Astoria Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylmar, California.
- Location
- 14040 Astoria Street, Sylmar, California 91342
- CMS Provider Number
- 056084
- Inspections on file
- 75
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Astoria Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow contact isolation and infection control practices for two residents on precautions for C-diff. A CNA entered a contact isolation room without gown and gloves and placed a resident’s food tray on a cart with other residents’ trays. There were no dedicated linen hampers in the isolation rooms to separate soiled linens and clothing from those of other residents. A family member was observed visiting a resident on contact precautions without PPE and reported not being informed of the reason for isolation or required precautions, despite facility policies requiring staff to educate visitors and use appropriate PPE and linen handling procedures.
A resident with C.-diff, moderate cognitive impairment, and significant ADL assistance needs had almost daily visitors while on contact isolation, but the facility failed to provide and document infection control education for those visitors. Although staff were trained on appropriate PPE use, contact precautions, and the need for soap-and-water handwashing rather than alcohol-based sanitizer for C.-diff, record review showed no evidence that similar teaching was extended to visitors. This failure occurred despite a written infection prevention and control policy stating that infection control procedures apply equally to staff, residents, visitors, and others, and are intended to prevent, detect, investigate, and control infections.
A resident with metabolic encephalopathy, pneumonia, osteoporosis, a history of falls, and moderately impaired cognition had physician orders for continuous O2 at 2 L/min via nasal cannula with O2 saturation checks every nursing shift and physician notification below specified saturation thresholds. For five days, there was no documented shift-by-shift O2 saturation monitoring while the resident was ordered continuous oxygen, and part of the record showed the resident on room air. In addition, the admission fall risk assessment documented no fall history, only one diagnosis, and a weak gait, yielding a low fall risk score, despite other records showing a history of falls, multiple diagnoses, and impaired gait per facility criteria. The DON and LVN acknowledged that the O2 monitoring was not documented and that the fall risk score should have been higher based on the resident’s condition and facility policy.
A resident with diabetes, Alzheimer’s disease, and hypertension experienced a change of condition after an incident of physical aggression by another resident. A CNA reported the event to an LVN, who later completed a change-of-condition evaluation with the wrong date and shift for when the incident occurred. The LVN also documented incorrect times for when the MD and the resident’s family were notified, and could not recall the actual notification times. The evaluation was not completed and signed until two days after the event, contrary to facility policies requiring accurate, timely documentation and completion by the end of the assigned shift.
Surveyors found that three residents with existing sacral pressure ulcers or moderate risk for pressure ulcers, as indicated by Braden scores and MDS assessments, were not consistently turned and repositioned every two hours as required by their care plans. These residents had significant conditions such as Parkinson’s disease, diabetes, muscle weakness, and failure to thrive, and required maximal to moderate staff assistance or were fully dependent for rolling. Review of medical records with the TxN and confirmation by the DON showed no documentation that the ordered q2h repositioning was carried out, despite a facility pressure ulcer prevention policy requiring monitoring and documentation of prevention techniques.
A resident with Parkinson’s disease, type 2 DM, and a stage 4 sacral pressure ulcer experienced a change in condition with fever, SOB, and altered responsiveness and was transferred to a GACH, where the resident remained and was later discharged. Despite the resident no longer being in the facility, an LVN later documented that the resident was in bed, able to make needs known, free of SOB or acute distress, had received and tolerated all due meds, was kept clean and dry, and had specific vital signs recorded. During review, the DON confirmed the resident had already been transferred out at the time of this entry and that the documentation was inaccurate and not consistent with the facility’s nursing documentation policy.
A resident with end-stage renal disease and a history of removing her AV fistula dressing returned from hemodialysis and was not assessed or monitored as required by her care plan. Staff failed to inspect the access site or communicate the resident's return, resulting in the resident being found unresponsive and bleeding from the fistula site, leading to her death. Additionally, the facility did not promptly develop a care plan for another resident admitted to hospice, causing a delay in care planning.
A resident with ESRD, anemia, and a history of removing her own AV fistula dressing returned from hemodialysis and was not properly assessed or monitored by nursing staff. The RN did not inspect the access site or check vital signs, and no post-dialysis assessment was documented. The resident was later found unresponsive with severe bleeding from the AV fistula site and was pronounced deceased. Facility staff failed to follow established protocols for post-dialysis care and monitoring.
Nursing staff, including an RN and an LVN, did not receive orientation or in-service training on dialysis care or assessment, as confirmed by skills checklists, job descriptions, and staff interviews. The Director of Staff Development and the DON acknowledged that dialysis care was not part of the orientation process, and the facility's policy on staff competency was not followed for dialysis care. This resulted in staff lacking the necessary knowledge and skills to safely care for residents requiring dialysis.
The facility did not update its Facility Assessment Tool after a change of ownership and the implementation of electronic medical records, and failed to specify required staff training for dialysis care. The assessment continued to list the previous facility name and omitted details about electronic health information technology and dialysis competencies, resulting in outdated and incomplete documentation.
A resident's MDS assessment did not include a documented diagnosis of dementia, even though this was present in the primary physician's History and Physical. The MDS Coordinator relied on outdated admission records instead of reviewing current physician documentation, leading to an incomplete and inaccurate assessment.
A CNA did not change her gown after repositioning a resident with a gastrostomy and before draining another resident's Foley catheter, despite both requiring enhanced barrier precautions. This failure to follow infection control protocols was confirmed by the DON and had the potential for cross-contamination.
A resident with cognitive impairment was involved in an incident where a family member attempted to have them sign a bank authorization form. Staff intervened and identified the situation as potential financial abuse, but the required five-day investigation report was not completed in accordance with facility policy.
A resident with multiple chronic conditions fell after attempting to steady herself on a wheelchair that was not within reach. Although staff assessed the resident and completed required documentation, there was no evidence that an IDT meeting was held within the facility's required timeframe to investigate the fall and address its causes, as mandated by facility policy.
A resident with multiple chronic conditions experienced a fall, and the required Post-Fall Assessment & Investigation was not completed or documented in the medical record as mandated by facility policy. Staff confirmed the omission, and review of the electronic record showed the assessment template was left incomplete, resulting in an incomplete medical record.
The facility did not ensure proper documentation and follow-up regarding advance directives for three residents. One resident's chart lacked evidence that advance directive information was provided, another had no copy of a living will in the chart despite acknowledging its existence, and a third resident's request for assistance in formulating an advance directive was not adequately followed up or documented by social services staff.
Multiple residents experienced deficiencies in their living environment, including an inaccurate wall clock for a resident with dementia, broken and unrepaired blinds with makeshift cardboard coverings for another, a torn fall mat with equipment placed on it for a resident at high risk for falls, and cracked or missing wall sockets at the bedside of a resident with severe impairments. Staff and maintenance were aware of these issues, but they were not addressed in accordance with facility policy, resulting in an environment that was not safe, clean, or homelike.
Multiple residents were subjected to physical restraints, such as bed pad alarms, bolstered mattresses, beds placed against walls, and side rails, without proper restraint assessments, physician orders, informed consent, or care plans. Staff confirmed that these interventions were implemented without following required protocols, and necessary documentation was only completed after the deficiencies were identified.
Two residents were administered psychotropic medications without proper diagnoses or monitoring. One received Seroquel without a qualifying mental health diagnosis, and pharmacy recommendations to discontinue the drug were not followed up or documented. The resident was also not referred for psychiatric evaluation as required. Another resident was prescribed Remeron for poor appetite related to depression, but staff failed to implement required monitoring for both the targeted behavior and medication side effects, as confirmed by nursing and DON interviews.
The facility did not develop or implement comprehensive care plans for multiple residents, including those who smoked, received psychotropic or antianxiety medications, or required BiPAP therapy. This included missing care plans for smoking safety, medication monitoring, and respiratory equipment care, as well as incomplete documentation and communication among staff regarding residents' needs and interventions.
Three residents did not have their care plans updated to reflect current infection control precautions or the use of low air loss mattresses for pressure ulcer prevention. Staff interviews and observations confirmed that care plans were not revised after changes in physician orders or resident condition, and that mattress settings did not match residents' weights as required. These deficiencies led to potential miscommunication and delays in necessary care.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, facility policy, and manufacturer guidelines. Nursing staff repeatedly administered insulin in the same abdominal and arm locations over an extended period, a practice confirmed by both nursing staff and the DON through record review and interviews.
Multiple deficiencies were identified when medications and hazardous materials were left unattended in resident rooms, topical medications were applied without proper orders, and safety equipment such as floor mats and bed positions were not properly maintained. Staff failed to follow facility policies, resulting in increased risk of accidents and injuries for several residents with complex medical needs.
Several residents requiring respiratory support did not receive care in accordance with professional standards, as BiPAP masks and nebulizer equipment were improperly stored, not cleaned or documented per manufacturer and facility policy, and oxygen tubing and masks were not labeled with the date of last change. Staff interviews confirmed inconsistent cleaning and documentation practices, and facility policies for infection control and equipment maintenance were not followed.
Multiple deficiencies were identified in the facility's pharmaceutical services, including failure to administer medications as ordered, administration of expired medications, late medication administration, incomplete documentation of discarded medications, and improper supervision of medication administration. These issues involved several residents with various medical conditions and were confirmed through staff interviews, record reviews, and direct observation.
Two residents receiving subcutaneous insulin did not have their injection sites rotated as required by physician orders, manufacturer guidelines, and facility policy. Nursing staff and the DON confirmed that insulin was repeatedly administered in the same areas, which was identified as a medication error according to facility policy and professional standards.
Surveyors found two unlabeled vials of meropenem in an IV cart after a resident's treatment was completed, and expired psyllium and docusate sodium in a medication cart. Nursing staff and leadership confirmed that these medications should have been discarded according to facility policy, but they remained accessible in storage areas.
Surveyors found that pureed mixed vegetables served to residents on a dysphagia puree diet were too thick and did not pass the required IDDSI Level 4 spoon tilt test. Staff did not consistently use the correct testing method to ensure proper food texture, and the Dietary Director confirmed the deficiency. Facility policies and recipes required these tests to be performed, but they were not followed, resulting in improper food consistency for all residents on a puree diet.
Surveyors found that kitchen staff failed to properly dispose of expired food, label and date various food items, and maintain sanitary storage and preparation practices. Observations included unlabeled produce, improperly stored thickener, mixed food items in bins, and unclean equipment. The dietary director confirmed that these actions did not follow facility policies for food safety and infection control.
Surveyors identified multiple failures in infection prevention and control, including lack of Enhanced Barrier Precautions for a resident with a history of VRE, improper disinfection of a cloth gait belt between residents, unclean supplement bottles on medication carts, staff not wearing or securing gowns during high-contact care, linen carts inadequately protected from dust, and improper storage and documentation of respiratory equipment. These deficiencies were confirmed through staff interviews, observations, and policy reviews.
Facility staff used the PT gym's therapy mat and surrounding area to store therapy equipment, broken items, and items awaiting disposal, making the space unavailable for resident therapy. The DOR and DON acknowledged that the cluttered environment prevented use of the therapy area for its intended purpose and did not meet expectations for a homelike, orderly setting.
Surveyors found that essential equipment was not maintained in safe working order, including a non-functional freezer light in the kitchen, a resident's bed controller with exposed wires, and cracked or missing wall sockets at the head of another resident's bed. Staff failed to report these hazards as required by facility policy, resulting in unsafe conditions for two residents with significant medical needs.
A CNA assisted a resident with severe cognitive impairment and total dependence for ADLs by standing over them during mealtime, rather than sitting at eye level as required by facility policy. Both the RN and DON confirmed that this practice did not uphold the resident's dignity, and facility policies specifically prohibit standing over residents while feeding.
A resident with multiple diagnoses, including depression and schizophrenia, was administered Remeron, a psychoactive medication, without documented informed consent from the resident or responsible party. Facility staff acknowledged the oversight, and the DON confirmed that informed consent should have been obtained prior to administration, as required by facility policy.
A resident with multiple medical and psychiatric conditions was allowed to self-administer medications left at the bedside by an LPN, despite a prior assessment indicating the resident was not a candidate for self-administration and without a new assessment or physician's order. Facility staff acknowledged that required procedures for assessing and authorizing self-administration were not followed, and medications were left unattended in the resident's room.
A resident with severe cognitive impairment, hemiplegia, and a high fall risk was found with their call light disconnected from the wall, despite requiring total assistance for daily activities. A CNA and the DON confirmed that staff are responsible for ensuring call lights are plugged in and functioning, in accordance with facility policy.
Two residents were admitted with significant medical needs—one requiring oxygen therapy for respiratory conditions and another prescribed an anticoagulant for blood clot prevention. Despite physician orders and facility policy requiring baseline care plans within 48 hours of admission, no such plans were developed or implemented for either resident, as confirmed by nursing staff. This resulted in a deficiency related to the timely provision of essential healthcare services.
A resident with bone and joint conditions did not have an orthopedic appointment scheduled as ordered by the physician, despite documented orders and facility policy requiring coordination between nursing and social services. Nursing staff did not complete or document the referral process, resulting in a delay of care.
Two residents at high risk for pressure ulcers did not have their low air loss mattresses set according to their actual weight, contrary to manufacturer instructions and facility policy. Staff and the DON confirmed the settings were incorrect, and that proper adjustment is necessary for pressure injury prevention.
A resident with decreased ROM in both upper extremities did not receive the ordered AAROM exercises to the left upper extremity during an RNA session, as only the right side was exercised. The RNA omitted the left side, believing the resident could move it independently, despite care plan and physician orders requiring AAROM to both sides. This failure was confirmed by staff interviews and review of facility policy.
Staff did not consistently follow protocols for labeling and handling enteral feeding equipment for two residents with gastrostomy tubes. Feeding formula and water flush bags were not labeled with required information such as time hung and rate of infusion, and a specialized valve was left uncapped and disconnected. Nursing staff and the DON confirmed these lapses, which did not comply with physician orders or facility policy.
A CNA did not receive an annual skills competency evaluation as required by facility policy, with the last evaluation occurring over a year prior. The DSD scheduled the next evaluation based on the hire date rather than the annual requirement, and the DON confirmed the evaluation was overdue. Facility policies mandate annual performance and competency reviews for all staff.
Two residents experienced medication errors when a nurse administered an incorrect dose of docusate sodium to one resident and another nurse prepared to give expired docusate sodium to a second resident. These actions resulted in a medication error rate above the acceptable threshold, as staff failed to follow physician orders and did not check medication expiration dates as required by facility policy.
A resident with a right humeral neck fracture did not receive a timely CT scan after it was ordered by the orthopedic physician. The facility delayed requesting authorization for the scan by a month, which led to the cancellation of a follow-up orthopedic appointment and a significant delay in diagnostic imaging. Staff interviews confirmed the delay was due to late submission of the authorization request, contrary to facility policy requiring prompt processing of diagnostic orders.
Kitchen staff were not routinely trained or evaluated for competency in preparing pureed foods for residents on a dysphagia puree diet, resulting in pureed mixed vegetables being served at an improper consistency that did not pass required IDDSI testing. The cook relied on subjective methods rather than the mandated spoon-tilt test, and the facility's competency checklist did not cover necessary IDDSI Level 4 testing procedures. The Dietary Director confirmed that the puree did not meet standards and should have been adjusted before service.
A resident with muscle wasting, atrophy, and a right humeral neck fracture did not receive occupational therapy (OT) at the frequency specified in their care plan and physician orders. Although the plan required OT five times a week, documentation showed the resident received fewer sessions in several weeks, with no explanation for the missed treatments. The Director of Rehabilitation confirmed the deficiency and lack of documentation for the missed OT sessions.
The facility failed to ensure timely completion of OT documentation for a resident, with progress notes and discharge summaries being signed well after the required period. Additionally, an LVN inaccurately documented the time of medication administration in the MAR, recording medications as given during the scheduled pass when they were actually administered later. These actions resulted in inaccurate and delayed clinical records, contrary to facility policy.
A resident with a UTI was initially prescribed ciprofloxacin, which was discontinued and replaced with Keflex after lab results showed resistance. The Antibiotic Log was not updated to reflect the change, incorrectly showing a full course of ciprofloxacin and omitting the Keflex prescription. Staff interviews and policy review confirmed the log was incomplete and not maintained as required by the facility's antibiotic stewardship policy.
A resident with dementia, a history of falls, and a recent spinal fracture was care planned to have a bed alarm for fall prevention. Surveyors observed that the bed alarm was not functioning, and staff confirmed it was not in use, despite the care plan and family agreement. The alarm device was found disconnected and turned off, contrary to facility policy and the resident's individualized care plan.
A resident with a history of falls and multiple risk factors suffered a new fracture after staff failed to ensure her bed alarm was turned on and functioning, despite care plan instructions. Staff interviews and observations confirmed the alarm was not operational, and the resident's fall risk assessment was inaccurately scored as low risk, overlooking her medical history and recent fall. These failures resulted in inadequate supervision and interventions.
Failure to Follow Contact Isolation and Visitor Education Practices for Residents with C-diff
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and contact isolation policies for two residents on contact precautions for Clostridium difficile (C-diff). Surveyors observed Certified Nursing Assistant (CNA) 1 enter the shared contact isolation room of Resident 1 and Resident 2 without wearing a gown and gloves, despite facility policy requiring these PPE items when entering contact isolation rooms. CNA 1 then removed Resident 1’s food tray from the isolation room and placed it on a cart with other residents’ food trays outside the room. Licensed Vocational Nurse (LVN) 1 stated that CNA 1’s actions went against facility policy and that entering a contact isolation room without appropriate PPE was not in accordance with the contact precautions protocol. The surveyors also observed that there were no designated linen carts or dedicated hampers for soiled linens and clothes in the contact isolation rooms for Resident 1 and Resident 2, even though the Infection Preventionist (IP) Nurse acknowledged that residents with C-diff were supposed to have their own red hamper to separate their linens from those of other residents. The facility’s policy on Resident Isolation-Category of Transmission stated that used linen soiled with blood, body fluids, secretions, and excretions must be handled in a manner that prevents contamination and transfer of microorganisms to other residents and the environment. During a tour of three rooms on contact precautions for C-diff, this lack of dedicated linen containers was consistently observed. In addition, the facility failed to educate a family member on required precautions when visiting a resident on contact isolation. Surveyors observed Family Member 1 inside Resident 1’s contact isolation room without wearing a gown or gloves. Family Member 1 reported not being informed why the resident was in contact isolation or what precautions to take while visiting. The Director of Nursing (DON) confirmed that Resident 1 and Resident 2 were on contact isolation for C-diff and that facility policy required staff to educate family members visiting residents in contact isolation rooms. The DON also stated that the purpose of the infection prevention and control and visitation policies was to prevent the spread of infection and to make visitors aware of the risk of exposure to communicable diseases. Resident 1’s records showed admission and readmission with diagnoses including C-diff, gout, and dementia, with the Minimum Data Set indicating impaired cognitive skills and total dependence on staff for mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident 2’s records showed admission with diagnoses including rheumatic multiple valve disease, bacteremia, and acute respiratory failure with hypoxia. Both residents were confirmed by the DON to be on contact isolation precautions for C-diff at the time of the observations.
Failure to Educate Visitors on C.-diff Isolation Precautions and Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy for a resident diagnosed with Clostridioides difficile (C.-diff). The resident was originally admitted with acute respiratory failure with hypoxia, pneumonia, and a cognitive communication deficit, and had moderate cognitive impairment per the MDS, requiring substantial/maximal assistance with toileting, bathing, and lower body dressing. A physician’s order directed staff to collect stool for C.-diff if diarrhea occurred, and the resident was confirmed positive for C.-diff on 4/18/2026. The facility’s Infection Prevention Nurse stated that for C.-diff, training was provided to licensed nurses and direct care staff on proper PPE use and handwashing, and acknowledged that a visitor was present with the resident daily and that it was important to inform visitors about PPE and handwashing after being in the resident’s room. A registered nurse reported receiving training on proper PPE use for contact isolation, including disposable gowns, gloves, and handwashing for at least 20 seconds, and stated that visitors and family are always educated on PPE use and hand hygiene, with specific emphasis that alcohol-based hand sanitizer is not effective for C.-diff. However, during review of the resident’s records with this nurse, there was no documentation of infection control teaching provided to visitors, despite the resident having almost daily visitors. The nurse identified the failure as a lack of education to the visitor regarding isolation precautions and the absence of documentation that such teaching was provided. The facility’s written Infection Prevention and Control Program policy states that infection control policies and procedures apply equally to all staff, consultants, contractors, residents, visitors, volunteer workers, and the general public, and are intended to prevent, detect, investigate, and control infections and maintain a safe and comfortable environment for personnel, residents, visitors, and the general public.
Failure to Monitor Oxygen Saturation and Accurately Assess Fall Risk
Penalty
Summary
The facility failed to follow professional standards of nursing practice for a resident who had been admitted with diagnoses including metabolic encephalopathy, pneumonia, age-related osteoporosis, and a documented history of falling. The resident’s MDS showed moderately impaired cognitive skills for daily decision making. Physician orders dated 3/14/2026 and 3/15/2026 directed continuous oxygen at 2 L/min via nasal cannula and required that the resident’s oxygen saturation be monitored every nursing shift, with instructions to notify the physician if saturation fell below specified thresholds. However, review of the medical record with an LVN and the DON showed no documented evidence that oxygen saturation was monitored every shift from 3/14/2026 to 3/19/2026, and an Oxygen Saturation Summary for part of that period indicated the resident was on room air. The LVN confirmed that there was no documentation of oxygen saturation monitoring for five days while the resident was ordered to receive continuous oxygen therapy. The DON stated that oxygen is considered a medication requiring a physician order and that oxygen saturation should be monitored and documented every shift according to those orders, further acknowledging that monitoring not documented is considered not done. Facility policies on Oxygen Administration required documentation of oxygen saturation levels as indicated and the patient’s response to oxygen therapy, but the resident’s record did not contain the required shift-by-shift monitoring entries for the specified period. The facility also failed to accurately assess the resident’s fall risk following readmission. The Nursing Admission Assessment dated 3/14/2026 documented that the resident had no history of falls, only one diagnosis, and a weak gait, resulting in a Fall Risk Assessment score of 10, which indicated low risk for falls. This conflicted with the Face Sheet, which listed a history of falling, and with the LVN’s statement that the resident had more than one diagnosis and an impaired gait as defined by the facility’s fall risk criteria. The DON agreed that the resident’s fall risk score should have been higher based on the assessment criteria. The facility’s Fall Management Program policy required licensed nurses to assess each resident’s fall risk upon admission, quarterly, and with significant change in condition, and to use that information to identify and implement interventions, but the inaccurate assessment led to an incorrect fall risk score for this resident.
Inaccurate and Delayed Change-of-Condition Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate, complete, and timely medical record for one resident who experienced a change of condition related to an incident of physical aggression by another resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, Alzheimer’s disease, and essential hypertension, and had severely impaired cognitive skills for daily decision-making per the most recent MDS. A CNA reported that another resident attempted to hit this resident on the evening of 3/9/2026, and an LVN responded to the incident. The LVN later created a Change of Condition (COC) Evaluation but documented the COC as occurring on 3/10/2026 during the night shift instead of on 3/9/2026 during the 3 p.m. to 11 p.m. shift when the incident actually occurred. The COC Evaluation also contained inaccurate information regarding the timing of notifications to the resident’s attending physician and family member. The form indicated that the physician was notified at 9:20 p.m. and the family member at 9:15 p.m. on 3/10/2026, while the LVN stated that both were notified after midnight on 3/10/2026 but could not recall the exact times. The LVN acknowledged that the COC Evaluation was inaccurate. The Assistant DON confirmed that the resident’s change in condition occurred on 3/9/2026, that the COC Evaluation was not completed and signed until 3/11/2026, and that facility policy required documentation of the correct date and time of the incident and notifications, with nursing documentation to be completed by the end of the assigned shift. These findings showed that the facility did not follow its own policies on change of condition notification and nursing documentation, resulting in inaccurate and untimely entries in the resident’s medical record.
Failure to Reposition Residents at Risk for Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards by not ensuring that three residents at moderate risk for pressure ulcers were turned and repositioned as care planned. One resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had a Braden score of 13 indicating moderate risk. The resident’s MDS showed moderately impaired cognition and a need for maximal assistance with rolling. The resident’s care plan, initiated shortly after admission, required assistance with turning and repositioning at least every two hours, but the treatment nurse and the DON both confirmed there was no documented evidence that this turning and repositioning occurred every two hours as ordered. Another resident was admitted with a stage 4 sacral pressure ulcer, muscle weakness, and adult failure to thrive, and had a Braden score of 13, also indicating moderate risk. This resident’s MDS showed severely impaired cognitive skills and total dependence on staff for rolling to either side. The interdisciplinary wound management care plan directed staff to reposition the resident every two hours or as often as necessary. During record review with the treatment nurse, it was determined there was no documented evidence that the resident was turned and repositioned every two hours, despite the care plan intervention and the resident’s dependence on staff for mobility. A third resident, admitted with type 2 diabetes mellitus, muscle weakness, and essential hypertension, had a Braden score of 14, indicating moderate risk, and required moderate assistance with rolling according to the MDS. This resident also had a sacrococcygeal pressure ulcer and an interdisciplinary wound management care plan that required repositioning every two hours or as often as indicated. The treatment nurse and the DON confirmed there was no documented evidence that this resident was turned and repositioned every two hours. The facility’s pressure ulcer prevention policy required nursing staff to monitor interventions for effectiveness and for licensed nurses to document the effectiveness of pressure ulcer prevention techniques weekly, but the lack of documentation of turning and repositioning for all three residents demonstrated that these interventions were not implemented as required.
Inaccurate Nursing Documentation Entered After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with accepted professional standards for one resident. The resident was admitted with Parkinson’s disease, type 2 diabetes mellitus, and a stage 4 sacral pressure ulcer, and had moderately impaired cognitive skills for daily decision-making per the MDS. A Change in Condition evaluation documented that the resident developed fever, shortness of breath, and a sudden change in level of consciousness or responsiveness. Progress notes show that on 12/10/2025 at 10:10 a.m., the resident was transferred to a general acute care hospital and did not return, ultimately being discharged from the hospital. Despite the resident’s transfer and non-return, a progress note dated 12/13/2025 was entered by an LVN documenting that she received the resident resting in bed, able to make needs known, being monitored for fever, congestion, and lethargy, with no shortness of breath or acute distress, no pain, all medications given and tolerated, and that the resident was kept clean and dry with call light within reach. The note also included specific vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) as if the resident were present in the facility. During interview and concurrent record review, the DON confirmed that the resident had been transferred out on 12/10/2025, did not return, and that the LVN’s 12/13/2025 documentation was inaccurate and not in accordance with the facility’s nursing documentation policy, which requires concise, clear, pertinent, and accurate documentation of resident status and care given.
Failure to Implement Hemodialysis Care Plan and Timely Hospice Care Planning
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with end-stage renal disease who required hemodialysis and had a left upper arm arteriovenous (AV) fistula. The resident had a documented history of removing her pressure dressing prematurely after dialysis, resulting in previous bleeding episodes. Despite care plan interventions specifying that the dressing should remain in place for at least four hours post-dialysis and that the access site should be monitored for bleeding, redness, swelling, and pain upon return from dialysis, staff did not perform or document a post-dialysis assessment or direct inspection of the AV fistula site after the resident returned from treatment. The resident was also on Eliquis, an anticoagulant, further increasing her risk for bleeding. On the day of the incident, the resident returned from hemodialysis and was assisted to her room by an RN, who did not visually inspect the AV fistula site or check vital signs, assuming the site was not bleeding because the clothing was not wet. The RN did not inform other staff of the resident's return, and both the assigned LVN and CNA were on lunch breaks and unaware of the resident's status. Approximately 30 minutes later, the CNA discovered the resident unresponsive and actively bleeding from the AV fistula site, with the pressure dressing removed and blood present on the bed and floor. Emergency services were called, but the resident was pronounced deceased shortly after their arrival. Interviews and record reviews confirmed that the required post-dialysis assessment was not completed, and there was no documentation of monitoring or care provided to the AV fistula site upon the resident's return. The care plan interventions related to hemodialysis and AV fistula monitoring were not implemented, and staff failed to communicate and coordinate care as required. Additionally, the facility failed to promptly develop and implement a person-centered care plan for another resident admitted to hospice, resulting in a delay in care planning.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with assigned nursing staff, review of policy and procedure on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis. Failures related to post-dialysis assessment, monitoring, communication, and documentation were identified.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN. The assessment will include direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. The CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The RN Supervisor and Charge Nurse reviewed and updated the person-centered care plans for residents receiving hemodialysis (Residents 2, 3, 4, 5, 6, 7, 8, and 9) to reflect each resident's individual needs and the required care of their dialysis access sites.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents (Residents 2, 3, 4, 5, 6, 7, 8, 9) receiving hemodialysis treatment. There were no other residents identified with deficiencies similar to those found for Resident 1.
- The DON and RN Supervisor conducted an audit of care plans related to dialysis care and the Nursing Facility Post Dialysis Assessment form for eight residents (Resident 2, 3, 4, 5, 6, 7, 8, and 9) receiving hemodialysis. The audit showed that all applicable care plan interventions were present and up to date for Residents 2, 3, 4, 5, 6, 7, 8, and 9.
- The DON and DSD provided in-service training to nursing staff regarding care planning, with emphasis on: a) Implementation of residents' individualized hemodialysis care plans; b) Completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment and nursing progress notes documenting the date and time residents returned to the facility, to be completed by LVNs or RNs following hemodialysis treatment; c) Comprehensive assessment and monitoring of residents by LVNs or RNs following dialysis treatment.
- The DON provided a one on one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care. The in-service addressed conducting pre and post dialysis assessments with focus on assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications. The in-service addressed documentation on the nurse's progress notes and the Nursing Facility Pre and Post Dialysis Assessment form. Licensed nurse will document in the nurse's progress notes resident's return to the facility from the hemodialysis treatment, including the date and time of the return and the care provided to the resident.
Failure to Assess and Monitor Dialysis Resident Post-Treatment Resulting in Fatal Hemorrhage
Penalty
Summary
A deficiency occurred when a resident with end-stage renal disease, anemia, atrial fibrillation, and a history of removing her own dialysis access site dressing was not properly assessed or monitored upon return from an outpatient hemodialysis treatment. The resident was prescribed Eliquis, increasing her risk for bleeding, and had documented prior incidents of prematurely removing her AV fistula dressing, resulting in bleeding. Despite these known risks and care plan interventions requiring monitoring of the access site and leaving the dressing in place for at least four hours post-dialysis, staff failed to conduct a post-dialysis assessment or monitor the resident for complications upon her return. On the day of the incident, the resident returned to the facility at approximately 7:10 p.m. after hemodialysis. The assigned RN assisted the resident to her room but did not visually inspect the AV fistula site, check vital signs, or document the resident's return. The RN assumed the site was not bleeding because the resident's clothing was not wet and did not notify other staff of the resident's return. Both the LVN and CNA assigned to the resident were on their lunch breaks and were not informed of the resident's return. No staff member was designated to receive or assess the resident upon her arrival, and there was no documentation of a post-dialysis assessment in the medical record. Approximately 40 minutes later, the CNA discovered the resident unresponsive, with the AV fistula dressing removed and active bleeding from the site. Blood was found on the bed, floor, and the resident's clothing. Emergency measures were initiated, but the resident was pronounced deceased by paramedics. Interviews and record reviews confirmed that facility staff did not follow established policies and procedures for post-dialysis assessment, monitoring, and documentation, nor did they implement the resident's care plan interventions for AV fistula care and monitoring.
Removal Plan
- The DON conducted a comprehensive review of Resident 1's hemodialysis-related care upon Resident 1's return from the hemodialysis treatment, including interviews with RN 1 and LVN 1, review of facility's P&P on Dialysis Care, forms used for dialysis care, nurses progress notes, and communication related to Resident 1's return from dialysis treatment, identifying failures related to post-dialysis assessment, monitoring, communication, and documentation.
- All residents returning from hemodialysis treatment or any off-site procedure will be assessed upon return at the soonest practicable time by the Charge Nurse and/or RN, including direct inspection of the hemodialysis access site, vital signs, bleeding assessment, condition of the resident, documentation of findings in the nursing progress notes, and the Nursing Facility Post Dialysis Assessment form. CNA will immediately notify any licensed nurse of any observed signs of bleeding or distress and will endorse findings to the LVN Charge Nurse and/or RN.
- The DON and Medical Records staff conducted an audit on the Nursing Facility Pre and Post Dialysis Assessment forms for eight residents receiving hemodialysis treatment, finding no other residents with deficiencies similar to those found for Resident 1.
- The Administrator and the DON reviewed and updated the P&P on Dialysis Care. The Dialysis Flow Sheet-Return Assessment form was updated to include signature columns for the Charge Nurse and RN Supervisor, as well as the inclusion of the Nursing Facility Pre and Post Dialysis Assessment form. The updated policy became effective and will be presented to the Quality Assurance Committee at the next monthly meeting.
- The Administrator notified the Medical Director regarding the details of the IJ issued by the SSA and the updated policy on Dialysis Care.
- The DON provided one-on-one in-service to RN 1 and LVN 1, who were assigned to Resident 1 during the 3 p.m. to 11 p.m. shift regarding P&P on Dialysis Care, focusing on conducting pre and post dialysis assessments, assessing the dialysis access site for signs of bleeding, resident's medical condition and other complications, and documentation requirements.
- The facility will ensure that residents who require hemodialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
- The DON and DSD provided in-service education to nursing staff regarding the updated policy on Dialysis Care, with emphasis on comprehensive assessment and monitoring of residents by LVNs or RNs post dialysis treatment, completion of the Nursing Facility Post-Dialysis Assessment form, the Dialysis Flow Sheet-Return Assessment, and nursing progress notes documenting the date and time residents return to the facility.
- The DON performed a competency check of RN 1 regarding dialysis care, including monitoring, documentation, and communication.
- The DON performed competency checks of licensed nurses regarding post dialysis observation, reporting, monitoring, interventions, and proper documentation.
- The DSD performed competency checks of CNAs regarding observation and reporting on resident's return post-dialysis and post procedure, monitoring, safety, and communication of observations.
- The DON conducted an audit on residents who returned from hemodialysis, showing all requirements were completed and in place for each of the reviewed residents, and that a process is in place to ensure appropriate assessment, monitoring, documentation, and clinical oversight for residents returning to the facility following outpatient hemodialysis.
Failure to Ensure Nursing Staff Competency in Dialysis Care and Assessment
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care for residents requiring dialysis. Specifically, two of five sampled staff, including a registered nurse and a licensed vocational nurse, did not receive orientation or in-service training on dialysis care, assessment, or site evaluation. Review of their annual skills checklists and job descriptions revealed no documentation of dialysis-related competencies, and interviews with staff confirmed that dialysis care and assessment were not included in their orientation or ongoing training. The Director of Staff Development acknowledged that dialysis care, assessment, and training were not part of the orientation process and had not been provided to nursing staff, including CNAs, until recently. Staff interviews further revealed a lack of instruction on how to assess dialysis sites for thrill and bruit, as well as on procedures for managing residents before and after dialysis treatments. Some staff demonstrated confusion regarding the correct methods for assessing dialysis access sites, indicating gaps in knowledge and skills necessary for safe resident care. The Director of Nursing confirmed that while an in-service on dialysis care was provided in the past year, there was no formal class or consistent inclusion of dialysis care and assessment in new staff orientation. The facility's policy required nursing staff to demonstrate competencies based on resident needs, but this policy was not followed regarding dialysis care. The lack of documented training and competency checks for dialysis care and assessment had the potential to impact the safe provision of nursing care for residents undergoing dialysis.
Failure to Update Facility Assessment Following Ownership and Service Changes
Penalty
Summary
The facility failed to accurately update its Facility Assessment Tool following significant operational changes, including a change of ownership and transition to electronic medical records. The assessment continued to reflect the previous facility name after the approved change of ownership and did not document the adoption of electronic health information technology, despite the facility's transition from paper to electronic records. Additionally, while the assessment listed dialysis as a service provided, it did not specify the necessary staff training or competencies required for dialysis care. These omissions were confirmed during interviews with the Administrator and Director of Nursing, who acknowledged that the Facility Assessment should have been updated to reflect these changes and ensure accurate information regarding services and staff competencies. The facility's policy requires annual and as-needed updates to the Facility Assessment to ensure resources and staff competencies align with resident needs, including during emergencies. However, the assessment was not updated to include the new facility name, the implementation of electronic medical records, or the specific training and competencies for dialysis care. This failure resulted in the Facility Assessment containing outdated and incomplete information, which could misinform staff and the public about the facility's capabilities and resources.
Failure to Accurately Reflect Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected all current medical diagnoses. Specifically, the MDS did not include a diagnosis of dementia, despite this being documented in the resident's History and Physical (H&P) by the primary physician. The MDS Coordinator acknowledged that during the assessment process, staff relied on the existing admission record rather than reviewing the most recent H&P for new or updated diagnoses. This omission was identified during a review of the resident's records and confirmed in interviews with both the MDS Coordinator and the Director of Nursing (DON). The DON stated that it is the responsibility of the MDS Coordinator to ensure that all diagnoses from the primary physician's notes are accurately reflected in the MDS and the resident's care plan. The facility's policy requires that the Resident Assessment Instrument (RAI) process includes comprehensive and up-to-date information about the resident's health status at the time of assessment. The failure to update the MDS with the dementia diagnosis resulted in an inaccurate assessment for the resident.
Failure to Change Gown Between Residents During Care Activities
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow infection control policies and procedures when providing care to two residents. After repositioning one resident who was severely cognitively impaired and dependent on staff for activities of daily living, CNA 1 washed her hands and changed gloves but did not change her gown before proceeding to drain the urinary catheter of another resident in the same room. The second resident had a diagnosis of osteomyelitis and acute kidney failure, required substantial assistance, and had physician orders for enhanced barrier precautions and continuous Foley catheter drainage. CNA 1 acknowledged during the observation that she did not change her gown as required to prevent contamination between residents. The Director of Nursing confirmed that CNA 1 did not follow the facility's infection control protocols, which require staff to change gowns between care activities for residents under isolation precautions. The facility's infection prevention and control policy, last reviewed in June 2025, mandates measures to prevent the development and transmission of infection in accordance with federal and state requirements. The failure to change gowns between residents had the potential to cause cross-contamination.
Failure to Timely Investigate and Report Alleged Financial Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of financial abuse involving a resident diagnosed with Alzheimer's Disease, major depressive disorder, and anxiety. The resident was noted to have the ability to understand and be understood, but could not make medical decisions. On the date of the incident, a staff member observed a male family member attempting to have the resident sign a 'Borrower Authorization' form to access the resident's bank information. The Social Services Director (SSD) intervened, questioned the family member, and was denied access to the document. The SSD determined that the resident lacked capacity to make such decisions and reported the incident as financial abuse on the same day. Despite recognizing the incident as potential financial abuse, the SSD did not complete the required five-day report, believing that submitting the SOC341 form was sufficient. The Director of Nursing (DON) later confirmed that the five-day report, which should have been submitted within five days of the incident, was not completed until much later. Facility policy required timely reporting and investigation of abuse allegations, but this protocol was not followed, resulting in a deficient practice.
Failure to Conduct Timely IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) meeting was conducted in a timely manner following a resident's fall, as required by the facility's own policy and procedure. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and type 2 diabetes, experienced a fall after attempting to steady herself on a wheelchair that was out of reach while exiting the bathroom. The resident's care plan identified her as having poor balance, an unsteady gait, and poor safety awareness, with interventions such as keeping the call light within reach and frequent visual checks. After the fall, staff physically assessed the resident and completed documentation, but there was no documented evidence that an IDT meeting occurred within the required 72-hour timeframe to investigate the incident and determine causative factors. Interviews with staff, including an LVN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that facility policy mandates an IDT meeting within 72 hours of a fall to review the event, conduct a root cause analysis, and implement interventions to prevent future incidents. However, the review of the resident's electronic medical record did not show that such a meeting took place after the fall. The facility's Fall Management Program policy specifically requires the IDT-Falls Committee to meet and document their findings and actions within this timeframe, but this protocol was not followed in this case.
Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented, as required by its own policy and procedure. After a resident experienced a fall, the required Post-Fall Assessment & Investigation was not completed or documented in the resident's medical record. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and diabetes mellitus type 2, reported falling while attempting to steady herself after leaving the bathroom. The fall was witnessed by her roommate, who sought staff assistance. Staff interviews confirmed that, although the facility's policy mandates a Post-Fall Assessment & Investigation following any resident fall, this documentation was not completed for the incident in question. Review of the resident's care plan and medical record showed that the Post-Fall Assessment & Investigation template was created in the electronic record but left incomplete. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that the assessment should have been completed by a registered nurse shortly after the incident, but it was not done. The facility's policy specifically requires this documentation to be maintained in the resident's medical record following a fall, and the failure to do so resulted in an incomplete record for the resident involved.
Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to show documented evidence that advance directives were discussed and appropriately managed for three sampled residents. For one resident with acute respiratory failure, pneumonia, and cerebral infarction, there was no Advance Directive Acknowledgement Form in the medical chart, despite the resident having intact cognition and the capacity to make decisions. Both the RN and Social Services Designee confirmed the absence of documentation, and the Social Services Designee admitted that although the family was spoken to, there was no proof that information about advance directives was provided. Another resident, admitted with multiple diagnoses including neuropathy and diabetes, had signed an Advance Directive Acknowledgement Form indicating the existence of a living will. However, the actual living will was not present in the resident's chart, and there was no documentation regarding its contents. The responsible Social Services staff member acknowledged forgetting to follow up and obtain a copy of the living will, which was necessary for staff to be aware of and honor the resident's wishes when the resident could no longer make decisions. A third resident, with diagnoses including congestive heart failure and urinary retention, had expressed interest in formulating an advance directive and requested assistance from the Ombudsman. Although the facility faxed a request to the Ombudsman, there was no documented follow-up or evidence in the medical record that assistance was provided or that the process was completed. The Social Services staff and Director both acknowledged that the lack of follow-up and documentation could result in delays or failure to honor the resident's wishes, as the process had been pending for over three months.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for four of six sampled residents, as evidenced by multiple deficiencies observed during the survey. For one resident with dementia and other cognitive impairments, the wall clock at the bedside consistently displayed the incorrect time over several days. Staff interviews confirmed awareness of the issue, and facility policy required the clock to be accurate to assist with reality orientation for residents with cognitive deficits. The clock was not corrected in a timely manner, despite its importance for resident orientation. Another resident, who had decision-making capacity and was dependent on staff for several activities of daily living, experienced ongoing issues with broken vertical blinds in their room. The missing and fallen slats were left on the floor, and cardboard was taped to the window to block light, as reported by the resident and observed by staff. The resident expressed dissatisfaction with the situation, stating it had persisted for months. Staff interviews revealed that maintenance requests were not consistently made or followed up on, and the environment was not maintained in a homelike or dignified manner, as required by facility policy. A third resident, identified as high risk for falls and with severe cognitive impairment, was found to have a fall mat at the bedside that was torn and had a side table placed on top of it. Staff acknowledged that the mat should not be torn or have equipment placed on it, as this compromised its function and the homelike appearance of the room. Additionally, another resident with severe cognitive and physical impairments had wall sockets at the head of the bed that were cracked and missing covers. Staff and maintenance personnel confirmed these issues and stated that they should have been addressed immediately to maintain a safe and homelike environment. Facility policies reviewed required prompt maintenance and upkeep of resident rooms, but these were not followed in these instances.
Failure to Ensure Residents' Right to Be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment, as evidenced by multiple instances involving five residents. For one resident with a history of falls and severe cognitive impairment, the facility did not accurately complete the physical restraint assessment form to reflect the use of a bed pad alarm, despite having a physician's order and care plan for fall risk. The restraint assessment did not indicate the current type of restraint or the reason for its use, and the admissions nurse did not document whether less restrictive measures had been attempted prior to the application of the restraint. Another resident with dementia and a history of falls was found to be using a bolstered mattress without a current physician's order, informed consent, restraint assessment, or care plan after discharge from hospice care. The facility continued to use the bolstered mattress as a restraint without completing the necessary documentation or obtaining consent from the resident's representative. Staff interviews confirmed that the required assessments and documentation were only completed after the deficiency was identified. Additional deficiencies were observed for three other residents. Two residents had their beds placed against the wall, which staff acknowledged as a form of restraint that limited the residents' ability to exit the bed from one side. There were no physician's orders, informed consents, restraint assessments, or care plans for this intervention. Another resident had three side rails up and a side table blocking the open side of the bed, also without the required physician's order, informed consent, restraint assessment, or care plan. In all cases, staff interviews confirmed that these interventions were implemented without following the facility's policy and procedure for restraint use, which requires pre-restraining assessment, physician's order, informed consent, and care planning.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraint
Penalty
Summary
Two residents were not protected from unnecessary psychotropic medication use, resulting in chemical restraint. One resident was administered Seroquel daily for psychosis, despite lacking a diagnosis of schizophrenia, depression, or bipolar disorder, which are the only acceptable indications for this medication in elderly patients. The resident's records, including the face sheet, care plan, and Minimum Data Set, did not support the use of Seroquel, and a Preadmission Screening and Resident Review confirmed the absence of a serious mental illness. The medication was continued after hospital readmission without proper verification, and the facility's own policies required antipsychotic medications to be used only when necessary for specific, documented conditions. A pharmacy recommendation to discontinue Seroquel due to lack of appropriate diagnosis was not followed up in a timely manner. The recommendation was not signed or dated by the attending physician, and there was no documentation of agreement or alternative action. Additionally, a psychiatrist consultation, as noted in the physician's progress notes, was not initiated after the resident's readmission, and the resident was not included on the list for psychiatric evaluation. Facility staff interviews confirmed that the necessary follow-up actions were not taken, and the resident continued to receive Seroquel unnecessarily. Another resident was prescribed Remeron for depression manifested by poor appetite, but there were no orders for monitoring the specific behavior (poor appetite) or for monitoring potential side effects of the medication. Nursing staff acknowledged missing the required monitoring orders, and the DON confirmed that such monitoring is necessary to determine the effectiveness of the medication and to identify any adverse effects. Facility policies required that psychotropic medications be supported by documented rationale, administered at correct doses and duration, and with adequate monitoring, which was not done in this case.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents in key areas, as observed through record reviews, interviews, and direct observation. For one resident with a history of urinary tract infection, end stage renal disease, and schizophrenia, the facility did not create a care plan addressing the resident's smoking habits, despite the resident being assessed for smoking and requiring supervision and a smoking apron. Staff interviews confirmed that the absence of a smoking care plan could result in staff being unaware of the resident's needs and the necessary safety precautions. Another resident with chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder was prescribed Remeron for depression and poor appetite. However, no care plan was developed to address the use of this medication, including monitoring for side effects and meal intake. Staff acknowledged that the care plan should have been created when the medication was ordered, and the lack of such a plan meant that staff would not know what interventions were in place or how to monitor the resident's response to the medication. Additionally, a resident with acute respiratory failure, COPD, and congestive heart failure was prescribed BiPAP therapy at night, but the care plan did not specify the cleaning schedule or duration of therapy. Observations revealed inconsistent cleaning and documentation practices for the BiPAP equipment, and staff interviews confirmed that the care plan lacked necessary details for proper care and infection control. Furthermore, two residents receiving antianxiety and psychotropic medications did not have care plans addressing the use of these drugs, their potential side effects, or monitoring requirements. Staff interviews indicated that the absence of these care plans could lead to unrecognized adverse effects and inconsistent care.
Failure to Revise Care Plans for Infection Control and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for three residents, resulting in deficiencies related to infection control and pressure ulcer prevention. For one resident with a history of vancomycin-resistant enterococcus (VRE) in the urine, the care plan was not updated to reflect the discontinuation of contact isolation and the implementation of enhanced barrier precautions (EBP) as ordered by the physician. Both the Infection Preventionist and the Director of Nursing confirmed that the care plan should have been revised to indicate the current precaution status, but it was not, which could create confusion among staff regarding the appropriate infection control measures. Two other residents, both at high risk for developing pressure ulcers, had physician orders for the use of low air loss mattresses (LALM) to preserve skin integrity. However, their care plans were not updated to include the LALM as an intervention for pressure ulcer prevention. Observations revealed that the LALM settings for both residents did not match their current weights, as required by manufacturer specifications and facility policy. Nursing staff acknowledged that the care plans should have been revised to reflect the use of LALM and that the settings should be adjusted according to the residents' weights to prevent skin breakdown. The facility's policy requires that care plans be developed and implemented within seven days of the comprehensive assessment and be reviewed and updated when there are changes in the resident's condition or interventions. Despite this, the care plans for these residents were not revised to reflect current orders and interventions, leading to potential miscommunication among staff and a delay in necessary care and services. The deficiencies were identified through record reviews, staff interviews, and direct observations.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to provide care in accordance with professional standards for two residents who were prescribed subcutaneous insulin, by not rotating the injection sites as required by physician orders, facility policy, and manufacturer guidelines. For one resident with severe cognitive impairment and total dependence on staff for activities of daily living, insulin was repeatedly administered in the same abdominal quadrants over several weeks, despite clear orders and documentation requiring site rotation. Both the registered nurse and the director of nursing confirmed that the administration sites were not rotated, acknowledging that this was not in compliance with professional standards or the physician's orders. Another resident, who was alert and oriented but had a history of diabetes and hemiplegia, also received insulin injections at the same sites on the abdomen and arm over a period of months. Medication administration records showed multiple instances where the injection sites were not rotated, contrary to the facility's policy and the manufacturer's prescribing information. Nursing staff confirmed that the sites were not rotated as required, and the director of nursing acknowledged that this practice did not follow established guidelines. Facility policy on insulin administration, as well as the manufacturer's guidelines for both types of insulin used, specifically require rotation of injection sites to prevent complications. The failure to rotate sites was confirmed through interviews with nursing staff and review of medical records, which documented repeated use of the same injection locations for both residents. This practice was not in accordance with professional standards, physician orders, or the facility's own procedures.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. In several instances, medications were left unattended and accessible in residents' shared rooms, despite assessments indicating that these residents were not safe candidates for self-administration. For example, one resident had a cup containing multiple medications left on the bedside table by an LVN, who stated that the resident preferred to take medications one at a time. However, there was no physician's order or assessment supporting self-administration, and facility policy required direct observation during medication administration. Additionally, topical medications such as A&D ointment were left at the bedside and on the floor, and were applied by a CNA without a physician's order, contrary to facility policy and scope of practice requirements. Hazardous materials were also found in resident rooms without proper supervision. One resident had a large aerosol can of bug spray stored on a dresser next to food items. Staff who observed the spray did not remove it, despite facility policy prohibiting hazardous chemicals in resident rooms and the potential for confused or wandering residents to misuse such items. The Director of Nursing confirmed that the presence of bug spray in a resident's room was not in accordance with facility policy and posed a risk to residents. Environmental hazards were present in the form of improper use and maintenance of safety equipment. Several residents who were at risk for falls had floor mats intended to prevent injury, but these mats were obstructed by furniture or medical equipment, such as visitor chairs and overbed tables, which compromised their effectiveness. In one case, a resident's fall mat had a significant tear, and in others, beds were not maintained in the lowest position as required by care plans. Additionally, a resident was found using a heating pad without a physician's order, and another had a bed remote with frayed wires, both of which posed risks of injury or electrocution. These deficiencies were observed during interviews and record reviews, and staff acknowledged that such practices were not in line with facility policies and procedures.
Deficient Respiratory Care and Infection Control for Residents Requiring Oxygen and BiPAP
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care and services in accordance with professional standards of practice for four residents requiring respiratory support. For one resident with acute respiratory failure, COPD, and CHF, the BiPAP mask was observed hanging on the wheelchair brake handle, not stored in a manner free from contamination. The BiPAP mask and nebulizer were stored together in an unlabelled plastic bag, lacking the resident's name and the date of last change. Staff interviews revealed inconsistent cleaning practices for the BiPAP mask, with some staff using alcohol wipes and others using soap and water, but without documentation of cleaning or adherence to the manufacturer's instructions. The care plan did not specify cleaning frequency or duration of BiPAP therapy, and administration records lacked consistent documentation of BiPAP use and cleaning, contrary to facility policy and manufacturer guidelines. For three other residents with diagnoses including acute respiratory failure, pneumonia, and COPD, oxygen was administered via nasal cannula or nebulizer, but the tubing and masks were not labeled with the date of last change. In some cases, nebulizer equipment was observed stored in a plastic bag with an outdated date, and in others, the tubing was not dated at all. Staff interviews confirmed that respiratory tubing and masks should be labeled and changed at regular intervals, as per facility policy, but this was not consistently done. The facility's policies required disposable supplies to be changed every 5 to 10 days and labeled with the date of last change, but these procedures were not followed. The Director of Nursing and other staff acknowledged that failure to clean and document respiratory equipment care, as well as improper storage and labeling, could lead to bacterial accumulation and potential infection. Facility policies and manufacturer instructions were reviewed, all of which emphasized the importance of regular cleaning, proper storage, and documentation of respiratory care. However, observations and staff interviews demonstrated that these standards were not consistently met for the residents reviewed, resulting in deficiencies in respiratory care and infection control practices.
Failure to Ensure Accurate Medication Administration and Proper Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. In several instances, medications were not administered according to physician orders. For example, one resident received a lower dose of docusate sodium than prescribed, and another was nearly given expired medication, which was only prevented by surveyor intervention. Additionally, medications were administered outside the required time frames, with some residents receiving their scheduled morning medications significantly late, and without proper documentation or physician notification regarding the delay. The facility also failed to maintain proper medication disposal practices. The Discarded Medication Log was incomplete, lacking required dates, signatures, and witness documentation for numerous medications belonging to several residents. Unlabeled and expired medications, such as meropenem vials, were found stored in the medication cart after the prescribed course was completed, contrary to facility policy. These lapses were confirmed through interviews with nursing staff and the DON, who acknowledged that the required procedures for medication destruction and documentation were not followed. Furthermore, medication administration practices were not consistently supervised. In one case, a nurse left multiple medications at a resident's bedside for self-administration, despite the resident not being assessed or authorized for self-administration. The medications were taken late, outside the scheduled administration window, and without staff observation, which was contrary to both physician orders and facility policy. These deficiencies were identified through direct observation, record review, and staff interviews, all of which confirmed that established protocols for medication administration and documentation were not adhered to.
Failure to Rotate Insulin Injection Sites for Two Residents
Penalty
Summary
The facility failed to ensure that insulin administration sites were rotated for two residents who were prescribed subcutaneous insulin, as required by physician orders, manufacturer guidelines, and professional standards. For one resident with a history of hemiplegia, diabetes mellitus, and gastrostomy status, records showed that insulin injections were repeatedly administered in the same abdominal quadrants over an extended period. Both the registered nurse and the Director of Nursing confirmed that the administration sites were not rotated as ordered, acknowledging that this practice did not comply with the physician's instructions, manufacturer recommendations, or facility policy. Another resident, diagnosed with type 2 diabetes mellitus and other conditions, also received insulin injections at non-rotated sites, primarily in the same abdominal quadrants. Medication administration records indicated multiple instances where the injection sites were not alternated. Interviews with nursing staff and the DON confirmed that the failure to rotate sites was a medication error, as it was not in accordance with the physician's order, manufacturer specifications, or accepted professional standards. Facility policies and procedures, as well as manufacturer guidelines for both types of insulin used, explicitly required rotation of injection sites to prevent adverse effects and ensure proper absorption. The facility's own definition of a medication error included failure to follow these requirements. The survey findings were based on direct record review, staff interviews, and policy examination, all of which demonstrated that the facility did not adhere to established protocols for insulin administration for the two residents reviewed.
Unlabeled and Expired Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors identified several deficiencies in the facility's management of medications and biologicals. In the medication room of Station A, two vials of meropenem, an intravenous antibiotic, were found unlabeled in the IV cart. The registered nurse confirmed that these vials should have been discarded after the prescribed course was completed, but they remained in the cart without proper labeling. Review of the resident's records indicated that the meropenem treatment had concluded, and the extra vials delivered by the pharmacy were not disposed of as required. In Station B, expired medications were found in the medication cart during inspection with the Infection Preventionist. Specifically, a container of psyllium and a bottle of docusate sodium, both used to treat constipation, were discovered with expiration dates that had already passed. The Infection Preventionist and Director of Staff Development both acknowledged that expired medications should be discarded, and that nurses are responsible for checking and removing such items from the cart. Further interviews with nursing staff confirmed that expired medications should not be present in medication carts and that staff are expected to check expiration dates before administration. The Director of Nursing reviewed facility policies, which require the disposal of expired and unlabeled medications and prohibit their storage or use. The presence of expired and unlabeled medications in both the medication room and carts was acknowledged as a failure to follow these established policies.
Pureed Food Consistency Not Maintained for Dysphagia Diets
Penalty
Summary
The facility failed to prepare pureed foods in a form designed to meet the individual needs of residents on a dysphagia puree diet, as required by the International Dysphagia Diet Initiative (IDDSI) Level 4 standards. During observation of the trayline, pureed mixed vegetables were found to be too thick and did not pass the spoon tilt test, which is used to assess the appropriate consistency for safe swallowing. Staff responsible for preparing the puree did not perform the required spoon tilt test, instead relying solely on mixing and visual assessment. The Dietary Director confirmed that the puree mixed vegetables did not fall off the spoon as required and acknowledged that the consistency should have been adjusted by adding more liquid. Review of facility policies and recipes indicated that all IDDSI texture modifications must pass established testing methods at the start and every 15 minutes during service. The facility's diet manual and IDDSI guidelines specify that pureed foods must not be sticky, must fall off the spoon in a single spoonful, and must not have liquid separation. Despite these requirements, the puree mixed vegetables served did not meet the necessary consistency standards, potentially affecting all residents on a puree diet at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, labeling, and sanitation practices. During a kitchen tour, a dietary aide identified several food items, including tomato soup and stewed prunes, that were not disposed of by their expiration dates. Additionally, various produce items such as mixed grapes, oranges, apples, carrots, purple cabbage, and leafy lettuce were found without proper labeling of received or expiration dates. Other items, such as grated Parmesan cheese and sliced deli meat, were missing required opened and expired dates. A frozen pepperoni bag was also incorrectly labeled with an expiration date. Further observations revealed improper storage practices, such as sliced cheeses being mixed with avocados and grapes in a single bin, which the dietary aide acknowledged should not occur due to contamination risks. A bin of thickener powder was found in the dry storage room without a product name, opened date, or expiration date, and was not stored in its original packaging as required. One of three plate warmer machines was found to have dried food debris, indicating it had not been cleaned as per facility policy. Interviews with the dietary director confirmed that staff are expected to inspect, label, and date all food items upon receipt and opening, and to store produce separately to prevent cross-contamination. The director also stated that opened food items should be discarded after three days and that equipment should be kept clean and in optimal working condition. Facility policies reviewed by surveyors supported these expectations, indicating that the observed practices were not in compliance with established procedures.
Failure to Implement Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices for multiple residents, as evidenced by surveyor observations, interviews, and record reviews. For one resident with a history of vancomycin-resistant enterococcus (VRE), staff did not implement Enhanced Barrier Precautions (EBP) as ordered, including the absence of required signage and personal protective equipment (PPE) at the room entrance. Staff members entered the resident's room and provided care, such as medication administration and linen changes, without wearing gowns, contrary to facility policy and physician orders. The Infection Preventionist and Director of Nursing confirmed that EBP should have been implemented for this resident due to their history of multidrug-resistant organisms (MDROs), but it was not done. In another instance, a Restorative Nursing Aide used a cloth gait belt with a resident on EBP and failed to properly disinfect it between uses. The aide stated she used bleach wipes on the cloth gait belt and then used it with another resident. The Infection Preventionist clarified that cloth gait belts are porous and cannot be properly disinfected with wipes, and that only vinyl gait belts should be used. The Director of Nursing confirmed that improper disinfection of shared equipment could lead to the spread of infection. Additionally, multiple medication carts were found with Prostat supplement bottles that were sticky and had visible drippings, indicating they were not cleaned before and after use as required by facility policy. Further deficiencies included staff not wearing gowns during high-contact care activities for residents on EBP, such as providing bed baths, and not securing gowns properly during medication administration. Linen carts were observed with loosely woven mesh covers that did not fully protect linens from dust. In the respiratory care area, a BiPAP mask was not stored in a manner free from contamination, and the nebulizer was not labeled with the resident's name or date last changed. Documentation and cleaning of the BiPAP equipment were inconsistent and not in accordance with physician orders or manufacturer instructions. These practices were confirmed by staff interviews and policy reviews, demonstrating a failure to follow established infection control protocols.
Cluttered Therapy Gym Limits Resident Access to Rehabilitative Services
Penalty
Summary
Facility staff failed to provide sufficient space and appropriate storage for equipment in the Physical Therapy (PT) gym, resulting in the therapy mat and surrounding area being used to store various items, including therapy balls, broken equipment, assistive devices, and items meant for disposal. Observations revealed that these items were stacked on and around the therapy mat, rendering the area unusable for resident therapy sessions. The Director of Rehabilitation confirmed that the therapy mat and its surrounding area could not be used for therapy due to the clutter and that items stored there were awaiting disposal. Interviews with facility leadership, including the Director of Nursing, emphasized the importance of maintaining a tidy, homelike, and hazard-free therapy environment, and acknowledged that the current use of the therapy area for storage was inappropriate. A review of facility policy indicated an expectation for cleanliness and order to promote a homelike environment, but there was no specific policy addressing the maintenance of uncluttered therapy areas or prohibiting the use of therapy spaces for storage.
Failure to Maintain Safe Equipment and Environment for Residents
Penalty
Summary
The facility failed to maintain essential equipment in safe working condition in several areas, as observed during surveyor inspections. In the kitchen, the light bulb inside the freezer used to store milk was found to be non-functional. Staff members, including the Dietary Aide and Dietary Director, were unaware of the issue, and the broken bulb had not been reported or addressed. Facility policy required that equipment be kept in optimal working condition and that staff notify supervisors and maintenance when repairs are needed, but this process was not followed. In the resident care areas, two residents were affected by unsafe equipment conditions. One resident, with a history of dementia, cerebral palsy, and high fall risk, was found with a bed controller that had exposed wires at its base. Multiple staff, including a CNA, Maintenance Supervisor, and DON, confirmed the presence of exposed wires and acknowledged that maintenance should have been notified immediately. The facility's policies emphasized the importance of maintaining equipment in good repair and ensuring a safe environment, but the required notifications and repairs were not made in a timely manner. Another resident, who had hemiplegia, aphasia, and was also at high risk for falls, was found to have wall sockets at the head of the bed that were cracked and missing covers. Staff interviews confirmed that these hazards had not been reported to maintenance as required. Facility policies outlined the responsibility of staff to identify and report hazards and for maintenance to keep the environment safe and homelike, but these procedures were not followed, resulting in unsafe conditions for the residents.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) assisted a resident with breakfast while standing over the resident, rather than sitting at eye level as required by facility policy. The resident involved had a history of pneumonia, dementia, and major depressive disorder, and was assessed as having severely impaired cognition and requiring total assistance with all activities of daily living. During the observation, the resident was in bed with the head elevated, and the CNA admitted to forgetting to get a chair, acknowledging that staff should be at eye level to respect the resident's dignity during mealtime assistance. Interviews with the Registered Nurse (RN) and Director of Nursing (DON) confirmed that staff are expected to sit at eye level when assisting residents with eating, both for dignity and safety reasons. Facility policies reviewed also specified that residents should be assisted with meals in a manner that maintains their dignity, explicitly stating that staff should not stand over residents while feeding them. The failure to follow these procedures resulted in care that did not maintain the resident's dignity.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident and/or their responsible party was informed in advance about the risks and benefits of a psychoactive medication, specifically Remeron (mirtazapine), which was prescribed for depression manifested by poor appetite. The resident had a history of chronic obstructive pulmonary disease, schizophrenia, and bipolar disorder, and was assessed as being able to make needs known but unable to make medical decisions. Despite this, there was no documented informed consent for the use of Remeron, as confirmed during interviews and record reviews with facility staff. The MDS Nurse and a Registered Nurse both acknowledged that the informed consent process was missed, with the RN stating she failed to complete the consent when the medication order was received. The Director of Nursing confirmed that it is the responsibility of licensed nurses to obtain informed consent prior to administering such medications, in accordance with facility policy. The facility's policy requires verification of informed consent with each order, but this was not followed in this instance.
Failure to Assess and Authorize Medication Self-Administration
Penalty
Summary
The facility failed to ensure that medication self-administration was clinically appropriate and did not honor a resident's right to self-administer medications. A resident with multiple diagnoses, including polyneuropathy, hypertension, major depressive disorder, anxiety disorder, binge eating disorder, and intellectual disabilities, was observed with medications left at the bedside for self-administration. The resident had previously been assessed as not wanting to self-administer medications and not being a candidate for safe self-administration. Despite this, a nurse left several medications at the bedside at the resident's request, without conducting a new assessment or obtaining a physician's order for self-administration. The resident was able to communicate effectively and had the capacity to make decisions, as documented in the medical record. During an interview, the resident confirmed that the medications belonged to them and that the nurse left them at the bedside because the resident preferred to take them one at a time. The nurse confirmed leaving the medications for the resident to self-administer, stating that the resident was alert and often requested this arrangement. However, the nurse acknowledged that the facility's process required an assessment and a physician's order before allowing self-administration, neither of which were completed in this case. Further review and interviews with facility staff, including the RN and DON, confirmed that the facility's policy required an interdisciplinary assessment and physician's order before permitting self-administration of medications. The staff recognized that the process was not followed when the nurse left medications at the bedside without proper assessment or documentation. Facility policies also specified that medications should not be left unattended at the bedside unless authorized, and that residents' rights to self-administer medications must be supported by a clinical determination of safety and appropriateness.
Call Light Not Connected for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, hemiplegia following a stroke, aphasia, and major depressive disorder was found in bed with their call light clipped to the sheet but disconnected from the wall. The resident required substantial to total assistance with all activities of daily living and was assessed as a fall risk. The care plan for this resident included an intervention to keep the call light and frequently used items within reach to minimize the risk of falls or injury. During an observation, a CNA confirmed that the call light was not plugged in and stated that all residents' call lights should be connected to the wall at all times to ensure proper functioning. The CNA acknowledged that staff are responsible for ensuring call lights are plugged in and operational before leaving residents' rooms. The DON also confirmed that staff should ensure call lights are connected and functioning to allow residents to call for assistance. Review of facility policy indicated that call lights should be plugged in at all times and answered promptly.
Failure to Develop Baseline Care Plans for Residents with Oxygen Therapy and Anticoagulant Orders
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with significant medical needs. For one resident admitted with diagnoses including pneumonia, chronic respiratory failure, and COPD, there was a physician order for oxygen therapy at 2 liters per minute via nasal cannula three times a day. Despite these orders and the resident's intact cognitive status, no baseline care plan addressing oxygen therapy was created or implemented. Both the registered nurse and the director of nursing confirmed that a baseline care plan should have been in place to address the resident's primary respiratory issues and to serve as a communication tool for coordinated care. For another resident admitted with chronic embolism, thrombosis, atrial fibrillation, and atherosclerosis of the aorta, there was a physician order for the anticoagulant Pradaxa to be administered twice daily. This resident had severe cognitive impairment and was identified as being on a high-risk drug class. Despite the order for anticoagulant therapy, no baseline care plan was developed to address the use of Pradaxa, including monitoring for adverse effects and identifying interventions to manage potential complications. The registered nurse acknowledged that a baseline care plan should have been initiated upon admission to ensure proper monitoring and care. The facility's policy and procedure on baseline care plans, last reviewed in January 2025, requires that a baseline plan of care be developed within 48 hours of admission to meet each resident's immediate health and safety needs. This plan must include initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The failure to develop and implement these baseline care plans for the two residents resulted in a deficiency related to the timely provision of essential healthcare services.
Failure to Schedule Orthopedic Appointment Following Physician Orders
Penalty
Summary
The facility failed to follow up and schedule an orthopedic appointment for a resident who was admitted with diagnoses including a disorder of bone, primary osteoarthritis of the right knee, and generalized muscle weakness. The resident's history and physical indicated possible lytic erosive bone changes in the femur, with a recommendation for an orthopedic referral. Physician orders were documented on two occasions to arrange for an orthopedic appointment, specifically for a lytic lesion in the left femur. Despite these orders, there was no evidence that the appointment was scheduled or that appropriate follow-up occurred. Interviews with nursing staff and the Director of Nursing revealed that the responsibility for scheduling the appointment and documenting follow-up was not fulfilled. The facility's policy required coordination between social services and nursing for such referrals, but this process was not completed as expected. The lack of action resulted in a delay of care and treatment for the resident, as the necessary orthopedic evaluation was not arranged in a timely manner.
Failure to Set Low Air Loss Mattress According to Resident Weight for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that two residents at high risk for pressure ulcers received care consistent with professional standards, specifically regarding the use of low air loss mattresses (LALM) set according to each resident's weight. For one resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, adult failure to thrive, and on palliative care, the LALM was observed set at 130 lbs, while the resident's actual weight was 158 lbs and the manufacturer's instructions indicated the setting should be between 150-180 lbs. Both a CNA and an LVN confirmed the setting was incorrect and acknowledged the importance of matching the mattress setting to the resident's weight to prevent pressure injuries. The DON also confirmed that the LALM should be set according to the resident's weight and that staff are responsible for ensuring this is done. For a second resident with diagnoses including abnormalities of gait, muscle weakness, and chronic embolism and thrombosis, the LALM was observed set at 270 lbs, while the resident's weight was 152 lbs and the manufacturer's instructions indicated the setting should be between 120-150 lbs. An LVN confirmed the setting was incorrect and stated that improper settings could cause pressure injuries. The DON reiterated that the LALM should be set according to the resident's weight and that staff are responsible for monitoring and reporting any discrepancies. In both cases, the facility's policy and procedure, as well as the manufacturer's specifications, required the LALM to be set based on the resident's weight. The failure to follow these guidelines resulted in the residents not receiving care consistent with professional standards for the prevention of pressure ulcers, as confirmed by staff interviews and documentation review.
Failure to Provide Ordered Range of Motion Exercises to Both Upper Extremities
Penalty
Summary
A deficiency occurred when a resident with osteoarthritis and chronic obstructive pulmonary disease, who had moderate cognitive impairment and decreased range of motion (ROM) in both upper extremities, did not receive the ordered active assisted range of motion (AAROM) exercises to the left upper extremity during a restorative nursing aide (RNA) session. The resident's care plan and physician orders specified that AAROM exercises were to be performed on both upper extremities daily to maintain or improve ROM and prevent further decline. However, during observation, the RNA only performed exercises on the right upper extremity and applied a splint, omitting the left side entirely. The RNA later acknowledged that the omission was due to the belief that the resident could move the left upper extremity independently, despite the care plan and orders requiring assistance for both sides. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed the importance of following RNA orders to prevent decline in mobility and function. Facility policy also required that restorative nursing care be provided as needed to promote optimal safety and independence, which was not followed in this instance.
Failure to Follow Enteral Feeding Protocols and Labeling Requirements
Penalty
Summary
Staff failed to follow facility protocols for the care and administration of enteral nutrition for two residents with gastrostomy tubes. For one resident with severe cognitive impairment and a history of dysphagia and malnutrition, observations revealed that the feeding formula and water flush bag were not labeled with the time they were hung or the rate of infusion, as required by physician orders and facility policy. Additionally, a specialized valve used with the feeding tube was disconnected and left uncapped, hanging from the feeding pump pole, contrary to infection control protocols. Interviews with nursing staff and the Director of Nursing confirmed that these labeling and handling procedures were not followed, which are necessary to ensure accurate administration and prevent contamination. For another resident with hemiplegia, aphasia, and severe cognitive impairment, the water flush bag was observed without the required label indicating the administration rate and frequency. Nursing staff acknowledged that the label should have included this information to ensure the resident received the correct amount of water flushes as ordered by the physician. The Director of Nursing confirmed that the omission of this information on the label did not comply with facility policy and could result in the resident not receiving the prescribed hydration. Record reviews for both residents showed clear physician orders for the administration of enteral nutrition and water flushes, specifying rates, frequencies, and labeling requirements. Facility policy and procedures also outlined the need for accurate labeling and safe handling of enteral feeding equipment to prevent errors and contamination. Despite these protocols, staff did not consistently implement them, as evidenced by direct observations and staff interviews.
Annual Staff Competency Evaluation Not Performed as Required
Penalty
Summary
The facility failed to ensure that staff competency evaluations were performed annually for one of six sampled staff members, specifically a Certified Nursing Assistant (CNA). Review of the CNA's employee file showed that the last skills competency evaluation was completed in January 2024, despite the CNA being employed since November 2022. The Director of Staff Development (DSD) indicated that the next competency evaluation was scheduled for November 2025, aligning with the month of hire rather than the annual requirement. The Director of Nursing (DON) confirmed that skills competency evaluations are supposed to be conducted annually and acknowledged that the evaluation for this CNA was overdue as of January 2025. Facility policy on performance evaluations requires that each employee's job performance be reviewed and evaluated at least annually, with skills competency being a component of this process. The DON stated that the DSD was responsible for conducting these evaluations and that the failure to perform the annual skills competency check was an oversight. The facility's policy on staffing also emphasizes the need for sufficient and competent nursing staff to provide care in accordance with resident care plans and facility assessments.
Medication Error Rate Exceeds Acceptable Threshold Due to Dosage and Expiration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with two medication errors identified out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a nurse administered an incorrect dosage of docusate sodium to a resident with chronic obstructive pulmonary disease, a history of falls, and fibromyalgia. The physician's order specified 250 mg of docusate sodium twice daily, but the nurse administered only 100 mg. This discrepancy was confirmed through record review and interviews with nursing staff and the Director of Nursing, who acknowledged that the medication was not given as ordered and that the lower dose would not be as effective in treating the resident's constipation. In the second instance, another nurse failed to check the expiration date before preparing docusate sodium for a resident diagnosed with dementia, constipation, and hypertension. The medication bottle had expired, but the nurse did not notice this until it was pointed out by the surveyor during the medication pass. The nurse admitted to not reading the expiration date, and facility staff confirmed that expired medications should not be administered due to safety concerns and potential ineffectiveness. Both incidents were observed during medication administration and were corroborated by interviews with nursing staff, the Director of Staff Development, the Infection Preventionist, and the Director of Nursing. Facility policy required medications to be administered according to prescriber orders and for expiration dates to be checked prior to administration, but these procedures were not followed in either case.
Delayed CT Scan Resulted in Missed Timely Orthopedic Follow-Up
Penalty
Summary
The facility failed to provide a timely computed tomography (CT) scan for one resident who had a right humeral neck fracture and muscle wasting. The CT scan was ordered by the orthopedic physician on 9/9/2024, with instructions for the resident to return to the orthopedic physician in one week with the scan results. However, the facility delayed requesting authorization for the CT scan until 10/9/2024, despite the order being received a month earlier. The business office was responsible for submitting authorizations for radiology services, but could not provide a reason for the delay in requesting authorization. Nursing notes indicated that the orthopedic follow-up appointment was cancelled due to the lack of a completed CT scan, and the resident was only able to attend the CT scan appointment on 10/21/2024, more than a month after the initial order. Interviews with facility staff, including the LVN, Business Office Manager, and DON, confirmed that the delay in obtaining the CT scan was due to the late submission of the authorization request. The DON acknowledged that radiology orders should be processed the same day they are received and that the delay in obtaining the CT scan was not appropriate. Facility policy required staff to process test requisitions and arrange for tests based on physician orders, but this was not followed in this case, resulting in a significant delay in diagnostic imaging and follow-up orthopedic care for the resident.
Failure to Ensure Proper Training and Competency in Puree Food Preparation for Dysphagia Diets
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in preparing pureed foods for residents on a dysphagia puree diet, as required by the International Dysphagia Diet Initiative (IDDSI) guidelines. During observation of the trayline, a cook was unable to verbalize or demonstrate the correct preparation of pureed mixed vegetables to achieve the required consistency. The pureed mixed vegetables were observed to be too thick and did not pass the spoon-tilt test, a standard method for assessing appropriate texture for safe swallowing. The cook stated that her method for checking consistency was limited to mixing the puree and adjusting with liquid or thickener based on feel, without performing the required spoon-tilt test. The Dietary Director confirmed that oversight was provided through spot checks and taste testing, but acknowledged that the puree mixed vegetables did not pass the spoon-tilt test during the trayline and should have been adjusted before service. The facility's recipe and policy documents specified that all IDDSI texture modifications must pass established testing methods at the start and every 15 minutes during service, but this protocol was not followed. Review of the competency checklist for the cook revealed that it did not include topics related to IDDSI Level 4 testing, such as the spoon-tilt or fork-drip tests. The facility's diet manual and IDDSI guidelines require that pureed foods for residents with dysphagia be lump-free, not sticky, and able to fall off a spoon in a single spoonful, with no separation of liquid and solid. The failure to properly prepare and test the puree consistency as outlined in facility policy and IDDSI standards resulted in the serving of food that did not meet safety requirements for residents on a dysphagia puree diet.
Failure to Provide Occupational Therapy as Ordered
Penalty
Summary
The facility failed to provide occupational therapy (OT) treatments five times a week as required by the OT plan of treatment and care plan for one resident. The resident, who was admitted with muscle wasting, atrophy, and a right humeral neck fracture, had moderate cognitive impairments and significant functional limitations, including dependence for dressing, bathing, and transfers. The care plan and OT evaluation both specified daily OT sessions five times a week for four weeks. However, OT treatment encounter notes showed that while the prescribed frequency was met during the first three weeks, the resident only received four sessions in the fourth week, and just one session per week in the subsequent two weeks. The Director of Rehabilitation confirmed during interview and record review that the resident did not receive OT treatment at the frequency specified in the plan of care, and there was no documentation explaining the missed sessions. The facility's policy required staff occupational therapists to follow relevant physician orders and implement treatment plans in consultation with the resident's physician, but this was not adhered to in this case.
Failure to Maintain Accurate and Timely Clinical Documentation
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for two residents, resulting in deficiencies related to documentation standards. For one resident, the Occupational Therapy (OT) Progress Notes and Discharge Summary were not completed within the required timeframe. The OT Progress Report dated 2/24/2025 was signed and completed on 3/4/2025, and the OT Progress Report dated 3/3/2025, as well as the OT Discharge Summary dated 3/4/2025, were both signed and completed on 3/17/2025. The Director of Rehabilitation confirmed that these documents were completed very late and emphasized the importance of timely documentation for continuity of care and accurate communication among healthcare providers. The facility's policy required progress reports and discharge summaries to be completed within seven days, which was not followed in these instances. Another deficiency was identified in the medication administration documentation for a different resident. The Licensed Vocational Nurse (LVN) left medications at the resident's bedside for self-administration, and the resident did not take them at the scheduled time. The LVN later documented in the Medication Administration Record (MAR) that the medications were administered during the scheduled morning pass, even though the resident actually took them later. The LVN admitted to documenting the administration before the resident took the medications and acknowledged that the MAR did not accurately reflect the actual time of administration. The Director of Nursing confirmed that the MAR should accurately document the time medications are given, as it is used by staff and physicians to track medication administration. Both deficiencies were confirmed through interviews, record reviews, and observations. The facility's policies and procedures for clinical documentation and medication administration were not followed, resulting in inaccurate and untimely records. These lapses in documentation could lead to miscommunication among staff and incomplete information regarding the care and services provided to residents.
Failure to Accurately Document Antibiotic Use in Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship policy for one resident by not accurately documenting antibiotic use in the Antibiotic Log. A resident was admitted with multiple diagnoses, including low back pain, history of falling, and hypertension. The resident was diagnosed with a urinary tract infection (UTI) and initially prescribed ciprofloxacin. The order for ciprofloxacin was discontinued the next day after urine culture and sensitivity results indicated resistance, and the antibiotic was changed to Keflex. However, the Antibiotic Log incorrectly showed ciprofloxacin as being administered for a full course and did not include any documentation of the Keflex prescription, including its start and completion dates. Interviews with facility staff, including the RN, Infection Preventionist (IP), and Director of Nursing (DON), confirmed that the Antibiotic Log was incomplete and not updated according to facility policy. The DON and IP acknowledged that the log should have reflected the change in antibiotics and that it is facility policy to monitor and document all antibiotic use. Review of the facility's policies further confirmed the requirement for accurate documentation and monitoring of antibiotic administration by the IP nurse.
Failure to Implement Bed Alarm as Care Planned for Fall Prevention
Penalty
Summary
The facility failed to implement a person-centered care plan for one resident by not ensuring that the resident's bed alarm was functioning as indicated in the care plan for fall prevention. The resident, who had a history of falls, unspecified dementia, and a recent fracture of the thoracic vertebrae, was admitted with a care plan intervention requiring a bed alarm while in bed. The care plan was reviewed and agreed upon by the resident's family member and the interdisciplinary team. However, during observation, the resident was able to move in bed without the bed alarm sounding, and both the resident and staff confirmed that the bed alarm was not in use or functioning at that time. Further investigation revealed that the bed alarm device was present but not turned on, and the sensor pad was not connected to the alarm machine. Staff interviews confirmed that the bed alarm should have been checked and ensured to be operational as part of the resident's care plan. The facility's policy emphasized the importance of individualized care plans and the responsibility of staff to implement interventions as designed. The failure to follow the care plan placed the resident at risk for falls and injury.
Failure to Ensure Bed Alarm Function and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to follow its fall prevention policy for a resident with a history of falls and multiple risk factors. The resident, who had diagnoses including unspecified thoracic vertebrae fractures, dementia, hypertension, osteoporosis, and a recent fall, experienced another fall resulting in a displaced proximal humerus fracture. Despite the care plan indicating the use of a bed alarm as an intervention, observations revealed that the bed alarm was not turned on or functioning. Staff interviews confirmed that the bed alarm was either not present or not operational, and the device was found disconnected from its sensor pad during inspection. Additionally, the facility did not accurately assess the resident's fall risk following the incident. The Fall Risk Assessment assigned a low-risk score, despite the resident's multiple predisposing conditions such as hypertension, osteoporosis, fractures, and a history of falls. Both the Director of Staff Development and the Director of Nursing acknowledged that the assessment was incorrect and that the resident should have been classified as high risk for falls based on her medical history and recent events. The facility's policies required staff to use devices like bed alarms as nursing interventions to prevent injury and to conduct thorough fall risk assessments considering all relevant diagnoses and recent incidents. However, the failure to ensure the bed alarm was functioning and the inaccurate fall risk assessment led to inadequate supervision and interventions for the resident, contrary to facility policy and procedure.
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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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