Adventist Health Delano
Inspection history, citations, penalties and survey trends for this long-term care facility in Delano, California.
- Location
- 1401 Garces Hwy, Delano, California 93215
- CMS Provider Number
- 056426
- Inspections on file
- 30
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Adventist Health Delano during CMS and state inspections, most recent first.
A resident with ALS, ventilator dependence, incontinence, and a stage 3 sacral pressure ulcer, assessed as totally dependent for care and requiring a Q2H turning/repositioning program, was repeatedly observed lying on the same side for several hours despite orders and facility policy requiring repositioning at least every two hours. Documentation showed the last recorded turn occurred several hours before the observation, and wound records indicated the sacral wound had deteriorated over time. Multiple CNAs and nursing staff reported there was no organized system to signal when residents needed to be turned, acknowledged that residents often waited longer than two hours—sometimes up to three hours—for repositioning, and the risk manager confirmed the absence of a set process for ensuring timely turning, contrary to the facility’s pressure injury prevention policy.
A resident who was fully dependent on staff for daily care due to severe medical conditions was observed with dry, flaky lips and significant debris on the teeth and tongue, indicating inadequate oral hygiene. Staff interviews confirmed that oral care was not being performed to the required standard, and there was no documentation of any difficulties in providing this care, despite facility policy requiring thorough oral hygiene.
A resident with a tracheostomy and cerebral infarction, who was cognitively intact, alleged abuse by a CNA using a communication board. After the allegation, the CNA was not removed from the facility or supervised, but was only told to avoid the resident's room and continued working her shift. Facility policy required separation or supervision of staff accused of abuse during investigations, but this was not followed.
The facility did not have a governing body responsible for establishing and implementing management policies, nor did it appoint a properly licensed administrator to manage operations, resulting in a deficiency in organizational leadership.
Surveyors found that a portable fire extinguisher located near the generator had not received its required annual inspection, as indicated by an outdated inspection tag. The Maintenance Director confirmed the missed inspection, which affected one smoke compartment and 23 residents.
Surveyors found that corridor doors were obstructed by a trash can and a bag of clothes, preventing proper closure. The Maintenance Director confirmed staff had placed these items, affecting one smoke compartment and 22 residents.
Surveyors found that the facility did not have documented agreements with other facilities or providers to receive residents during emergencies, as required in the Emergency Operations Plan. The Safety Director acknowledged an agreement with the county but could not provide supporting documentation.
The facility did not have a qualified Director of Activities overseeing the resident activities program, as the previous director had been on medical leave and no interim was appointed. CNAs, trained by a unit clerk, were conducting and assessing activities without the required supervision, and the facility could not provide a job description for the Director of Activities. This resulted in the activities program not being managed according to facility policy.
Two dented cans of garbanzo beans were found stored with other canned foods in the dry storage area, contrary to facility policy requiring dented cans to be separated for return or credit. This failure was identified during an inspection and confirmed by staff, indicating noncompliance with established food safety procedures.
Nursing staff used non-bleach wipes to disinfect a glucometer after use on three residents, contrary to manufacturer guidelines requiring bleach-based products. Infection control precaution signage was inconsistently posted and did not match current orders for several residents, and some staff lacked knowledge of the different types of precautions. Additionally, an EMTT failed to remove PPE and perform hand hygiene after caring for a resident on enhanced barrier precautions.
The facility did not ensure that informed consent for psychotropic medications was properly obtained according to policy for two residents. In both cases, nursing staff obtained signatures for consent, and the physician signed at a later date, rather than directly reviewing medication information and obtaining consent prior to administration as required.
A resident with a diagnosis of Bipolar Disorder and prescribed Risperidone was admitted with a PASRR that did not reflect their mental health condition or medication use. Facility staff did not review or update the PASRR after admission to accurately document the resident's diagnoses and treatments, and there was no policy in place for ongoing PASRR review.
A nurse did not follow facility policy for medication administration via a GTube when she failed to flush the tube with water between giving multiple medications to a resident who was NPO and receiving continuous tube feeding.
The QAA committee did not meet at least quarterly as required, with only three meetings held over a twelve-month period. The RNM confirmed the lack of quarterly meetings, and the facility's QAPI policy did not specify meeting frequency.
The facility failed to provide adequate nail care for four residents, leading to potential health risks. A resident with immobility was observed with long fingernails containing debris, posing an infection risk. Another resident required assistance for nail trimming, which was not provided. Two more residents were found with long fingernails, one of whom had contracted hands, increasing the risk of skin breakdown. The facility's policy on resident care management was not followed.
A facility failed to follow its restraint management policy for a resident using a right-hand mitten restraint. The resident's restraint was not monitored every two hours as required, with missing documentation on several occasions. Additionally, the order for the restraint was not renewed every three days as mandated by the facility's policy.
The facility failed to monitor and document medication room temperatures consistently, with missing entries in the logs from August 2024 to January 2025. This affected all residents with medications stored in the room, potentially altering medication effectiveness. The Facility Manager confirmed the importance of maintaining appropriate room temperatures to prevent medications from going bad.
The facility failed to secure hazardous materials in resident areas, posing a risk to 25 residents, including those using oxygen. Items like dust/lint remover, germicidal cleaner, and liquid glycol were accessible in the activities room, contrary to the facility's policy on hazardous materials management.
The facility failed to implement its food storage policy, resulting in numerous unlabeled and undated food items in resident areas. This included perishable and non-perishable goods, which were not properly identified or stored according to the facility's guidelines. The oversight was acknowledged by the Facility Manager, highlighting a systemic failure to adhere to food safety practices.
A facility failed to provide a resident with their home medications upon discharge. During an observation, two boxes of Albuterol Sulfate, a medication for breathing difficulties, were found in the medication room labeled with the resident's name. The Facility Manager confirmed the resident was discharged a month ago and the medication should have been sent home, as it was purchased by the resident's insurance. The facility could not provide a policy for discharge medications.
A facility failed to report an abuse allegation involving a resident's call light to CDPH within 24 hours and did not complete the investigation within five days. The resident, who had intact cognition but was unable to speak or move, relied on a communication board. Two CNAs implicated in the allegation continued working without being removed or monitored, contrary to facility policy.
A facility failed to provide timely podiatry care and administer IV antibiotics as ordered, leading to surgical intervention and delayed treatment for a resident's foot infections. Another resident also experienced a lack of podiatry care, with overgrown and discolored toenails. The facility lacked documentation and a podiatry policy.
A facility failed to notify a family member about a resident's change in condition, specifically a black discoloration on the resident's right heel. The family member discovered the issue during a podiatry appointment and was informed by staff that the condition had been present for some time. A nurse confirmed the presence of a dry callus and a wound consultant had seen it, but there was no record of family notification. The facility also failed to provide a change of condition policy when requested.
A resident with quadriplegia and other health issues had grievances regarding care that were not addressed by the facility. Despite being cognitively intact and dependent on staff, the resident's family reported issues such as the need for podiatry services and poor hygiene care. The facility's grievance policy was not followed, leaving the complaints unresolved.
A resident in a persistent vegetative state with a history of cardiac arrest and anoxic brain injury was found with maggots in their mouth due to inadequate oral care. Despite an MD's order to increase oral care frequency, the facility failed to update the care plan, resulting in continued twice-daily care instead of every six hours.
The facility failed to provide adequate staffing, affecting 12 out of 13 sampled residents who were dependent on staff for all aspects of care. Staff interviews and observations confirmed that essential tasks like turning residents every two hours and checking for incontinence were not being performed. This led to new skin wounds for two residents, highlighting the facility's inability to meet resident needs due to insufficient staffing.
The facility failed to follow their abuse policy when an LVN accused of hitting and pushing a resident was not removed from the schedule or monitored during the investigation. The resident had severe cognitive impairments and a history of chronic respiratory failure. Despite the policy requiring monitoring, the LVN continued to work without supervision.
A facility failed to complete an investigation for an abuse allegation within five working days. A resident's sister reported that an LVN had hit and aggressively pushed the resident's head. The investigation was delayed due to the DON being at a conference and the PCE being unaware of the allegation. The facility's policy did not specify a timeframe for completing abuse investigations, leading to a significant lapse in response.
The facility failed to provide adequate staffing, resulting in residents not being turned every two hours, delays in answering call lights, and incomplete RNA exercises. Interviews and record reviews confirmed that the workload was too high for CNAs to meet the residents' needs.
The facility failed to ensure that 41 licensed nurses were competent in managing nephrostomy and G-tube care. One resident's nephrostomy bag was placed on the floor, leading to potential contamination and infection. Additionally, two residents with G-tubes were administered medications improperly, with an LVN not following proper procedures. The facility's policies and procedures were found to be inadequate in ensuring proper training and competency for the nurses.
The facility failed to implement an effective QAPI program. Meeting minutes showed blank action columns for survey findings, and the QM admitted to a lack of data and collaboration. The DON confirmed the QAPI's ineffectiveness without data. The QAPI plan was not effectively implemented due to the absence of data and departmental assessment.
The facility failed to conduct proper infection control surveillance, store and label oxygen tubing correctly, maintain a clean environment for a nephrostomy, and ensure proper hand hygiene practices among staff. These deficiencies had the potential to cause serious infections among residents, staff, and visitors.
The facility failed to complete Minimum Data Set (MDS) quarterly assessments for multiple residents within the required timeframe. The MDS Coordinator admitted to being behind on assessments and cited a lack of trained staff and recent training as contributing factors. This failure had the potential to delay the development and implementation of individualized care plans.
The facility failed to maintain professional standards of quality, including improper care of a nephrostomy tube, incorrect administration of medications through a G-tube, a CNA performing tasks outside their scope of practice, and a missed physician order for a psychiatric consult, leading to delays in care.
The facility failed to follow its policy for pressure ulcer care by not turning and repositioning a completely immobile resident every two hours, as required. Despite being at very high risk for skin breakdown, the resident was left in the same position for extended periods, compromising the healing process of a stage 4 pressure injury.
The facility failed to provide the Restorative Nursing Assistant (RNA) program to maintain or improve mobility for five residents. Observations and interviews revealed that residents were not receiving the prescribed range of motion (ROM) exercises. Staffing records indicated inconsistent assignment of RNA duties, and several dates showed no RNA staff assigned at all. Interviews with CNAs revealed they were overwhelmed with other duties and lacked proper training and access to residents' RNA orders. The Director of Nursing acknowledged awareness of the issue but admitted there was no plan to replace the RNA staff who had left.
The facility failed to maintain safe and sanitary food handling practices in one freezer and one refrigerator. Open food items in Freezer #6 and Refrigerator #5 were found without open dates, contrary to the facility's policy. The Certified Dietary Manager confirmed that all food items should be labeled with a use-by date and opened date.
The facility failed to create a policy and procedure for safe food handling and storage of food brought to residents by family and visitors. Staff members, including the Activities Director, Regulatory Specialist, and Registered Nurses, were unaware of any existing guidelines, and the Director of Nursing confirmed the absence of such a policy.
The facility failed to perform the antibiotic stewardship program for three residents when critical information was missing from the Infection Surveillance Log. The Infection Preventionist acknowledged the mistake, and the Director of Infection Prevention admitted to not reviewing the log, contrary to the facility's policy on optimizing clinical outcomes and appropriate antimicrobial use.
The facility failed to follow their P&P for a resident who did not have a spare tracheostomy tube at the bedside. Observations revealed the absence of an ambu bag, emergency blow by, and spare tracheostomy supplies. Staff confirmed that these items should have been present, and the facility's P&P required a second tracheostomy tube to be kept at the bedside.
A facility failed to consistently monitor a resident's behavior who was on Sertraline for depression. The resident showed signs of frustration and sadness, but staff did not regularly document these behaviors. The Pharmacist Supervisor found no evidence of behavior review, and the DON confirmed missing and incomplete monitoring sheets for several months.
The facility failed to ensure a gradual dose reduction (GDR) for an anti-depressant medication prescribed to a resident. The Pharmacist Supervisor confirmed that the review for GDR should have started in November 2023, but no documentation was found. The facility's policy required at least two GDR attempts within the first year of residency or after medication initiation, with at least one month between attempts. The lack of GDR documentation could potentially indicate the unnecessary continuation of the medication.
The facility failed to label and date an IV solution and tubing for a resident, and also failed to date the glucose QC testing strips vial upon opening on one of the medication carts. The RN admitted the IV bag was not labeled, and the DON confirmed this was against policy. The LVN and CN acknowledged the QC strips should be dated upon opening.
Failure to Consistently Reposition High-Risk Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered turning and repositioning interventions every two hours for a resident with significant risk factors and an existing pressure ulcer. The resident was admitted with severe sepsis with septic shock, ALS, and ventilator dependence, and was assessed on the MDS as having a BIMS score of 0, being totally dependent on staff for all care, and always incontinent of bowel and bladder. The MDS documented that the resident was at risk for developing pressure ulcers and required a turning/repositioning program. Subsequent wound documentation showed the development of a sacral shearing injury that progressed to a stage 3 pressure ulcer not present on admission, with measurements indicating deterioration over time and the need for strict repositioning every two hours. On the day of survey observation, the resident was repeatedly observed lying on the left side with pillows to the back at multiple time points over several hours. Nursing staff interviews confirmed that the resident was supposed to be turned and repositioned every two hours due to the stage 3 pressure ulcer. However, the electronic medical chart for that day showed the last documented turn to the left side at 10:05 a.m., and by 1:47 p.m. the wound nurse acknowledged the resident should have been turned around noon but remained on the left side. Multiple CNAs and nursing staff reported there was no organized or set process in the facility to know when residents needed to be turned and repositioned. CNAs stated they tried to remember when to turn residents, that residents often waited more than two hours, sometimes up to three hours, and that turning could be delayed more than 30 minutes past the intended time, especially when staffing was short or staff were busy. The risk manager confirmed the facility did not have a set process for determining when it was time to turn and reposition residents, despite a written policy requiring repositioning at least every two hours for residents unable to reposition themselves and applying this standard to residents with stage 3 pressure injuries.
Failure to Provide Adequate Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral hygiene for one of three sampled residents who was completely dependent on staff for all activities of daily living due to severe medical conditions, including ALS, ventilator dependence, and chronic respiratory failure. During observation, the resident was found in bed, unable to verbally respond, with dry, flaky lips and significant white to yellowish debris covering the teeth and tongue. The tongue had a visible film elevated approximately 1/16 of an inch, indicating a lack of proper and consistent oral care. Interviews with facility staff revealed that oral care was not being performed to the required standard. The Director of Staff Development acknowledged that the resident's mouth and tongue needed cleaning and that staff should be providing oral hygiene every shift, but admitted it was not being done adequately. A respiratory technician stated oral care had been attempted earlier but described the resident as difficult to clean, without having reported these difficulties to nursing or supervisory staff. Review of the resident's care plan confirmed the need for staff-assisted oral care, but there was no documentation of any challenges in providing this care. Facility policy required thorough oral hygiene, including cleaning the cheeks, palate, and tongue, and applying lubricant to dry lips, but these procedures were not followed as observed.
Failure to Separate Accused Staff Following Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure for one resident who alleged abuse by a Certified Nursing Assistant (CNA). The resident, who had a tracheostomy and cerebral infarction and was assessed as cognitively intact, communicated an allegation of bullying by a CNA using a letter board. The allegation was reported to the facility's Nursing Facility Supervisor (NFS) and Quality Assurance Nurse (QAN), who confirmed that the accused CNA was neither removed from the facility nor placed under supervision after the allegation was made. The CNA continued to work her shift and was only instructed not to enter the resident's room, but no further action was taken to separate her from other residents or to monitor her interactions. Review of the facility's policy indicated that in cases of alleged abuse, the involved staff member should be assigned to non-patient care activities or, if not possible, should be supervised at all times during the investigation. The policy emphasizes the need to protect residents from potential abuse during investigations. However, the facility did not follow these procedures, as the CNA remained in her regular duties without supervision or reassignment, potentially exposing other residents to risk.
Failure to Establish Governing Body and Appoint Licensed Administrator
Penalty
Summary
The facility failed to establish a governing body that is legally responsible for setting and implementing policies for the management and operation of the facility. Additionally, the facility did not appoint a properly licensed administrator to oversee the management of the facility. These actions resulted in a deficiency related to the facility's organizational structure and leadership responsibilities.
Missed Annual Inspection of Portable Fire Extinguisher
Penalty
Summary
The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by a missed annual inspection. During a facility tour, surveyors observed that the exterior portable fire extinguisher located adjacent to the generator had an inspection tag dated over a year prior. The Maintenance Director confirmed that the annual inspection had not yet been completed at the time of the survey. This deficiency affected one of two smoke compartments and impacted 23 of 45 residents.
Plan Of Correction
K 355 Immediate Correction: The fire extinguisher was replaced with one that had completed the annual inspection timely. This finding had the potential to affect all residents. No harm was identified. Sustainment: The Facilities Staff was educated by the Facilities Manager on the importance of ensuring all fire extinguishers have their required inspection and maintenance. See attached education signature sheet. Monitoring: The specified fire extinguisher location will be included in ongoing EOC rounds to ensure it doesn't get missed again in the future due to its remote location. Data will be collected and reported out to the EOC Committee and the SCU Quality Assurance committee as part of the facility QAPI program. Person Responsible: Facilities Manager
Corridor Doors Obstructed by Staff Items
Penalty
Summary
During a facility tour, surveyors observed that corridor doors intended to protect openings were obstructed, preventing them from closing as required by NFPA 101 Life Safety Code. Specifically, the corridor door of Room 226 was blocked by a trash can, and the corridor door of Room 221 was obstructed by a plastic bag full of clothes. These obstructions resulted in both doors being unable to close properly. The Maintenance Director confirmed during interviews that staff had placed these items in front of the doors, with the intention of moving them later. These findings affected one of two smoke compartments in the facility and impacted 22 of 45 residents. The report does not provide additional details about the medical history or condition of the residents involved at the time of the deficiency.
Plan Of Correction
Immediate Correction: The items blocking the doors were removed. All residents have the potential to be impacted by the finding, but no harm was identified and no other doors were found blocked upon inspection. Sustainment: Education was provided to the SCU staff by the Director of Staff Development on the requirement that all fire doors remain clear and able to close properly in order to protect life and property in case of fire. See attached sign-in sheets. Monitoring: Rounding will occur three times a week by the Manager of the Special Care Department to verify that no doors are blocked or obstructed in any way. Data will be collected and reported out to the SCU Quality Assurance Committee as part of the facility's QAPI program. Person Responsible: SCU Nurse Manager
Missing Documentation of Emergency Transfer Arrangements
Penalty
Summary
The facility failed to maintain an Emergency Operations Plan (EOP) that included required documentation of arrangements with other facilities or providers to receive residents in the event of limitations or cessation of operations. During a record review and interview with the Safety Director, surveyors found that the facility could not provide evidence of such agreements or arrangements as mandated by federal regulations. The Safety Director stated that there was an agreement with the county, but was unable to produce any documentation to support this claim. This lack of documented arrangements was identified during the review of the EOP and confirmed in the interview, resulting in a deficiency related to emergency preparedness and continuity of care for residents.
Plan Of Correction
Immediate Corrections: The Emergency Management binder and missing documentation were located and returned to the AHDL site. See attached Kern County Emergency Operation Manual, ADHL KCHCC Partner Participation Agreement, and the AH Delano Grant Letter. All residents had the potential to be affected by this issue, but no harm was identified for any residents. Sustainment: The Accreditation Manager educated the Facilities Manager on the requirement to maintain the Emergency Operations Manual on site at all times, and to not allow the binder to be removed for any reason, even short term use. Likewise, the Emergency Management Manager was also educated to complete any updates or changes to the manual on site, and not to take it to another location to work on it. Monitoring: The Manager of Facilities will verify the binder is in the unit at least monthly to ensure that the Manual is still on site and has not been removed. This will continue for 6 months to ensure sustainment. Data will be reported out to the SCU Quality Assurance Committee as part of the QAPI program. Person Responsible: Facilities Manager E 025
Lack of Qualified Activities Director for Resident Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified full-time Director of Activities for all 45 residents. According to interviews with staff, the Director of Activities had been out on medical leave since February 2025, and no interim Director of Activities had been appointed. Certified Nursing Assistants (CNAs) were trained by a unit clerk to complete the Activities Evaluation in the electronic health record system and on paper, but there was no qualified individual overseeing the activities program. The Registered Nurse Manager confirmed that CNAs were responsible for assessing and conducting activities in the absence of a Director of Activities. The facility was unable to provide a job description for the Activities Director when requested. Review of the facility's policy indicated that the activities program should be under the direct supervision of an Activities Coordinator, who is responsible for planning, coordinating, and directing activities, as well as participating in resident assessments and care planning. The lack of a qualified Director of Activities meant that the program was not being supervised or managed according to facility policy, potentially impacting the quality and appropriateness of activities provided to residents.
Failure to Remove Dented Canned Food from Storage
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the storage of foods and physical environment when two out of six 12-ounce cans of garbanzo beans with significant dents were not removed from the dry storage room. During an observation in the dry food storage area, the lead staff member identified and removed the dented cans, noting that they should not have been stored with other canned foods intended for resident use. The facility's policy required that any dented cans be placed in a designated section for return or credit, which was not followed in this instance. This lapse was confirmed during interviews and a review of the facility's written procedures.
Infection Control Failures in Disinfection, Precaution Signage, and PPE Use
Penalty
Summary
Nursing staff failed to properly disinfect a glucometer after use on three residents. The staff used Super Sani-Cloth Germicidal Disposable Wipes, which contain isopropyl alcohol and quaternary ammonium compounds, instead of the manufacturer-recommended hospital-approved germicidal bleach products. The infection preventionist confirmed that the facility used these wipes, which do not contain bleach, for glucometer disinfection. Manufacturer guidelines specifically require the use of EPA-registered bleach products for cleaning the glucometer, but this protocol was not followed. The facility did not implement its own infection control policies regarding the posting and accuracy of infection control precaution (ICP) signage for residents. In several cases, the signage on residents' doors did not match the current physician orders or the residents' actual precaution status. For example, one resident had a contact precautions sign posted despite not having an active order for contact precautions, while another resident had enhanced barrier precautions (EBP) signage posted when the order was for contact precautions due to a multidrug-resistant organism. Staff interviews revealed a lack of knowledge about the different types of ICPs and the reasons for their use, and attendance records showed that not all staff had received required training on these precautions. Additionally, an Emergency Medical Technician Transport (EMTT) staff member failed to remove personal protective equipment (PPE) and perform hand hygiene after providing care to a resident under enhanced barrier precautions. The EMTT exited the resident's room still wearing gown and gloves and did not clean his hands, contrary to facility policy and posted instructions. Both the EMTT and a licensed nurse acknowledged that PPE should have been removed and hand hygiene performed before leaving the room. The facility's policies and CDC guidelines require proper disposal of PPE and hand hygiene to prevent the spread of infection.
Failure to Obtain Proper Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and complete informed consent for psychotropic medications for two of four sampled residents. For one resident, the consent for Seroquel 25 mg at bedtime was signed by nursing staff on one date and by the physician on a later date, with the process described as nurses obtaining consent from the family or resident and the physician signing during their visit. For another resident, the consent for Risperidone 1 mg at bedtime was similarly signed by nurses and then by the physician at a later date, with the nurse stating that consents are obtained from the family and resident in the facility. A review of the facility's policy indicated that it is the physician's responsibility to review medication information and obtain informed consent from the patient or legal guardian prior to the initial administration of the medication. The policy also allows for consent to be obtained in person or by telephone, with a licensed nurse witnessing the conversation if consent is given verbally. The documented process in these cases did not align with the facility's policy, as the physician did not directly obtain informed consent prior to medication administration.
Failure to Accurately Complete and Review PASRR for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to accurately review and complete the annual Pre-Admission Screening Assessment and Resident Review (PASRR) for a resident. The PASRR Level 1 Screening, completed prior to admission, indicated that the resident did not have a serious diagnosed mental disorder and was not prescribed psychotropic medications for mental illness. However, upon review of the resident's diagnosis list and physician orders, it was found that the resident had a diagnosis of Bipolar Disorder and was prescribed Risperidone, a medication used to treat this condition. These diagnoses and medications were not reflected in the PASRR documentation. Interviews with facility staff revealed that while the hospital completed the initial PASRR upon admission, the facility did not review or update the PASRR to reflect the resident's current diagnoses and medication orders. The Registered Nurse confirmed that the resident's mental health diagnosis was present in the medical record but not on the PASRR. Additionally, the facility did not have a policy in place for reviewing or updating PASRRs after admission.
Failure to Flush GTube Between Medications During Administration
Penalty
Summary
Licensed Vocational Nurse (LVN) 2 failed to follow the facility's policy and procedure for medication administration through a feeding tube for one resident with a gastrostomy tube (GTube). During a medication pass, LVN 2 administered Docusate Sodium via the GTube and proceeded to administer the next medication without flushing the tube with water in between, as required by the facility's policy. The policy specifically states that when giving multiple medications, the tube should be flushed with 5-10 mL of water between medications. LVN 2 acknowledged during an interview that she did not flush the tube as required. The resident involved had orders for continuous tube feeding and was NPO (nothing by mouth) at the time of the incident.
QAA Committee Failed to Meet Quarterly as Required
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee met at least quarterly as required by regulation. Record review and interview with the Registered Nurse Manager (RNM) revealed that the QAA committee only met three times over a twelve-month period, with meeting dates documented as 1/20/25, 9/12/24, and 5/23/24. The RNM confirmed these were the only meetings held during the past year and acknowledged that the committee did not meet quarterly. Additionally, review of the facility's Quality Assurance and Performance Improvement Plan policy did not specify the required frequency for QAA committee meetings.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for four residents, leading to potential health risks. Resident 1, who was totally dependent on assistance for personal hygiene due to immobility, was observed with long fingernails containing dark gray debris. The Infection Preventionist noted that Resident 1 was at risk for infection due to behaviors such as digging or putting hands in briefs. Licensed Vocational Nurse 1 acknowledged that trimming should have been done. Similarly, Resident 2, who also required total assistance, was found with long fingernails and debris, and LVN 2 admitted the need for trimming. Residents 3 and 4 were also observed with long fingernails and debris. Resident 3 required total assistance for personal hygiene, and the Infection Preventionist confirmed the need for nail trimming. Resident 4, with contracted hands, was at risk for skin breakdown due to long fingernails touching the palms. The facility's policy on resident care management, which mandates a comprehensive approach to meet residents' needs, was not followed, as confirmed by the Risk and Regulatory Analyst during a review of the facility's procedures.
Failure to Monitor and Renew Restraint Orders
Penalty
Summary
The facility failed to adhere to its policy and procedure on restraint management for a resident who was using a right-hand mitten restraint to prevent the pulling of medical devices. The resident's restraint was not monitored every two hours as required, with missing documentation on several occasions, including specific times on multiple days. This lack of monitoring was confirmed through interviews with staff and a review of the resident's restraint flowsheet, which showed gaps in the required documentation. Additionally, the facility did not renew the order for the resident's restraint every three days as mandated by their policy. The order for the restraint, initially placed by a physician, had not been renewed since its original date. This oversight was acknowledged by the staff during interviews and was further supported by a review of the facility's restraint management policy, which clearly stated the need for renewal every three days if restraints were to be continued.
Failure to Monitor Medication Room Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the temperatures in the medication room, which is crucial for maintaining the effectiveness of medications stored there. This deficiency was identified through observation, interviews, and record reviews, revealing missing entries in the medication room temperature logs (MRTL) for several months. The Facility Manager acknowledged that there should be no missing entries, as the purpose of the MRTL is to ensure the room temperature is appropriate to prevent medications from going bad. The missing entries spanned from August 2024 to January 2025, affecting all 34 residents who had medications stored in the room. The facility's policy and procedure on air exchange rate, filtration, air pressure relationship, temperature, and humidity, dated July 27, 2022, requires daily documentation of room temperature in the Air Pressure Relationship, Temperature and Humidity - Mitigation form. This documentation is necessary to demonstrate compliance with adopted codes and to record any mitigation and corrective actions for failures. However, the facility did not adhere to this policy, as evidenced by the numerous missing entries in the MRTL, which could potentially alter the effectiveness of the medications for all residents in the facility.
Failure to Secure Hazardous Materials in Resident Areas
Penalty
Summary
The facility failed to implement its policy on hazardous materials for 25 out of 34 sampled residents. During an observation and interview in the activities room, it was noted that several hazardous items were not secured and were accessible to residents. These items included a can of dust/lint remover, a bottle of foaming germicidal cleaner, and eight cans of liquid glycol with wick. The Quality Assurance (QA) staff confirmed that these items should not be in resident care areas as they pose a risk to residents, especially since some residents use oxygen, which is flammable. The facility's policy on hazardous materials, waste management handling, storage, transport, and disposal was reviewed. It indicated that hazardous chemicals should be properly identified, segregated, contained, stored, transported, treated, and disposed of to minimize health risks. The policy defines hazardous substances as those that are toxic, corrosive, irritants, flammable, or combustible. The presence of these unsecured hazardous materials in the activities room, where residents requiring oxygen frequently gather, represents a failure to adhere to the facility's policy, potentially endangering the residents' safety.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy on the storage and labeling of food items brought in by family and visitors for 11 of 34 sampled residents. During observations, numerous food items in the resident refrigerator and cabinets were found unlabeled, undated, and without identification of ownership. These items included perishable goods such as chocolate cake, lemon pie, and various condiments, as well as non-perishable items like coffee grounds and cookies. The lack of proper labeling and dating of these items was confirmed by the Facility Manager (FM), who acknowledged the oversight and the potential risk of foodborne illness. The facility's policy, titled "Use and Storage of Foods Brought to Residents by Family and Visitors," mandates that all food items brought into the facility must be labeled with the resident's name, content, preparation date, and a discard/use-by date. Additionally, the policy requires that perishable foods be stored in designated refrigeration units separate from the main kitchen, and non-perishable foods be stored in airtight containers to prevent staleness and pest infestation. However, during the survey, it was evident that these procedures were not followed, as multiple food items were found without the necessary labeling and dating. The deficiency was observed over two consecutive days, with the FM admitting that the food items should have been labeled and dated according to the facility's policy. Despite the findings from the first day, similar issues were noted the following day, indicating a systemic failure to adhere to the established food safety and sanitation practices. This oversight had the potential to compromise the health and safety of the residents by increasing the risk of foodborne illnesses due to improper food storage and handling.
Failure to Provide Discharge Medications
Penalty
Summary
The facility failed to provide home medications for one of the sampled residents, identified as Resident 12, upon discharge. During an observation in the facility medication room, two boxes labeled with Resident 12's name were found containing Albuterol Sulfate, a medication used to treat breathing difficulties. The boxes, dated 12/22/24, contained 120 vials of the medication and had a note indicating that Resident 12 was discharged, although no specific discharge date was provided. During an interview, the Facility Manager confirmed that Resident 12 was discharged approximately a month prior and acknowledged that the Albuterol should have been sent home with the resident, as it was purchased by the resident's insurance. A review of Resident 12's order summary confirmed the discharge, but the facility was unable to provide a policy or procedure for discharge medications when requested.
Failure to Report and Investigate Abuse Allegation Timely
Penalty
Summary
The facility failed to implement its policy and procedure for abuse prevention and reporting for a resident who made an allegation of abuse. The resident, who had intact cognition but was unable to speak or move, relied on a communication board and a call light to indicate needs. During a care conference, the resident's family member reported an allegation of abuse involving staff taking away the resident's call light. However, the facility did not report this allegation to the California Department of Public Health (CDPH) within the required 24-hour timeframe, as the report was not made until several days later. Additionally, the facility did not complete the investigation into the abuse allegation within the mandated five-day period. The investigation, which should have been completed by a specific date, was delayed and only concluded ten days after the allegation was made. The department manager was unsure of who was responsible for handling abuse allegations, indicating a lack of clarity and adherence to the facility's procedures. Furthermore, two Certified Nursing Assistants (CNAs) who were implicated in the abuse allegation continued to work in the facility without being removed or monitored, contrary to the facility's policy. The CNAs were not taken off the schedule or observed while working with residents, which was a requirement during the investigation period. This oversight allowed the CNAs to continue their duties without the necessary precautions being taken to protect the residents, as outlined in the facility's policy and procedure for handling suspected abuse cases.
Deficiencies in Podiatry Care and Antibiotic Administration
Penalty
Summary
The facility failed to ensure timely podiatry care and treatment for a resident, resulting in the need for surgical intervention and intravenous antibiotics due to infections in the resident's feet. The resident, who had a history of quadriplegia, COPD, tracheostomy, and diabetes mellitus, was dependent on staff for lower body dressing and footwear. Despite a physician's order for a podiatry consult dated over a year prior, the resident was not seen by a podiatrist until much later, leading to the diagnosis of infected ingrown toenails requiring surgical and antibiotic treatment. Additionally, the facility did not administer IV antibiotics as ordered by the physician for the resident's foot infections. The antibiotics were prescribed to start immediately after a podiatry procedure, but there was a delay of three days before the treatment began. This delay was due to a missed physician order, as confirmed by a registered nurse, and was not documented in the resident's medication administration record. Another resident also experienced a lack of timely podiatry care. Despite having a physician's order for podiatry consults every two months, the resident had not been seen by a podiatrist for several months. The resident's toenails were overgrown, discolored, and thick, indicating a need for podiatry care. The facility lacked documentation of assessments or monitoring of the resident's feet, and no podiatry policy and procedure were provided when requested.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a family member regarding a change in condition for a resident, specifically concerning the resident's right heel. The family member noticed the resident's right heel was black with a possible skin injury during a podiatry appointment and was informed by unspecified facility staff that the heel had been in that condition for a while. However, the family member had not been informed about this change in condition. A registered nurse confirmed the presence of a dry callus with a black color on the resident's heel and mentioned that a wound consultant had seen it, with podiatry scheduled to follow up. The nurse was unsure if the family member had been contacted about this change. A review of the resident's electronic medical record by the Quality Assurance team revealed that the issue with the resident's right heel was first noted on August 28, 2024. However, there was no documentation indicating that the family member was notified of this change in condition. Additionally, when a request was made for the facility's change of condition policy and procedure, no such policy or procedure was provided by the facility.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adhere to its grievance policy and procedure for a resident diagnosed with quadriplegia, COPD, acute on chronic respiratory failure with hypoxia, and a tracheostomy. The resident was cognitively intact and completely dependent on staff for personal care. Despite these needs, grievances regarding the resident's care were not addressed by the facility. The resident's family member reported issues such as the need for podiatry services, foul odor in the resident's hair and beard, pain and discharge in the resident's eye, and lack of communication when the resident refused care. During an interview, the family member stated that grievances had been verbally communicated to the facility staff for almost a year without resolution. A meeting was held with various staff members, including a registered nurse, social services director, and a respiratory therapist, where these issues were discussed. However, the family member did not receive any response from the facility regarding these grievances, some of which had been outstanding for months. The facility's policy required grievances to be documented in writing and investigated by an impartial team. However, the social services director admitted that the complaints raised during the interdisciplinary team meeting were not processed as grievances. The facility's failure to follow its grievance procedure resulted in the resident's care issues remaining unaddressed, as confirmed by the social services director who was unsure if any follow-up actions were taken.
Failure to Implement MD Orders for Oral Care
Penalty
Summary
The facility failed to implement the Medical Doctor's orders for a resident who was in a persistent vegetative state and completely dependent on staff for all aspects of care. The resident had a history of cardiac arrest, anoxic brain injury, and acute on chronic respiratory failure. During oral care, maggots were discovered in the resident's mouth, and it was noted that the resident was NPO and unable to close his mouth completely due to his medical condition. Following this discovery, the MD ordered an increase in oral care frequency from twice a day to every six hours. However, the facility did not input the new order into the resident's care plan, and the resident continued to receive oral care only twice a day. Interviews with staff revealed that the MD's order to increase oral care frequency was not executed. The facility's policy required all orders to be recorded and double-checked by the night nurse every 24 hours, but this process was not followed, leading to the deficiency in care for the resident.
Inadequate Staffing Leads to Deficient Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Observations, interviews, and record reviews revealed that 12 out of 13 sampled residents were affected by this staffing shortage. Residents who were completely dependent on staff for all aspects of care, such as those with functional quadriplegia, chronic respiratory failure, and persistent vegetative states, were not receiving the necessary assistance. For instance, Resident 1, who is incontinent and requires complete assistance, reported waiting 20 to 30 minutes for help due to insufficient staffing. Similarly, Resident 2, who cannot turn herself in bed, was only turned twice a day instead of every two hours as required. Interviews with staff members, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), confirmed the staffing issues. They reported being overwhelmed and unable to perform essential tasks like turning residents every two hours and checking for incontinence. One CNA mentioned being assigned 21 total care residents with another CNA, which is far beyond the manageable workload. The Director of Nursing (DON) acknowledged that approximately 98% of the residents were total care and that the current staffing levels were inadequate to meet their needs. The inadequate staffing led to new skin wounds for two residents, Resident 10 and Resident 12. Resident 10 developed a sore on her buttocks due to not being turned or changed every two hours, while Resident 12 acquired a blister on the left foot and an abrasion on the coccyx. The Wound Nurse confirmed that these wounds were preventable and attributed them to the lack of staffing. Observations also showed that multiple residents were left in the same position for extended periods, further highlighting the facility's failure to provide adequate care due to insufficient staffing.
Failure to Follow Abuse Policy and Procedure
Penalty
Summary
The facility failed to follow their policy and procedure on abuse for one of 13 sampled residents when the alleged abuser, an LVN, was not removed from the working schedule and/or monitored until cleared from the abuse allegation. Resident 13, who had a history of chronic respiratory failure, dependence on a respirator, a tracheostomy, and a myoneural disorder, was allegedly hit and aggressively pushed by the LVN. Despite the allegation, the LVN continued to work on subsequent days without being directly monitored, contrary to the facility's policy that requires staff accused of abuse to be monitored by their immediate supervisor during the investigation period. Interviews with the facility staff, including an RN, the Social Services Director, and the Risk and Regulation Analyst, confirmed that the LVN was not removed from the schedule and was not directly monitored while the investigation was ongoing. The facility's policy clearly states that staff members accused of abuse should not be assigned to the involved patient and must be monitored by their immediate supervisor. However, the LVN worked on two separate days after the allegation without such monitoring, and the investigation into the abuse allegation was still incomplete at the time of the surveyor's review.
Failure to Timely Investigate Abuse Allegation
Penalty
Summary
The facility failed to complete an investigation for an allegation of abuse within five working days. On 4/24/24, Resident 13's sister reported that a Licensed Vocational Nurse (LVN) had hit and aggressively pushed Resident 13's head. Despite this serious allegation, the investigation was not completed until 5/7/24, which is beyond the five-day timeframe typically expected for such investigations. Interviews with staff revealed that the Director of Nursing (DON) was unavailable due to attending a conference, and the Patient Care Executive (PCE) covering for the DON was unaware of the abuse allegation. Additionally, the Risk and Regulation Analyst (RRA) admitted that the facility's policy and procedure did not specify a timeframe for completing abuse investigations, highlighting a gap in their protocol. The delay in completing the investigation had the potential to compromise the thoroughness of the investigation and could have resulted in further abuse. The Social Services Director (SSD) confirmed that the investigation had not been completed as of 5/1/24, and the facility's Investigative Report Summary indicated that the investigation was only completed on 5/7/24. This failure to promptly investigate the abuse allegation demonstrates a significant lapse in the facility's response to serious incidents, potentially putting residents at risk.
Inadequate Staffing and Care Deficiencies
Penalty
Summary
The facility failed to provide adequate direct care staff to meet the daily needs of residents, resulting in several deficiencies. Residents 21, 18, 34, and 31 were not turned every two hours as required, increasing the risk of pressure injuries. Interviews with CNAs revealed that the workload was too high, with each CNA responsible for up to 16 residents, making it difficult to adhere to the turning schedule. Record reviews confirmed that the turning policy was not consistently followed, as documented in the Hourly Rounding Reports (HRR) for the residents involved. Resident 21 experienced delays in having her call light answered, sometimes waiting up to 30 minutes. This delay was attributed to the insufficient number of CNAs available to respond promptly. Additionally, Resident 21 reported that her face and hands were not cleaned before meals unless she specifically requested it, further indicating a lack of adequate care due to staffing shortages. The facility also failed to perform the Restorative Nursing Assistant (RNA) program as ordered for Residents 21, 34, and 19. CNAs were given the additional responsibility of RNA exercises, but they reported not having enough time to complete these tasks. Interviews with staff and residents confirmed that the RNA exercises were not being performed regularly, and the facility's Patient Oriented Council (POC) minutes indicated ongoing concerns about staffing levels and the quality of care provided.
Deficiency in Nephrostomy and G-Tube Care Competency
Penalty
Summary
The facility failed to ensure that 41 licensed nurses were competent in managing nephrostomy and gastrostomy (G-tube) care for residents. Specifically, one resident with a nephrostomy tube had their nephrostomy bag placed on the floor, which could lead to contamination and infection. The nurses involved admitted to not being trained in nephrostomy care, and there were no competencies in place for this procedure. The Infection Preventionist and Director of Nursing confirmed the lack of training and communication regarding nephrostomy care, which may have contributed to the resident's repeated urinary tract infections (UTIs). Additionally, two residents with G-tubes were administered medications improperly. An LVN was observed crushing and mixing multiple medications together and administering them through the G-tube without flushing it with water before or after the medication administration. The LVN acknowledged the mistake and admitted to not following proper procedures. The Clinical Nurse Educator confirmed that the competency checklist did not cover G-tube medication administration, and the Director of Nursing acknowledged the lack of competencies for this procedure. The facility's policies and procedures for medication administration through a feeding tube and employee competency were reviewed and found to be inadequate in ensuring proper training and competency for the nurses. The deficiencies in training and competency for both nephrostomy and G-tube care led to potential risks for the residents involved, including infections and improper medication administration.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement and maintain an effective Quality Assurance Performance Improvement Program (QAPI). During a review of the facility's Special Care Unit (SCU) Quality Assurance Meeting Minutes, it was found that the action column for the survey findings was left blank. The Quality Manager (QM) admitted that the QAPI was not collaborative and that no data was provided to present in QAPI meetings because she was unable to pull reports. The Director of Nursing (DON) confirmed that the QAPI would not be effective without data to support it. The facility's Quality Assurance and Performance Improvement Plan (QAPI) for the Special Care Unit (SCU) outlined a performance improvement model that included identifying opportunities for improvement, developing a plan for improvement, and collecting data. However, the plan was not effectively implemented as there was no data gathered or assessed at the department level. The Quality/Risk Coordinator was responsible for managing and coordinating performance improvement activities, but the lack of data and collaboration hindered the effectiveness of the QAPI program.
Infection Control Deficiencies
Penalty
Summary
The facility failed to conduct proper infection control surveillance, which included the collection of data, analysis, tracking, and trending of infections for all 46 residents. The Infection Preventionist (IP) and Director of Infection Prevention (DIP) did not perform their duties to complete infection control surveillance. The Infection Surveillance Log (ISL) was incomplete, with missing information for several residents. The IP admitted to not completing the ISL and not updating the facility floor map regularly. The DIP also did not review the ISL, contrary to their job description requirements. This lack of surveillance and data analysis hindered the facility's ability to trace infection sources and evaluate control measures effectively. The facility also failed to store and label oxygen tubing properly to prevent contamination. In one instance, a resident's oxygen tubing was found undated and hanging on a metal hook without a plastic bag. The Licensed Vocational Nurse (LVN) and Respiratory Therapist (RT) confirmed that the tubing should be changed every seven days or when it becomes dirty, but no policy was provided for proper storage and labeling. Additionally, the facility did not ensure that a resident's nephrostomy was secured and maintained in a clean environment. The nephrostomy bag was observed on the floor, and the site was not covered with a dressing. LVNs admitted to not receiving proper training for nephrostomy care, and the IP acknowledged that the site should be kept sterile to prevent infections. Furthermore, the facility failed to ensure proper hand hygiene practices among staff. In two separate instances, LVNs did not change gloves or perform hand hygiene after administering medications through a gastrostomy (G-tube) before providing oral care or suctioning a tracheostomy. The IP confirmed that nurses should change gloves and perform hand hygiene between different tasks to prevent cross-contamination. These failures in infection control practices had the potential to cause serious infections among residents, staff, and visitors in the facility.
Failure to Complete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) quarterly assessments were completed for five of nine sampled residents. During interviews and record reviews, the Minimum Data Set Coordinator (MDSC) admitted to being behind on assessments and acknowledged that quarterly MDS assessments need to be completed within 14 days of the Assessment Reference Date (ARD). Specific residents, including Resident 1, Resident 19, Resident 21, Resident 34, and Resident 13, had overdue MDS assessments, with some not being completed since December of the previous year. The MDSC also mentioned a lack of trained staff to assist with the assessments and noted that she had not received recent training herself, contributing to the delay in completing the assessments on time. The Resident Assessment Instrument Manual, dated October 2023, specifies that the MDS completion date must be no later than 14 days after the ARD and that quarterly assessments must be completed at least every 92 days following the previous OBRA assessment. The failure to complete these assessments in a timely manner had the potential to delay the development and implementation of individualized care plans for the affected residents. The MDSC's statements and the review of the residents' records confirmed that the facility was out of compliance with these requirements.
Multiple Deficiencies in Professional Standards of Quality
Penalty
Summary
The facility failed to ensure professional standards of quality in several instances. One resident's nephrostomy tube was not secured and maintained in a clean environment, with the nephrostomy bag found on the floor and the site not covered with a dressing. Multiple staff members, including LVNs, admitted to not being trained in sterile procedures for nephrostomy care, leading to repeated urinary tract infections for the resident. There was a lack of communication and training regarding nephrostomy procedures and infections among the staff. In another instance, multiple medications were crushed and administered together through a G-tube for two residents. The LVN did not flush the G-tube with water before or after medication administration, which is against the facility's policy. The LVN acknowledged the mistake, and the Charge Nurse confirmed that medications should be given separately in the G-tube. The facility's policy clearly states that medications should not be mixed and that the G-tube should be flushed with water before and after administration. Additionally, a CNA performed work outside of their scope of practice by reconnecting a resident to Blow By oxygen therapy via a tracheostomy. The CNA believed this was part of their job description, but the Respiratory Therapist Manager and the Director of Nursing confirmed that only RNs, LVNs, and Respiratory Therapists should perform this task. The facility's policy also indicated that unlicensed personnel should not perform invasive procedures or tracheostomy care. Furthermore, a physician order for a psychiatric consult was not followed for another resident, resulting in a delay of care. The Director of Nursing admitted that the order was missed and not completed timely, which was against the facility's policy for double-checking orders every 24 hours.
Failure to Reposition Resident Every Two Hours
Penalty
Summary
The facility failed to implement their policy and procedure for pressure ulcer care and prevention when staff did not turn and reposition Resident 15 every two hours. Resident 15 was completely immobile and had a very high risk for skin breakdown, as indicated by a Braden Scale Score of 9. Despite physician orders and wound care consultant recommendations to reposition the resident every two hours, the hourly rounding report showed multiple instances where Resident 15 was not turned for extended periods, sometimes up to six hours. This failure was confirmed through interviews with the wound care consultant and a registered nurse, who both acknowledged that the resident should have been turned every two hours to promote healing and prevent further skin breakdown. The facility's policy and procedure titled 'Pressure Injury or Skin/Wound Conditions- Assessment, Prevention and Management' clearly stated that patients at risk should be repositioned at least every two hours if they are unable to reposition themselves. However, the documentation in the electronic health record showed that this was not consistently done for Resident 15. The registered nurse admitted that the lack of regular repositioning could compromise the healing process of the resident's wound. This deficiency had the potential to result in impaired healing or worsening of the pressure injury to Resident 15's coccyx.
Failure to Provide Restorative Nursing Assistant Program
Penalty
Summary
The facility failed to provide the Restorative Nursing Assistant (RNA) program to maintain or improve mobility for five residents. Observations and interviews revealed that residents were not receiving the prescribed range of motion (ROM) exercises. For instance, Resident 31's family member and the resident themselves confirmed that RNA care was not being provided as ordered. Staffing records indicated inconsistent assignment of RNA duties, and several dates showed no RNA staff assigned at all. Additionally, Resident 31's ROM order sheet specified daily passive ROM exercises, which were not being carried out according to the resident and family member's statements. Resident 354 also reported not receiving prescribed exercises, and their flow sheet showed multiple dates with no documented ROM exercises. Similarly, Resident 19 stated that ROM exercises were now infrequent, and their flow sheet indicated several dates with no documented exercises or application of ankle-foot orthoses (AFO). Resident 1 had limited ROM in both hands, and their flow sheet showed missing documentation for several dates. Interviews with CNAs revealed that they were overwhelmed with other duties and lacked proper training and access to residents' RNA orders, making it difficult to perform and document the required exercises. The Director of Nursing (DON) acknowledged awareness of the residents' concerns regarding the RNA program but admitted there was no plan to replace the RNA staff who had left. The facility's policy and procedure documents and job summaries indicated responsibilities for ensuring the quality and effectiveness of patient care, which were not being met. The lack of a structured RNA program and inadequate staffing and training led to the failure to provide necessary ROM exercises, potentially impacting the residents' mobility and range of motion.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
The facility failed to maintain safe and sanitary food handling practices in one of three sampled freezers (Freezer #6) and one of three sampled refrigerators (Refrigerator #5). During an observation and interview with a Dietary Aide (DA), it was found that Freezer #6 contained an open four-pound bag of frozen mixed peas and carrots, an open four-pound bag of sliced carrots, and an open large half-empty bag of tater tots, all without open dates. Similarly, Refrigerator #5 contained a half-empty one-gallon jar of mayonnaise and a half-empty one-gallon jar of dill pickle relish, both without open dates. The Certified Dietary Manager (CDM) confirmed that all food items should be labeled with a use-by date and opened date as per the facility's policy. The facility's policy on food storage mandates that all stored food must be properly labeled and dated with the product name, date opened or prepared, and use-by date.
Lack of Policy for Safe Food Handling and Storage
Penalty
Summary
The facility failed to create a policy and procedure (P&P) to ensure safe food handling and storage guidelines for food brought to residents by family and visitors. During an observation and interview, the Activities Director (AD) mentioned that the refrigerator in the activities room was for resident use and contained items like ice cream and orange juice labeled with patient labels. The AD was responsible for cleaning the refrigerator and checking its temperature daily but was unsure if there was a P&P for safe food handling and storage. Interviews with the Regulatory Specialist (RS), Registered Nurse (RN) 2, and RN 1 revealed that they were also unaware of any existing P&P for this purpose. The Director of Nursing (DON) confirmed that the facility did not have a P&P for the safe handling and storage of food brought by family and visitors, although the AD was responsible for monitoring the resident refrigerator in the activities room. The deficiency was identified through multiple interviews and observations, highlighting a lack of awareness and formal guidelines among staff members regarding the safe handling and storage of food brought in by family and visitors. The absence of a P&P for this process was confirmed by the DON, who acknowledged that the facility should have had such a policy in place. This failure had the potential to result in foodborne illness for residents, as there were no established procedures to ensure the safety of the food being stored and consumed by residents.
Failure to Perform Antibiotic Stewardship Program
Penalty
Summary
The facility failed to perform the antibiotic stewardship program for three sampled residents (Resident 19, Resident 20, and Resident 27) when the surveillance data collection form and infection surveillance log were not completed. During a review of the Infection Surveillance Log (ISL) dated March 2024, it was found that critical information was missing for these residents, including dates of onset of symptoms, criteria for antibiotic use, organism details, re-cultured dates, and resolution dates. The Infection Preventionist acknowledged the mistake, and the Director of Infection Prevention admitted to not reviewing the ISL. The facility's policy and procedure on antibiotic stewardship, dated December 2022, emphasized the importance of optimizing clinical outcomes and appropriate antimicrobial use, which was not adhered to in this instance.
Failure to Maintain Emergency Tracheostomy Supplies at Bedside
Penalty
Summary
The facility failed to follow their Policy and Procedure (P&P) titled Tracheostomy Tube and inner Cannula Changing for Resident 24, who did not have a spare tracheostomy tube at the bedside. During an observation on 4/7/24 at 10:24 a.m., it was noted that Resident 24's room lacked an ambu bag, emergency blow by, and a spare tracheostomy tube or supplies. This was confirmed again on 4/9/24 at 8:37 a.m. during a concurrent observation and interview with LVN 6, who acknowledged that the supplies should have been at the bedside or on the hook in the closet area. RT 2 later confirmed that the emergency tracheostomy supplies were not moved when Resident 24 was relocated. The facility's P&P, dated 2/22/23, clearly indicated that a second tracheostomy tube should always be kept at the bedside.
Failure to Monitor Resident's Behavior on Psychotropic Medication
Penalty
Summary
The facility failed to ensure consistent monitoring of a resident's behavior who was on a psychotropic medication, Sertraline, for depression. The resident, identified as Resident 48, exhibited signs of frustration and sadness, as noted by an LVN and a CNA. However, the CNA admitted to not regularly documenting the resident's behavior or mood. A review of the Drug Regimen Review (DRR) by the Pharmacist Supervisor revealed that the resident's behaviors were not reviewed, and there was no documentation to confirm that the pharmacist had reviewed the behaviors. The Director of Nursing (DON) confirmed that there were missing monitoring sheets for February and March 2024 and incomplete documentation for January 2024. The facility's policy and procedure for Monthly Drug Regimen Review required the monitoring of behavioral expressions, indications of distress, and the onset or worsening of signs and symptoms. The DON acknowledged that the expected documentation was not maintained, and the behaviors were not monitored daily as required. This lack of consistent monitoring and documentation could prevent staff from identifying changes in the resident's mood or behavior, which is crucial for managing the resident's condition and medication regimen effectively.
Failure to Implement Gradual Dose Reduction for Anti-Depressant Medication
Penalty
Summary
The facility failed to ensure that a gradual dose reduction (GDR) was provided for an anti-depressant medication prescribed to Resident 45. During an interview and record review with the Pharmacist Supervisor (PS), it was revealed that Resident 45, who was admitted on an unspecified date, was prescribed Sertraline on 10/25/23. The PS noted that the review for GDR should have started in November 2023, but there was no documentation of any GDR attempts. The facility's policy indicated that within the first year of residency or after the initiation of medication, at least two GDR attempts should be made in separate quarters with at least one month between attempts. The PS confirmed that the pharmacy review was supposed to occur every three months, and the lack of GDR documentation could potentially indicate the unnecessary continuation of the medication.
Failure to Label and Date IV Solution and Glucose QC Testing Strips
Penalty
Summary
The facility failed to properly label and date an intravenous (IV) solution and tubing for one of the residents. During an observation, it was noted that the IV solution being administered to the resident did not have a patient identifier label or date, and the IV tubing was also missing a label with the date of first use. The Registered Nurse (RN) admitted that the IV bag was changed that morning but had not been labeled or dated. The Director of Nursing (DON) confirmed that without a label, the RN would be unable to complete the triple check procedure, and the facility's policy and procedure required the IV bag and tubing to be labeled with a patient identification sticker and the date and time it was hung on the patient. Additionally, the facility failed to date the glucose Quality Control (QC) testing strips vial upon opening on one of the medication carts. During an observation and interview, it was found that the vial containing the QC test strips was not dated. The Licensed Vocational Nurse (LVN) acknowledged that the test strips should be dated when opened. The Charge Nurse (CN) confirmed that QC strips should be dated upon opening and are only good for six months after opening. The manufacturer's guidelines indicated that test strips are stable for up to six months or until the expiration date, whichever comes first.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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