean field. During wound care, the TN handled personal items such as keys, a cell phone, and the computer, then accessed wound care supplies from the treatment cart without performing hand hygiene afterward. The TN touched gauze pads with ungloved hands, sprayed them with wound cleanser, and later used those same gauze pads to cleanse the resident’s wound. The TN also set up supplies on a bathroom counter using a non‑impervious paper towel as a barrier, contrary to facility policy requiring an impervious barrier, and did not date or initial the new dressing. For the second resident, who had diagnoses including congestive heart failure, protein-calorie malnutrition, hypertension, GERD, neuromuscular bladder dysfunction, a stage 3 pressure ulcer of the right hip, urethrocutaneous fistula, UTI, and an indwelling catheter, the TN again failed to follow infection prevention practices during wound care. The TN unlocked the treatment cart with keys from her pocket, returned the keys to her pocket, and touched the computer before retrieving wound care supplies, then proceeded without performing hand hygiene until later in the process. She prepared gauze pads in cups with wound cleanser while gloved, then removed her gloves and continued the setup. In the resident’s room, she cleaned only half of the bedside table with a wet, soapy paper towel and dried it with another towel, then placed a non‑impervious paper towel as a barrier for wound supplies, while the other half of the table remained cluttered with personal items including a basin with cups and straws hanging over the wound supplies. During the wound care for the second resident, the TN washed her hands in the bathroom for approximately six seconds before donning gloves. She removed the old dressing from the right hip pressure ulcer, changed gloves, and then used gauze from one cup to clean the hip pressure ulcer. Without performing hand hygiene or changing gloves between dirty and clean tasks, she then used gauze from a second cup to clean the resident’s suprapubic catheter site, which she stated had drainage and had been cauterized the previous week. After removing her gloves, she did not perform hand hygiene before placing a split drain gauze around the suprapubic catheter and applying calcium alginate and a bordered foam dressing to the right hip wound. The TN later acknowledged that she did not wash her hands when going from dirty to clean tasks, that she should have changed gloves before moving to the secondary dressing, and that she had not received wound care training from the facility despite functioning as the wound care nurse and IP. Facility policies required clean technique, prevention of supply and surface contamination, use of an impervious barrier, handwashing after removing dirty gloves and before donning clean gloves, and labeling new dressings with initials, date, and time, as well as adherence to handwashing guidelines consistent with CDC recommendations for at least 15 seconds of rubbing. Interviews with the TN, Nurse Practitioner (NP), and Director of Nursing (DON) further clarified the expectations and deviations from practice. The TN stated she believed she performed hand hygiene when entering rooms and after touching anything dirty, but acknowledged she did not wash her hands between dirty and clean tasks and recognized that setting up wound supplies next to personal items would be an infection control issue. The NP stated that the suprapubic catheter and pressure ulcer should be cleaned one at a time and not treated simultaneously, and that she would not want wound contaminants introduced to the suprapubic catheter. The DON reported that the TN had been performing wound care since around November, had no wound care certification, and had received no specific wound care training from the facility, although the DON believed the TN had prior wound care experience elsewhere. The DON stated that staff should clean hands and change gloves when going from dirty to clean tasks, that separate areas such as a suprapubic catheter and a pressure ulcer should not be treated at the same time due to infection concerns, that dressings should be dated as a standard practice, that bedside tables should be clean, uncluttered, and disinfected rather than just washed with soap and water, and that a brief six‑second handwash was not appropriate.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors for two residents during medication administration. For the first resident, who had multiple complex diagnoses including pneumonia, COPD, CHF, atrial fibrillation, pulmonary hypertension, peripheral vascular disease, chronic kidney disease stage 3, hypertension, hyperlipidemia, and aortic valve stenosis, a nurse on her first day at the facility administered another resident’s medications in error. The resident was cognitively intact and receiving numerous scheduled medications, including diuretics, anticoagulants, antihypertensives, electrolyte replacements, and oxygen. A Medication Error Report documented that the resident was mistakenly given four incorrect medications intended for another resident, including a blood sugar–lowering medication, an antidepressant, a uric acid–lowering medication, and an antihypertensive with side effects of hypotension and hyperkalemia and label warnings related to diabetic medications. The error for the first resident occurred when an LPN, new to LTC and to the facility’s computer system, misidentified the resident and pulled the wrong medications. The LPN reported that it was her first day, she had limited orientation time with an RN preceptor that morning, and she had not been checked off as competent to administer medications independently. She stated she did not yet know the residents, found the electronic photos too small to distinguish individuals, and did not know how to enter orders into the computer. She described feeling overstimulated and attempting to work independently. The UM, who was simultaneously functioning as wound nurse, UM, and preceptor, left the LPN alone on the cart after the LPN stated she felt comfortable, despite the UM not having observed her passing medications and not having completed the medication portion of the competency checklist. The RN who precepted earlier in the day stated the LPN had only observed her, had not performed tasks independently, and had not been checked off to administer medications alone. Following the wrong-medication administration to the first resident, vital signs later showed hypotension and hypoglycemia, and the resident was sent to the hospital. Hospital records documented treatment for a medication error, hypotension, hypoglycemia, elevated heart enzymes, and acute kidney injury, with very low blood pressure on arrival and the resident reporting feeling like they were dying. Documentation from the hospital indicated facility staff reported the resident had been hypotensive for two hours. The pharmacist, after reviewing the resident’s scheduled medications and the medications given in error, stated she would have monitored for low blood pressure, low blood sugar, and oversedation, and identified multiple medications that could contribute to these effects. The NP stated it was difficult to determine whether the medication error caused the event, noting the resident’s existing pneumonia and kidney function issues. The resident’s representative reported being notified of a severe drop in blood pressure and stated that a physician advised seeking legal advice. The second resident involved in the deficiency had multiple diagnoses including critical illness myopathy, metabolic encephalopathy, cerebral edema, diabetes, morbid obesity, respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, cognitive communication deficit, dysphagia, hyperlipidemia, bipolar disorder, hypertension, and chronic kidney disease, and was cognitively intact. This resident was on a complex medication regimen including antipsychotics, antidepressants, anticoagulants, antibiotics, diuretics, opioids, and hypoglycemics. A Medication Error Report documented that the resident was accidentally given two sleeping pills instead of two pain pills. The error occurred while an LPN in training and her preceptor were both pulling medications from the same cart, with the trainee pulling non-controlled medications and the preceptor pulling narcotics. For the second resident, the trainee LPN reported that the resident had requested a pain pill but was given sleeping pills instead. She stated that the mistake was discovered later when controlled medications were counted and that the sleeping pill, a controlled medication, was stored in the narcotic box with other controlled medications. She reported that the preceptor punched the medication from the wrong card, that the pills were both small white tablets, and that they were trying to hurry. The trainee LPN stated she did not recall any specific competency check-offs and that her license had simply been verified. The pharmacist stated that the dose of sleeping medication given exceeded the recommended daily dose and would definitely increase sedation, with potential for amnesia, CNS depression, and breathing interruptions if the resident did not use a pressurized mask while sleeping, as well as possible sleepwalking episodes. The NP later reported there were no adverse side effects observed in this resident. The facility’s written Medication Administration policy required that medications be administered in accordance with orders, that the individual administering medications verify resident identity before administration, and that the label be checked three times to ensure the right resident, medication, dose, and route. The policy also stated that medications ordered for one resident may not be administered to another, and that new personnel authorized to administer medications would not be permitted to prepare or administer medications until oriented to the facility’s medication administration system. It further required that a charge nurse accompany new nursing personnel on medication rounds for a minimum of three days to ensure procedures were followed and proper resident identification methods were learned. Interviews with the UM, RN preceptor, and LPNs indicated that the new nurses involved in both medication errors were allowed to participate in or conduct medication passes without full completion of competency checklists, without consistent direct observation, and while preceptors were performing multiple roles or sharing the cart, contributing to the misadministration of medications to both residents.
Failure to Implement Effective Nurse Orientation and Competency Validation Leading to Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective nurse training and competency program for new LPN staff, resulting in incomplete orientation and unverified competencies for at least two nurses. The facility maintained a New Trainee Folder and a Licensed Nurse Competency Skills Check-off form intended to cover unit safety, communication, infection control, nursing care, emergency procedures, equipment, medication administration, pain management, resident rights, abuse, dementia care, QAPI, person-centered care, cultural competency, and HIPAA. Human Resources reported that the competency checklist was to be printed and placed in a staffing binder, completed by the preceptor over the first three days, and then signed off by leadership. However, for both reviewed LPNs, these competency checklists were not completed, and there was no documented verification that they had met medication administration or other required competencies before functioning independently. One LPN, on her first day working in the facility and with no prior LTC experience, was involved in a medication error in which a resident received another resident’s medications. This LPN reported that she had only been trained by an RN from 6 AM to 10 AM on how residents took their medications and who had swallowing issues, and that she did not know how to enter orders into the computer system and was unfamiliar with the software. The RN preceptor stated that the LPN had only observed her and had not performed any tasks independently before the RN left, and that she had not checked the LPN off to administer medications alone. The Unit Manager acknowledged that the LPN had no LTC experience, that she did not complete the medication portion of the competency checklist, and that she left the LPN alone on the cart after the LPN stated she felt comfortable, despite not having seen her pass medications. The facility’s Medication Administration policy required that new personnel not administer medications until oriented to the system and that a charge nurse accompany them on medication rounds for a minimum of three days, but this process was not followed or documented for this LPN. Another new LPN, also without a completed competency checklist, was involved in a separate medication error in which a resident requesting pain medication received sleeping pills instead. This LPN reported that she was in training with a preceptor, and that both nurses were pulling medications from the same cart, with the preceptor handling controlled substances. The error occurred when the preceptor punched a sleeping pill from the wrong card, and the trainee LPN administered it, noting that the pills were both small and white and that they were trying to hurry. The LPN stated she did not recall any specific competency check-offs being done beyond a license check. The Unit Manager and ADON both confirmed that preceptors were simply floor nurses who had been at the facility longer, with no formal preceptor training, and that the current training program had only recently started. Employee files for both LPNs lacked completed Licensed Nurse Competency Skills Check-off forms as of the survey date, and leadership interviews showed uncertainty about when competency checklists should be completed and how much training the LPNs had actually received before being allowed to function independently.
Failure to Provide Regular Nail Care, Protective Sleeves, and Shaving for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide regular nail care and use of protective geri-sleeves for one resident and shaving/personal grooming for another resident, as required by their care plans and ADL needs. For Resident #91, surveyors observed on multiple occasions that the resident’s fingernails extended over the tips of the fingers, despite a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. The resident had Parkinson’s disease with dyskinesia, severe cognitive impairment (BIMS score of 04), required substantial/maximal assistance with showering and personal hygiene, and had a history of skin tears on the right arm. The care plan also included an intervention to encourage use of geri-sleeves due to potential skin integrity impairment, but the resident was repeatedly observed with arms exposed and without geri-sleeves in place. Record review for Resident #91 showed ADL tasks for checking, cutting, and filing nails weekly, and for encouraging geri-sleeves as tolerated, were marked as completed on several dates; however, there were no staff initials to identify who performed these tasks. During interviews, CNAs and a MA-C demonstrated uncertainty about who was responsible for placing geri-sleeves on the resident, when they should be applied, and whether the resident was supposed to wear them at all. One CNA believed hospice aides provided nail care and that they visited three times a week, while another CNA stated she provided nail care when needed and that the resident did not wear geri-sleeves, even though she acknowledged the resident would need them due to fragile skin. The DON reported there was no facility policy for ADLs and did not provide skills check-offs for the CNAs involved. For Resident #107, surveyors twice observed visible hair on the resident’s chin, and the resident reported that staff had not offered to shave the chin. The resident had a diagnosis of other specified forms of tremors, moderate cognitive impairment (BIMS score of 09), and required substantial/maximal assistance with showering and personal hygiene. The care plan required staff assistance with bathing/showering and personal hygiene, and the ADL task list showed scheduled bath days and documented completion of a task to check for facial hair and shave as needed on several dates, again without staff initials. Progress notes did not show any refusal of shaving by the resident. A CNA stated she determined needed care by looking in the resident’s closet care plan, that CNAs were responsible for bathing/showering, and that staff checked for facial hair on shower days and should check daily. She acknowledged seeing facial hair that morning and intended to shave the resident later. The DON stated CNAs were responsible for checking and removing facial hair during showers and as needed, and that CNAs should not document facial hair removal when it had not been done.
Failure to Safely Manage Self-Administration of Inhalers and Medication Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident approved for self-administration of medications could follow instructions so that medications were not left at the bedside. The resident had diagnoses including respiratory failure, heart failure, type 2 diabetes, and COPD, and was receiving oxygen via concentrator. Record review showed orders for a beta2-agonist inhaler and a corticosteroid inhaler, but no physician order for self-administration rights was initially found. The facility’s policy required that residents who self-administer be assessed by the IDT to ensure they could safely administer and store medications out of reach of other residents. On multiple observations, surveyors found the resident’s inhalers and lockbox not secured as required. During one observation, the resident was resting in bed with eyes closed, the oxygen concentrator running at two liters via nasal cannula, but the nasal cannula was not in place, and both the corticosteroid and beta2-agonist inhalers were left unsupervised on the over-bed table. The resident stated they had been told they could use their own inhalers. On a later observation, a lockbox with the key left in the lock was seen on the over-bed table, and the resident stated the lockbox contained prescription inhalers but could not recall when it was provided. On another observation, the lockbox with the key still in the lock remained on the over-bed table while the resident was resting with oxygen in place. Interviews with staff confirmed that the resident had been approved for self-administration but revealed gaps in adherence to policy and lack of staff familiarity with self-administration procedures. An LPN stated the resident had been approved to self-administer inhalers at the bedside unsupervised and acknowledged not being familiar with the self-administration policy, while also stating that medications should not be left unattended on the over-bed table and that the lockbox should not have the key in the lock. The DON described the process for approving self-administration, including assessment, demonstration of use, and locked storage, and stated it would not be appropriate to leave a key in the lock or medications out on the over-bed table. Another LPN reported there had not been prior residents with self-administration rights and agreed that medications should not be stored on the over-bed table or in a lockbox with the key in place. CNAs stated that any medications found on the over-bed table would be reported to a nurse and that residents were not allowed to have unstored medication out in the open in their rooms.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days of a resident’s hospice service election, as required by the CMS RAI Manual. The resident had a terminal prognosis related to Parkinson’s disease and a quarterly MDS dated 02/20/2026 showed severe cognitive impairment (BIMS score of 4) and no hospice services. The care plan, reviewed on 03/16/2026 and revised on 04/07/2025, was updated with an intervention initiated on 04/20/2026 indicating that a named hospice provider would supply a CNA up to five times weekly, an RN weekly and PRN, social services monthly and PRN, and chaplain services monthly and PRN, with a contact number listed. A CNA reported that the resident’s baths were being provided by hospice aides who visited about three days a week. Record review showed no physician’s order for hospice services in the electronic health record at the time of survey, and progress notes from 03/01/2026 through 04/24/2026 contained no hospice notes. During interview, the MDS Coordinator stated she completes all MDS assessments and had not done a significant change MDS for this resident’s hospice admission because there was no physician’s order in the system to alert her. Upon review, she identified that an order to admit the resident to hospice services was dated 03/24/2026 but was not entered into the system until 04/23/2026, and acknowledged that the ARD should have been set within 14 days of hospice election, by 04/07/2026. The DON stated that the nurse on duty when the resident was admitted to hospice should have entered an admission order for hospice and expressed that she believed nurses understood they were responsible for adding such orders, treating them like any other order.
Failure to Care Plan Communication Deficit for Nonverbal Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a communication deficit for a nonverbal resident. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, major depressive disorder, and anxiety disorder, and was unable to move the right side of the body, including the face and mouth, due to a stroke. The admission MDS documented unclear speech, that the resident rarely or never made themself understood, sometimes understood others, and responded adequately only to simple, direct communication, while the BIMS score was 15, indicating intact cognition. The Baseline Care Plan noted the resident did not communicate easily with staff, but on review of the Comprehensive Care Plan initiated at admission, no communication deficit with corresponding interventions had been initiated. Record review showed multiple assessments and notes documenting the resident’s nonverbal status and alternative communication methods, but these findings were not translated into a specific communication care plan problem with individualized interventions. The Nursing Admit/Readmit/Quarterly Assessment described the resident as soft spoken and mouthing words, and progress notes indicated the resident was very soft spoken, nonverbal, able to shake the head yes and no, and utilized sign language. A social services admission assessment documented that the resident’s speech was clear, that the resident was nonverbal, used sign language as another mode of communication, and rarely or never was able to make themself understood but could understand others. An APRN note and an SLP evaluation further confirmed that the resident communicated by nodding or shaking the head and had impaired communication skills. Interviews with staff demonstrated that, in the absence of a care-planned communication deficit with defined interventions, staff relied on general approaches and did not have consistent tools or guidance for communicating with the resident. CNAs and an RNA reported communicating with the resident by asking yes/no questions, observing body language and facial cues, and noting that the resident used the left hand to indicate numbers or point to areas of pain, while also stating they did not know sign language and had not seen communication boards or other aids. An LPN reported talking to nonverbal residents as to verbal residents, using facial expressions to interpret needs, and was unaware of any communication boards or specific interventions for nonverbal residents. The MDS coordinator and DON acknowledged that a communication deficit should have been triggered and care planned at admission for a nonverbal resident, and the DON further stated the facility did not have policies for care plans, comprehensive care plans, communication, or communicating with nonverbal residents.
Failure to Use Required Gait Belt During Transfer Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to utilize appropriate transfer equipment, specifically a gait belt, during a toilet transfer for one resident, resulting in a fall and knee abrasion. The resident had medical diagnoses including a left lower leg blood clot, stage 4 kidney disease, type 2 diabetes, neuropathy, and was care planned as high risk for falls with gait and balance problems and limited mobility related to weakness. The resident was also non‑weight bearing on the left lower extremity and required assistance of two staff members with all transfers. The admission MDS showed the resident was cognitively intact and had a history of a fall in the prior months. Prior to the cited incident, the resident had experienced multiple falls at the facility. An unwitnessed incident report documented that the resident slid out of a wheelchair while trying to pick up a ring from the floor, with no injury. A later witnessed incident documented that the resident’s legs gave out during a transfer, and the resident was assisted to the floor without injury and then transferred back to the wheelchair using a gait belt and two staff. These events established that the resident had recurrent episodes of legs “giving out” and required two‑person assistance and a gait belt for safe transfers. On the date of the deficiency, during a transfer from wheelchair to toilet in the bathroom, two staff members (a MA‑C and a CNA) attempted to stand and pivot the resident using the right leg while the resident held onto grab bars, but they did not use a gait belt. The resident’s legs collapsed, and the resident went down to the knees, sustaining an abrasion to the right kneecap, which the resident attributed to the lack of a gait belt. Interviews with the resident, nursing staff, therapy staff, and administration confirmed that the resident was non‑weight bearing on the left leg, required two‑person assistance and a gait belt for transfers, and that facility expectations and policy required use of a gait belt for all assisted transfers. Staff involved acknowledged they “forgot” to use the gait belt during this transfer, and other staff confirmed that gait belts were expected to be used with every transfer when assistance was needed.
Failure to Maintain Active Oxygen Orders and Humidified Oxygen for Resident Comfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure that oxygen therapy orders were properly scheduled and active before administration and to provide humidified oxygen in accordance with a resident’s preferences and comfort needs. Resident #125, who had diagnoses including respiratory failure, heart failure, and type II diabetes, had an active order entered on 04/15/2026 for oxygen at 2–4 liters via nasal cannula, but the order lacked a start date and did not appear as a scheduled order in the electronic record. The admission MDS in progress with an ARD of 04/20/2026 did not indicate that the resident was receiving oxygen therapy, despite documentation on the resident’s oxygen saturation summary that the resident was on oxygen on multiple dates in April. An LPN confirmed that the oxygen order had been present since 04/15/2026 but was not set up as a scheduled order and had no active date. The facility also failed to provide and maintain humidified water for the resident’s nasal comfort over several days. On multiple observations from 04/20/2026 through 04/22/2026, the resident’s humidifier bottle was found undated or dated but empty, while the resident was receiving 2 liters of oxygen via nasal cannula. The resident repeatedly reported that their nose was very dry and that the humidifier bottle had been empty since Monday, and stated they had asked staff to change the water bottle but could not identify to whom. An LPN acknowledged that the humidified water bottle dated 04/21/2026 was empty and stated it should not have been empty at 2 liters of oxygen, suspecting that someone may have dated an empty bottle without actually changing it. The administrator and DON stated their expectation that humidified water bottles be changed on Tuesday evenings with the tubing or when empty, but there was no facility policy addressing oxygen tubing, storage, or humidified water bottles, and the existing oxygen safety policy only addressed handling oxygen, not equipment.
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