Alhambra Healthcare & Wellness Centre, Lp
Inspection history, citations, penalties and survey trends for this long-term care facility in Alhambra, California.
- Location
- 415 South Garfield, Alhambra, California 91801
- CMS Provider Number
- 055760
- Inspections on file
- 27
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Alhambra Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Two residents were not treated with dignity: one was left with food particles on her clothing and bed after a meal, and another was addressed by staff with a term she did not prefer, rather than her chosen name. Staff acknowledged these actions did not align with facility policy requiring respect for resident preferences and cleanliness.
Two residents with feeding tubes did not receive care according to physician orders and facility policy: one resident's head of bed was not elevated to the required angle during enteral feeding, and another resident's feeding tube was not properly connected, resulting in nutritional supplement leaking onto the bed and floor. The DON and staff confirmed these practices did not meet established procedures for safe and effective enteral feeding.
Two residents did not receive respiratory care in accordance with facility policy: one resident's suction equipment was not discarded and replaced after use as required, and another resident received oxygen therapy without a physician's order. These deficiencies were confirmed through observation, record review, and staff interviews.
Expired vegetables, including lettuce, cilantro, parsley, and cucumbers, were discovered in the kitchen refrigerator during an observation. A dietary aide confirmed the items were past their expiration dates and acknowledged the risk of illness from consuming expired food. The registered dietitian reviewed facility policy and confirmed the vegetables had not been checked or discarded as required.
Surveyors observed improper disposal of garbage, including overflowing trash bins, uncovered containers, trash bags on the floor, and the use of a hamper as a trash can. Dietary staff confirmed that these practices did not follow facility policy, which requires waste to be placed in closable, covered containers.
Staff and a visitor failed to follow infection control protocols, including improper glove removal and hand hygiene after providing peri-care to a resident with severe cognitive impairment and multiple diagnoses, and incorrect use of PPE such as not wearing a face shield and improper N-95 mask placement in isolation rooms, contrary to facility policy during a COVID-19 outbreak.
The facility did not complete required surveillance data collection forms before administering antibiotics to three residents with various infections and impairments. The IPN and DON confirmed that these forms, which are necessary to assess the need for antibiotics and are mandated by facility policy, were not filled out prior to starting antibiotic therapy.
A resident with significant physical and cognitive impairments was not provided with a Low Air Loss (LAL) mattress set to their comfort level as ordered by the physician. Despite ongoing complaints from the resident and their responsible party about the mattress being too hard and lacking air, staff did not adjust the mattress settings for several months. Staff interviews confirmed awareness of the issue, and facility policy required mattresses to promote comfort, but this was not implemented.
A resident dependent on staff for daily care and receiving tube feeding was left in an unclean and unsafe environment after Glucerna formula spilled onto their bedding, bedrail padding, and the floor. Staff did not promptly clean the spill or replace soiled items, resulting in unsanitary conditions and an accident hazard, in violation of facility policy.
A resident with significant physical and cognitive impairments, fully dependent on staff for hygiene and incontinence care, was found with dried stool on the skin and soiled incontinent brief, indicating staff did not provide required cleaning. Staff and DON interviews confirmed this was not in accordance with facility protocols for maintaining resident cleanliness and dignity.
A resident with end stage renal disease and generalized edema, who required dialysis, was given more fluids than prescribed by the physician on multiple occasions. Despite a care plan and physician order limiting fluid intake to 1000cc per day, records showed the resident received up to 1420cc on several days. Staff interviews and record reviews confirmed that the fluid restriction was not followed as required by facility policy.
A resident with paraplegia and dizziness did not receive a scheduled dose of Meclizine at the prescribed time, as it was administered over an hour late by an LVN. Facility policy requires medications to be given within one hour of the scheduled time, and both the LVN and DON confirmed the importance of timely administration for effective treatment.
A resident with malnutrition and dysphagia was repeatedly served a pureed diet instead of the physician-ordered mechanical soft diet, despite documented complaints and clear dietary orders. Staff interviews and observations confirmed the mismatch between the prescribed and provided diets.
A resident with dysphagia and a mechanically altered diet order was fed regular food brought by family, which was not checked by an LVN as required by facility policy. The DON confirmed that the food should have been reviewed for compliance with the resident's diet, and the family was not educated on safe food handling or dietary restrictions.
A room was found to house more than four residents, exceeding regulatory limits. The room was divided by a wall with two beds on one side and three on the other, but only had a single entry/exit door, making it a single room with five residents. Interviews and observations confirmed that residents and staff had sufficient space and no concerns about care or privacy, but the room did not meet occupancy requirements.
The facility failed to implement a scheduled toileting program for three residents who were assessed as candidates for the bowel and bladder program. Despite being identified as good candidates, there were no orders or care plans for scheduled toileting, which could aid in improving continence status. Interviews with staff confirmed the absence of necessary orders and care plans, contrary to the facility's policy and procedure.
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. A resident's oxygen was not administered as ordered, and nasal cannulas for two residents were not stored properly, risking contamination. Another resident's oxygen equipment was not labeled with the date of use, and a fourth resident lacked necessary suction equipment at the bedside. These actions violated the facility's policy on safe and sanitary oxygen therapy.
The facility failed to follow proper food handling practices, as observed during a survey. A container of rice and a container of brown sugar were not sealed properly, and a can opener was found dirty with dried food residue, gunk, and rust. The Dietary Supervisor confirmed these deficiencies, which were against the facility's policies requiring tight-fitting lids for food storage and sanitation of the can opener between uses.
The facility failed to follow infection control practices during incontinence care for a resident, as a CNA did not change gloves before touching the resident's personal items, increasing infection risk. Additionally, the facility did not conduct water testing for legionella or other pathogens, contrary to guidelines, as they believed it unnecessary without reported cases of legionnaires' disease. This lack of testing contradicts both the facility's policy and national guidelines, which recommend regular water quality assessments.
A facility failed to provide an appropriate call light system for a resident with severe cognitive and physical impairments, resulting in the call light being inaccessible. The resident's care plan required the call light to be within reach, but it was found on the floor, and the DON acknowledged the need for a padded alarm instead of a button due to the resident's condition.
A facility failed to maintain a current copy of a resident's advance directive in their medical record. The resident, admitted with cancer and immunodeficiency, had the capacity to make decisions but was moderately impaired in cognitive skills. Despite facility policy requiring the inclusion of advance directives in medical records upon admission, the document was missing, as confirmed by the DON and Social Services.
A facility failed to initiate a comprehensive care plan for a resident's pressure injury, resulting in delayed care. The resident, at risk for pressure injuries, developed a stage 2 pressure injury, but no treatment orders or care plan were in place. Interviews with staff confirmed the absence of a care plan, despite facility policies requiring timely development and updates of care plans.
A resident with muscle weakness and osteoarthritis experienced a decline in mobility, but the care plan was not updated to reflect these changes. Despite therapy evaluations indicating impairments in both upper and lower extremities, the care plan remained unchanged, leading to inadequate care. Facility staff acknowledged the need for revision, and the facility's policy requires updates for new problems or changes in condition.
Two residents in an LTC facility did not receive the required one-to-one feeding assistance as ordered, leading to untouched meal trays and inadequate supervision during meals. Resident 643, with severe cognitive impairment and dysphagia, was not included in the feeding assistance list, while Resident 10, with cognitive impairment and other health issues, was left to feed herself unsupervised. These actions were contrary to the facility's policies on resident care and dignity.
A resident with a history of muscle weakness and osteoporosis developed a Stage 2 pressure injury due to the facility's failure to notify the physician and update care plans. The resident's initial MASD progressed without proper treatment orders or a wound consult, contrary to the facility's policies.
A resident with diabetic neuropathy missed a dose of gabapentin due to the facility's failure to maintain an adequate supply. The medication was not reordered in time, despite the facility's policy requiring refills to be ordered three to four days in advance. This oversight was identified during a medication pass observation and confirmed through staff interviews.
The facility failed to refrigerate unused insulin pens for two residents, as required by its Medication Storage policy. During an observation, a Novolin R Flex Pen and a Basaglar Kwik Pen were found in a medication cart instead of being refrigerated. LVN 4 and the ADON confirmed the need for refrigeration to maintain medication potency, as per the facility's policy.
The facility was found to have a room exceeding the maximum allowed number of residents, with five beds in a room divided by a wall but sharing a single entry door. Despite this, residents could move freely, and staff had enough space to provide care. A waiver request was submitted and recommended for approval, with no resident concerns reported.
A resident assessed as high risk for falls was not provided necessary assistance when getting up from bed to go to the bathroom, resulting in an unwitnessed fall and head injury. The facility failed to initiate a fall care plan as required by their policy, despite the resident's need for substantial assistance with daily activities. The lack of communication between physical therapy and nursing staff contributed to the incident.
A resident with a history of dysphagia and generalized muscle weakness was found unresponsive and without a pulse. Instead of immediately initiating CPR, an LVN checked the resident's code status at the nurses' station, causing a delay. The resident was also moved to his bed before CPR was started. The resident had been given a regular-texture sandwich, posing a choking risk. The delay in CPR and inappropriate diet contributed to the resident's death, as paramedics pronounced the resident dead 35 minutes after becoming unresponsive.
A resident with dysphagia was given a regular texture sandwich instead of a mechanical soft texture diet as ordered by the physician. The CNA did not verify the resident's diet order, and the UAP provided the inappropriate sandwich. The DSS confirmed the resident's diet required a mechanical soft texture with nectar thick consistency. The facility's Snack Spreadsheet also indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids. This led to the resident choking, losing consciousness, and subsequently passing away.
A resident with a history of respiratory issues experienced a significant drop in oxygen saturation, which was not promptly reported to the doctor by the facility staff. Despite the facility's policy requiring immediate notification, the doctor was only informed after the resident became unresponsive and expired.
A resident with multiple respiratory and cardiac conditions was given oxygen therapy without an active physician's order. Staff assumed there was an order and did not follow protocol to inform the doctor, placing the resident at risk for inadequate oxygen therapy.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Two residents were not treated with respect and dignity according to facility policy. One resident, who had severe cognitive impairment and required assistance with most activities of daily living, was observed with food particles on her gown and bed linen after a meal. Staff interviews confirmed that the resident was not cleaned up after eating, and that it is the responsibility of staff to ensure residents are clean from food particles to maintain their dignity. Facility policy requires provision of a clean, comfortable bed and environment to support resident dignity and well-being. Another resident, who was moderately impaired cognitively and required some assistance with personal care, was addressed by a staff member as "grandma" rather than by her preferred name. The resident expressed that she did not like being called "grandma" and preferred to be addressed as "Miss." Staff and the Director of Nursing acknowledged that addressing the resident by a name other than her preference was inappropriate and not in accordance with the facility's policy, which requires staff to speak respectfully and use residents' names of choice.
Failure to Ensure Proper Gastrostomy Tube Practices and Procedures
Penalty
Summary
The facility failed to implement proper gastrostomy tube (GT) practices and procedures for two residents. For one resident with a history of hemiplegia, hemiparesis, acute respiratory failure, and dementia, the head of bed was observed to be elevated at only 20 degrees during enteral feeding, despite physician orders and care plan interventions requiring elevation to at least 30-45 degrees. The Director of Nursing confirmed that the observed bed elevation was below the required angle, and facility policy also specified a minimum of 30 degrees during enteral feedings. For another resident with diagnoses including gastrostomy, dementia, and dysphagia, the GT feeding was not properly connected, resulting in Glucerna leaking into the resident's bed and onto the floor. The resident was dependent on staff for most activities and received more than half of their nutrition through the feeding tube. The nurse present acknowledged that the feeding should not be leaking and that staff are responsible for ensuring all tubing is properly connected so the resident receives the prescribed nutrition. Facility policy required that enteral feedings be administered as ordered by the attending physician, with procedures to check tube placement and ensure proper connection of feeding containers and tubing. The Director of Nursing confirmed that improper connection of the GT feeding could result in the resident not receiving the full prescribed amount of nutrition.
Failure to Follow Respiratory Care Protocols and Physician Orders
Penalty
Summary
Two deficiencies were identified during the review of respiratory care provided to residents. For one resident with hemiplegia, hemiparesis, dementia, gastrostomy, and dysphagia, there was an order to swab/suction every shift as appropriate, and a separate order to suction as needed for excessive secretions. However, observation revealed that suction equipment, including a yankauer, suction tubing, and a collection canister, remained at the bedside well beyond the facility's policy for single-use items. The equipment was dated several days prior and had not been discarded or replaced after use, contrary to the facility's protocol and infection control policy. Staff interviews confirmed that the equipment should have been changed after each use to prevent contamination and infection, but this was not done. A second deficiency involved another resident with diagnoses including type 2 diabetes, cerebral infarction, and dependence on oxygen. This resident was observed receiving oxygen therapy at two liters per minute, but a review of the medical record revealed there was no physician's order for the administration of oxygen. Staff confirmed that the resident was receiving oxygen without a doctor's order, which was not in accordance with the facility's policy that requires a physician's order for oxygen therapy. The DON also confirmed that the policy mandates administration of oxygen only per physician orders. Both deficiencies were substantiated through direct observation, record review, and staff interviews. The facility failed to follow its own policies regarding the safe administration of respiratory care, specifically in the areas of equipment management and ensuring proper physician authorization for oxygen therapy.
Expired Vegetables Found in Kitchen Refrigerator
Penalty
Summary
During a kitchen observation, expired vegetables including lettuce, cilantro, parsley, and cucumbers were found stored in the facility's refrigerator, with expiration dates ranging from 6/19/2025 to 6/22/2025. The dietary aide present confirmed that the vegetables were expired and acknowledged that consuming expired food could make residents sick. Review of the facility's Food Storage and Handling policy indicated that fresh vegetables should be checked, sorted, labeled, and dated, but the registered dietitian confirmed that the expired vegetables had not been checked or discarded as required. The dietitian also stated that the labels clearly indicated the vegetables were expired and should have been thrown away.
Improper Disposal of Garbage in Facility's Disposal Area
Penalty
Summary
During a kitchen observation, surveyors found that the facility failed to properly dispose of garbage in the designated disposal area. Specifically, trash bins were seen overflowing, some bins had lids that were not fully closed, trash bags were left on the floor, a hamper was being used as a trash can, and some trash cans were uncovered. A dietary aide confirmed that trash bags should not be on the floor, trash should be covered, and hampers are not appropriate for use as trash cans, noting that uncovered trash can attract animals and spread disease. Review of the facility's waste management policy indicated that waste containers must be closable, waste must be disposed of in appropriate non-combustible containers, and waste bags must be placed in covered bins. The dietary supervisor also confirmed that trash should be disposed of in closable containers and not left on the floor or in hampers.
Deficient Infection Control Practices and Improper PPE Use
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as outlined in its own policies and procedures. Certified Nurse Assistant 1 (CNA 1) was observed exiting a resident's room after providing peri-care while still wearing contaminated gloves and used those gloves to close the resident's door. CNA 1 acknowledged during an interview that gloves should have been removed and hand hygiene performed before leaving the room. The Infection Preventionist Nurse (IPN) and Director of Nursing (DON) both confirmed that this action was not in accordance with facility policy and could contribute to the spread of infection, especially during an ongoing COVID-19 outbreak in the facility. The facility's policies require gloves to be discarded in the room where care is provided and for staff to perform hand hygiene before and after glove removal and upon exiting a resident's room. Additionally, there were failures related to the use of personal protective equipment (PPE) in rooms under novel respiratory precautions. CNA 1 was observed entering an isolation room without wearing a required face shield, despite signage and facility policy indicating that a face shield, N-95 mask, gown, and gloves must be worn before entry. CNA 1 admitted knowledge of the requirement but did not comply. In another instance, a family member (FM 2) was observed entering a resident's room with an N-95 mask worn incorrectly, with the metallic strip under the chin instead of over the nose, which was confirmed by a Licensed Vocational Nurse (LVN 2) to be improper and not in line with the facility's instructions for proper fit and use. The facility's policies on management of COVID-19 and transmission-based precautions require strict adherence to PPE protocols, including correct donning and doffing procedures and proper use of equipment to prevent the spread of communicable diseases. Observations and interviews confirmed that staff and visitors did not consistently follow these protocols, resulting in deficiencies in infection control practices.
Failure to Complete Antibiotic Surveillance Forms Prior to Administration
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program protocol by not completing the required surveillance data collection forms prior to administering antibiotic therapy to three residents. For each of these residents, antibiotics were prescribed and administered without the documented assessment to determine if the criteria for antibiotic use were met, as required by facility policy. The Infection Preventionist Nurse (IPN) confirmed in interviews that the surveillance data collection forms were not completed for any of the three residents before antibiotics were given. One resident was readmitted with diagnoses including sepsis and contact dermatitis and was prescribed Cephalexin for a urinary tract infection. Another resident, admitted with immune system disorder and malnutrition, received Sulfamethoxazole-Trimethoprim for a left buttock ulcer secondary to a ruptured abscess. The third resident, admitted with MRSA and malnutrition, was prescribed Ciprofloxacin for a urinary tract infection. In each case, the Minimum Data Set (MDS) assessments indicated varying levels of cognitive and physical impairment, and the physician orders for antibiotics were documented in the residents' records. Interviews with the IPN and the Director of Nursing (DON) confirmed that the surveillance data collection forms, which are intended to evaluate the necessity of antibiotic use and prevent antibiotic resistance, were not completed as required by the facility's policies. The facility's policies specify that the IPN is responsible for collecting and analyzing infection surveillance data and ensuring adherence to antibiotic stewardship processes, including the completion of surveillance forms prior to antibiotic administration.
Failure to Adjust LAL Mattress to Resident Comfort Level
Penalty
Summary
A deficiency occurred when the facility failed to accommodate the needs and preferences of a resident by not ensuring that the resident's Low Air Loss (LAL) mattress was set to the comfort level as ordered by the physician. The resident, who was admitted with diagnoses including scoliosis, chest and rib deformity, and muscle weakness, was dependent on staff for most activities of daily living and was moderately impaired in cognitive skills. Physician orders specified that the LAL mattress should be adjusted for the resident's comfort, yet observations revealed that the mattress had very little air, and the metal part of the bed could be felt with minor pressure. The resident repeatedly complained about the mattress being uncomfortable and lacking sufficient air. Interviews with staff and the resident's responsible party confirmed that complaints about the mattress had persisted for two to three months, with both the resident and their responsible party noting the mattress was hard and uncomfortable. Staff acknowledged that the mattress should be set to the resident's comfort level in accordance with physician orders and resident rights. Facility policies also required providing a comfortable mattress to promote comfort and prevent complications of immobility, but these were not followed in this instance.
Failure to Maintain Clean and Safe Resident Environment After Enteral Feeding Spill
Penalty
Summary
Facility staff failed to maintain a safe, clean, and homelike environment for a resident who was dependent on staff for most activities of daily living and received the majority of nutrition through a gastrostomy tube. The resident, who had diagnoses including dementia and dysphagia, was found with spilled Glucerna formula on their fitted bed sheet, bed sheet, bedrail padding, and the floor. Staff present at the time acknowledged that the enteral feeding formula had leaked and that the environment was not clean or sanitary. Housekeeping had not been called to clean the floor, and the bedrail padding had not been replaced or cleaned at the time of observation. The facility's policy and procedure required staff to provide a safe, clean, and comfortable environment and to pay close attention to cleanliness and order. Despite this, staff did not promptly address the spill or ensure the resident's environment was sanitary. The Director of Nursing confirmed that the situation was unacceptable and that any staff member could have assisted in cleaning the environment and bedside padding. This failure resulted in an unclean environment and accident hazard for the resident, other residents, and facility staff.
Failure to Provide Adequate Incontinence and Hygiene Care
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including perineal hygiene and incontinence care, was found in bed with brown residue on the right inner thigh and a brown smear on the outside and top of the incontinent brief. The resident had a history of hemiplegia, hemiparesis, dementia, and Parkinson's disease, and was documented as always incontinent and requiring total assistance for toileting and hygiene. Staff interviews confirmed that the presence of stool on the resident's skin and brief indicated that the resident had not been fully cleaned or checked as required. Facility policy required that residents who are incontinent be kept clean, dry, and comfortable, and that perineal care be provided to maintain cleanliness and prevent skin breakdown. Both the CNA and LVN present at the time of observation acknowledged that the resident should have been cleaned properly, and the DON confirmed that facility protocol mandates residents be left clean, presentable, and odor free. The failure to provide adequate assistance with hygiene and incontinence care was directly observed and confirmed through staff interviews and record review.
Failure to Follow Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a resident receiving dialysis, resulting in the resident being given more fluids than prescribed on multiple occasions. The physician's order and care plan specified a strict fluid restriction of 1000cc per 24 hours, divided among the three nursing shifts. However, medication administration records showed that the resident received a total of 1420cc of fluid on several days, exceeding the prescribed limit. This discrepancy was confirmed during interviews with both a licensed vocational nurse and the director of nursing, who acknowledged that the physician's order was not being followed. The resident involved had diagnoses of end stage renal disease and generalized edema, and required dialysis as well as assistance with daily activities. The facility's policies on fluid restriction and dialysis management required strict adherence to physician orders, but these were not followed in practice. The failure to comply with the fluid restriction was documented through record reviews, staff interviews, and review of facility policies.
Failure to Administer Scheduled Medication on Time
Penalty
Summary
A scheduled medication was not administered on time to a resident with paraplegia and dizziness. The resident was admitted with these diagnoses and was assessed to have intact cognitive skills, requiring varying levels of assistance for daily activities. The resident had a physician's order for Meclizine to be given three times daily for dizziness. On the day in question, the medication was scheduled for 8:00 AM but was not administered until 9:40 AM, as observed by surveyors and confirmed by the LVN responsible for medication administration. The facility's Medication Administration policy requires medications to be given within one hour before or after the scheduled time, and emphasizes the importance of administering medications at the right time. The LVN acknowledged the medication was given late and stated that late administration could result in symptoms not being relieved on time. The Director of Nursing confirmed the policy and the importance of timely medication administration to ensure proper treatment of residents' medical conditions.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
A deficiency occurred when a resident with diagnoses of protein-calorie malnutrition and hyperlipidemia, who was moderately cognitively impaired and dependent on staff for several activities of daily living, was not provided with the therapeutic diet as ordered by the physician. The resident's Minimum Data Set and speech therapy evaluation indicated a need for a carbohydrate-controlled, mechanical soft diet with regular/thin liquid consistency, and the physician's order specified a dysphagia mechanical soft texture. However, multiple observations revealed that the resident was consistently served a pureed diet instead of the ordered mechanical soft diet. Interviews with the resident, a CNA, and the Director of Dietary Services confirmed that the resident had been complaining about the food texture for at least a week, and possibly as long as six months. The Director of Dietary Services acknowledged that the resident's tray did not match the physician's order, and the DON confirmed that the diet should have followed the speech therapy evaluation and physician's order. The facility's policy required meals to be consistent with physician orders and resident preferences, but this was not followed in the resident's case.
Failure to Review Family-Brought Food for Resident with Dysphagia
Penalty
Summary
The facility failed to implement its policy regarding the review and storage of food brought in by family members for a resident with significant swallowing difficulties. Specifically, a resident with diagnoses including dysphagia, hyperlipidemia, and adult failure to thrive, and who was on a mechanically altered, fortified diet as ordered by the physician, was observed being fed a regular diet of wonton soup and kiwi by a family member. The resident's care plan and physician orders required adherence to a mechanically altered diet due to the risk of choking and aspiration. Despite this, the food brought in by the family was not checked by the Licensed Vocational Nurse (LVN) as required by facility policy. Interviews with the LVN and the Director of Nursing (DON) confirmed that the food was not reviewed for compliance with the resident's prescribed diet, and that the family was not educated on the facility's policy or the resident's dietary needs. The facility's policy required staff to review the diet order with the resident's representative and assist families in understanding safe food handling practices, but this was not followed in this instance.
Room Occupancy Exceeds Regulatory Limit
Penalty
Summary
The facility failed to ensure that one of its rooms did not exceed the maximum occupancy of four residents per room, as required by regulations. Specifically, the room in question was separated by a wall into two sections, with two beds on one side and three beds on the other, but only had a single door for entry and exit, effectively making it a single room with five residents. This arrangement was confirmed through observation, interviews, and record review, including a review of the facility's room waiver, which acknowledged the configuration and the number of residents in the room. Interviews with the administrator, residents, and nursing staff confirmed the presence of more than four residents in the combined room. Despite the room's size and the ability for residents and staff to move freely and provide care, the room did not meet the regulatory requirement for maximum occupancy. The residents and staff did not express concerns about space, privacy, or the ability to provide care, and observations indicated that the room's configuration did not adversely affect health or safety at the time of the survey.
Failure to Implement Scheduled Toileting Program
Penalty
Summary
The facility failed to implement a toileting schedule for three residents who were assessed as candidates for the bowel and bladder (B&B) program. Resident 40, who was occasionally incontinent with urinary continence and always continent with bowel continence, was identified as a good candidate for retraining on multiple occasions. Despite this, there was no order for a scheduled toileting program, as confirmed by interviews with the Certified Nursing Assistant and Licensed Vocational Nurse. The Assistant Director of Nursing acknowledged that without a scheduled toileting order, Resident 40's incontinence may not improve. Resident 16, who was always incontinent for bowel continence, was also identified as a good candidate for scheduled toileting. However, the Director of Nursing confirmed that there was no physician's order for scheduled toileting, which could aid in restoring bowel and bladder continence. The lack of a scheduled toileting program for Resident 16 was a missed opportunity to improve their continence status. Resident 82, who was frequently incontinent and had a Foley catheter, was assessed as a candidate for scheduled toileting. Despite this, there was no care plan implemented for a scheduled toileting program. The Assistant Director of Nursing stated that a scheduled toileting program could help improve incontinence status and promote dignity, but it was not in place for Resident 82. The facility's policy and procedure emphasized the importance of providing appropriate treatment and services to restore bowel and bladder function, which was not adhered to in these cases.
Deficiencies in Respiratory Care Services
Penalty
Summary
The facility failed to provide necessary respiratory care services for four residents, leading to several deficiencies. For Resident 2, the facility did not administer oxygen via nasal cannula according to the physician's order, as the nasal cannula was found hanging at the back of the wheelchair and not in use. This oversight was confirmed by both a CNA and an LVN, who acknowledged that the nasal cannula should have been placed in a plastic bag to prevent contamination. Additionally, the Assistant Director of Nursing (ADON) noted that the resident could develop shortness of breath and hypoxia if the oxygen was not provided as ordered. For Residents 2 and 49, the facility failed to ensure that the nasal cannula was stored in a clean plastic bag when not in use, which could lead to respiratory infections. Resident 49's nasal cannula was observed wrapped around the bedside rail, exposed to potential contamination. Both an LVN and the ADON confirmed that the nasal cannula should be stored in a plastic bag to avoid exposure to germs. The facility's policy on oxygen therapy, which requires oxygen to be administered under safe and sanitary conditions, was not followed. Resident 641's oxygen nasal cannula and water container for humidified oxygen were not labeled with the date of first use or change, as observed by a physical therapist and a CNA. This lack of labeling is against the facility's policy, which requires such equipment to be changed and dated every seven days. Additionally, Resident 63, who required suctioning as needed, did not have a suction canister or yaunker readily available at the bedside, and the nebulizer tubing was found on the floor. The Infection Preventionist and the Director of Nursing acknowledged the absence of a policy for suctioning and proper storage of oxygen and nebulizer tubing, which are crucial for infection control and resident safety.
Improper Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as observed during a survey. Specifically, a container of rice and a container of brown sugar were not sealed properly, which was confirmed by the Dietary Supervisor (DS) during an interview. Additionally, a can opener was found to be dirty, with dried food residue, gunk, and rust present. These observations were made during a kitchen inspection, and the DS acknowledged the improper sealing of the containers and the unclean state of the can opener. The facility's policies and procedures, as reviewed, require that opened food products be stored in containers with tight-fitting lids and that all storage products be labeled and dated. The policy also mandates routine monitoring for pest activity. Furthermore, the can opener is supposed to be sanitized between uses according to the manufacturer's guidelines. The DS confirmed that all food containers should be tightly closed to prevent pest infestation and that the can opener should be cleaned after each use.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident. The resident, who was admitted with diagnoses of muscle weakness and hypertension, was observed to be severely impaired in cognitive skills and required assistance with daily activities, including toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) was seen providing perineal care to the resident without changing gloves before touching the resident's personal items, such as the call light, blanket, bed rail, and bed remote. This action was acknowledged by the CNA and the Infection Preventionist Nurse as a breach of infection control protocol, as it increased the risk of spreading infection. Additionally, the facility did not implement water sample testing to validate its water management program's control measures. Interviews with the Infection Preventionist and Maintenance Supervisor revealed that the facility did not conduct testing for legionella or other waterborne pathogens, as they believed there was no need due to the absence of reported cases of legionnaires' disease among residents. The facility's policy and procedure on water management, as well as guidelines from the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention, emphasize the importance of environmental testing to validate the effectiveness of control measures in preventing waterborne pathogens. The facility's failure to conduct initial or ongoing water testing for legionella and other pathogens was further confirmed by the Administrator, who stated that testing was not deemed necessary unless there were issues with water temperature. This lack of testing contradicts the facility's own policy and national guidelines, which recommend regular water quality assessments to prevent conditions conducive to legionella growth, especially in healthcare settings serving at-risk populations.
Inadequate Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to provide an appropriate call light system for a resident, identified as Resident 5, who was admitted with diagnoses of muscle weakness and osteoarthritis. The resident's care plan, revised on two occasions, indicated the need for the call light to be within reach due to the resident's risk for injury and falls. However, during an observation, it was noted that the call light was on the floor and not accessible to the resident, who had both arms and legs contracted. The Director of Nursing (DON) acknowledged that the call light should have been a padded alarm instead of a button due to the resident's condition and inability to use the standard call light. The resident's medical records, including an Occupational Therapy Evaluation and Minimum Data Set, highlighted severe impairments in cognitive skills and physical abilities, indicating dependency on assistance for daily activities. Despite these documented needs, the facility's policy on call systems, which required call cords to be within the resident's reach, was not adhered to. This oversight had the potential to delay necessary care and services for the resident, as the call light was not appropriately adapted to the resident's physical limitations.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a current copy of a resident's advance directive in the medical record, which is a legal document that provides instructions for medical care if the resident cannot communicate their wishes. This deficiency was identified for one resident who was admitted with diagnoses of malignant neoplasm of the left lower limb and immunodeficiency. The resident had the capacity to understand and make decisions as per the History and Physical dated January 8, 2024, but was noted to be moderately impaired in cognitive skills for daily decision-making according to the Minimum Data Set dated May 17, 2024. During a record review on June 25, 2024, it was found that there was no advance directive in the resident's chart. Interviews with the Director of Nursing (DON) and Social Services (SS) confirmed that the facility did not have the resident's advance directive and acknowledged that it should have been followed up shortly after admission. The facility's policy, revised in July 2018, requires that a copy of the advance directive be obtained upon admission and included in the resident's medical record, which was not adhered to in this case.
Failure to Initiate Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was initiated for a resident, resulting in delayed care and services for the resident's pressure injury. The resident was admitted with diagnoses of muscle weakness and osteoporosis and was at risk of developing pressure injuries, as indicated by the Braden Scale. Despite these risks, the facility did not develop a care plan to address the resident's pressure injury, which was observed by a CNA and later classified as a stage 2 pressure injury by a treatment nurse. Interviews with facility staff, including a CNA, a treatment nurse, the DON, and the ADON, revealed that there were no orders for treatment of the resident's pressure injury, and the facility did not have a care plan in place for the injury. The facility's policies required the development of a comprehensive care plan within seven days of the MDS assessment and updates to the care plan with the onset of new problems or changes in condition. However, these procedures were not followed, leading to the deficiency.
Failure to Revise Care Plan for Resident with Declining Mobility
Penalty
Summary
The facility failed to revise the care plan for one of the sampled residents, identified as Resident 5, which led to inadequate care for the resident's needs. Resident 5 was admitted with diagnoses of muscle weakness and osteoarthritis and was noted to have impaired cognitive skills, requiring extensive assistance with daily activities. Despite the resident's declining mobility, as evidenced by occupational and physical therapy evaluations indicating impairments in both upper and lower extremities, the care plan was not updated to reflect these changes. Observations showed the resident with contracted arms and legs, and interviews with facility staff confirmed that the care plan should have been revised to address the resident's declining condition. The Assistant Director of Nursing acknowledged that the care plan needed revision since the resident was no longer in the Restorative Nursing Assistant program and had experienced a decline in mobility. The Director of Rehabilitation also noted the resident's declining mobility and recommended splinting to prevent contractures. The facility's policy on comprehensive person-centered care planning requires care plans to be revised at the onset of new problems or changes in condition, which was not adhered to in this case.
Failure to Provide Required Feeding Assistance
Penalty
Summary
The facility failed to provide one-to-one feeding assistance for two residents, Resident 643 and Resident 10, as ordered. Resident 643, who was admitted with a displaced intertrochanteric fracture and dysphagia, was observed multiple times with untouched meal trays and no staff assistance, despite having an order for 1:1 feeding assistance. The Assistant Director of Nursing (ADON) confirmed that Resident 643 was not included in the list of residents requiring feeding assistance, which was an oversight. The Speech Therapist and Director of Rehab noted that Resident 643 needed 1:1 support for feeding to ensure safety and adequate food intake. Resident 10, admitted with anemia, malnutrition, and end-stage heart failure, also required assistance with feeding. Observations revealed that Resident 10 was feeding herself with food all over her mouth and clothes, contrary to the care plan that required staff supervision during meals. The ADON confirmed that Resident 10's care plan indicated a need for assistance with eating and personal hygiene due to cognitive impairment and other health issues. CNA 7 admitted to leaving Resident 10 to feed herself, which was not in line with the required supervision for safety and dignity. The facility's policies on resident rights and quality of life emphasize the need for individualized care to maintain residents' dignity and well-being. However, the failure to provide the necessary feeding assistance for Residents 643 and 10, as per their care plans, put them at risk for weight loss, aspiration, and compromised dignity. The oversight in including Resident 643 in the feeding assistance list and the lack of supervision for Resident 10 highlight deficiencies in the facility's adherence to its policies.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate treatment for a Stage 2 pressure injury for one of the sampled residents, Resident 26. Initially, Resident 26 had Moisture-Associated Skin Damage (MASD) on the sacrum area, which progressed to a Stage 2 pressure injury. Despite this progression, the facility did not notify the physician, resulting in no wound treatment orders being issued. Additionally, there was no Change of Condition form completed to document the progression of the wound. Interviews and record reviews revealed that Resident 26's physician orders did not reflect the presence of a pressure injury, and there was no order for a wound consult. Consequently, Resident 26 had not been seen by a wound doctor after the wound progressed. Furthermore, Resident 26's care plan did not indicate any pressure injuries, contrary to the facility's policies and procedures, which require care plans to be reviewed and revised upon the onset of new problems or changes in condition. The facility's policies also mandate daily observation and reporting of any signs of active pressure injuries, which was not adhered to in this case.
Failure to Maintain Adequate Medication Supply
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with type 2 diabetes mellitus and diabetic neuropathy, had a sufficient supply of gabapentin, a nerve pain medication, as per the physician's order and facility policy. The physician's order required the administration of gabapentin 100 mg twice daily for neuropathy. However, during a medication pass observation, it was noted that the resident did not have any gabapentin available in the medication cart, resulting in a missed morning dose. Interviews with the Licensed Vocational Nurses (LVN) and the Assistant Director of Nursing (ADON) revealed that the licensed nurse responsible for the resident's medication should have ordered a refill when the stock was low. The facility's policy required medications to be reordered three to four days in advance to ensure an adequate supply. The failure to reorder the medication in a timely manner led to the resident missing a dose, which could potentially result in unrelieved nerve pain.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to adhere to its Medication Storage policy by not refrigerating unused insulin pens for two residents, which is a requirement for maintaining the medication's effectiveness. During an observation of Medication Cart 3, it was found that a Novolin R Flex Pen belonging to one resident and a Basaglar Kwik Pen belonging to another resident were not stored in the refrigerator as required. Both insulin pens had green stickers indicating the need for refrigeration, yet they were found in the medication cart instead. Licensed Vocational Nurse (LVN 4) confirmed that the insulin pens should have been refrigerated, and the Assistant Director of Nursing (ADON) reiterated the importance of proper storage to maintain the potency of the medications. The facility's policy, dated August 2019, specifies that medications should be stored according to the manufacturer's recommendations, which include refrigeration for these insulin pens. The failure to store these medications properly could compromise their effectiveness, posing a risk to the residents' health.
Room Capacity Exceeded in Shared Resident Room
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents in a shared room to no more than four. During an observation, it was noted that one room, identified by specific room numbers, was divided by a wall and contained a total of five beds, with two beds on one side and three on the other, accessible through a single door. This setup did not meet the requirement of having no more than four residents per room. Despite the room's configuration, residents were able to move freely, and nursing staff had adequate space to provide care with dignity and privacy. The facility had submitted a room waiver request, indicating sufficient space and safety for residents, and the Department recommended approval of this waiver. Interviews with residents revealed no concerns about room size.
Failure to Prevent Fall for High-Risk Resident
Penalty
Summary
The facility failed to prevent a fall for a resident who was assessed as high risk for falls. The resident, admitted with diagnoses including muscle weakness, history of falling, and abnormality of gait and stability, had a high fall risk score of 11. Despite requiring substantial assistance with daily activities such as toileting and transfers, the resident was not provided assistance when getting up from the bed to go to the bathroom. This lack of assistance led to an unwitnessed fall in the resident's room, resulting in a head injury and transfer to a general acute care hospital. The facility did not initiate a fall care plan for the resident, as required by their policy and procedure. The Director of Nursing acknowledged that the resident was assessed as high risk for falls and should have had a fall care plan in place. Additionally, the Physical Therapy Director noted the need for communication with nursing staff regarding the resident's assistance needs. The facility's policy on fall management emphasizes the importance of documenting interventions on the resident's care plan when a fall risk factor is identified, which was not done in this case.
Delayed CPR Initiation and Inappropriate Diet Lead to Resident Fatality
Penalty
Summary
The facility failed to ensure immediate initiation of CPR for Resident 1, who was found unresponsive and without a pulse. Instead of starting CPR right away, LVN 1 walked to the nurses' station to check on Resident 1's code status before beginning CPR. Additionally, Resident 1 was moved from outside his room to his bed before CPR was initiated, causing a delay in life-saving measures. Despite Resident 1's need for immediate CPR due to cardiac and respiratory arrest, the staff did not act promptly, resulting in the resident being pronounced dead by paramedics 35 minutes after becoming unresponsive. Resident 1 had a history of dysphagia and generalized muscle weakness, requiring a specific diet and supervision with eating. Despite these known conditions, Resident 1 was given a sandwich of regular texture, which posed a choking risk. The staff's delay in recognizing the severity of the situation and the failure to provide appropriate care, such as immediate CPR and addressing the choking incident effectively, contributed to the tragic outcome. The facility's policy on cardiopulmonary resuscitation was not followed, as staff did not initiate CPR promptly upon finding Resident 1 unresponsive.
Failure to Adhere to Dysphagia Diet Order Results in Resident's Death
Penalty
Summary
The facility failed to follow the physician's order to provide a mechanical soft texture diet for a resident with dysphagia, resulting in a tragic incident. Despite the resident's documented need for a specific diet due to difficulty swallowing, the Certified Nursing Assistant (CNA) did not verify the resident's diet order before allowing them to consume a sandwich of regular texture and unknown content. This failure led to the resident choking and subsequently losing consciousness, ultimately resulting in their death. The deficiency was exacerbated by the actions of the Uncertified Assistive Personnel (UAP), who handed the inappropriate sandwich to the resident despite being instructed by the CNA to obtain it from the facility's refrigerator. The Dietary Service Supervisor (DSS) confirmed that the resident should not have been given a sandwich due to being on a dysphagia mechanical soft diet with nectar thick consistency. Additionally, the facility's Snack Spreadsheet indicated that sandwiches were not recommended for residents on a dysphagia diet with thick liquids, highlighting a breakdown in communication and adherence to established protocols.
Failure to Notify Doctor of Resident's Low Oxygen Saturation
Penalty
Summary
The facility failed to notify the doctor of a resident's change in condition, specifically a decreased oxygen saturation level of 78%. The resident, who had a history of pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was found by an LVN to be short of breath with uneven breathing. Despite the facility's policy requiring immediate notification of significant changes in condition, the LVN did not inform the doctor of the resident's low oxygen saturation level. The Director of Nursing (DON) was informed of the situation but also did not notify the doctor until after the resident became unresponsive and expired. Interviews and record reviews revealed that the resident's vital signs, including the low oxygen saturation level, were documented but not communicated to the doctor in a timely manner. The medical doctor confirmed that he was only informed of the resident's condition after the resident had already passed away. The facility's policy and procedure clearly stated that physicians should be informed immediately of any significant changes in a resident's condition, which was not followed in this case, leading to a failure in providing timely medical intervention for the resident.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident had an active doctor's order for oxygen therapy before and during its administration. The resident, who had diagnoses including pneumonia, acute respiratory failure, moderate persistent asthma, and congestive heart failure, was given oxygen at 2 liters per minute on multiple occasions without a physician's order. This was confirmed through a review of the resident's Medication Administration Records and Order Summary, which did not indicate an active physician's order for the oxygen therapy during the specified period. Interviews with the CNA, LVN, and DON revealed that the staff assumed there was an active order and did not follow the facility's protocol to inform the doctor and obtain a proper order for the oxygen therapy. The resident's primary doctor confirmed that he did not order oxygen administration and was unaware that the resident was receiving oxygen therapy. The facility's policy and procedure for oxygen therapy, which requires licensed nursing staff to administer oxygen as prescribed by the doctor, was not followed. This failure placed the resident at risk for inadequate oxygen therapy, which could negatively impact their health and well-being. The DON acknowledged that administering oxygen without a physician's order is a significant problem that could lead to respiratory distress and potentially fatal outcomes for the resident.
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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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