Bay Crest Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrance, California.
- Location
- 3750 Garnet Street, Torrance, California 90503
- CMS Provider Number
- 055559
- Inspections on file
- 87
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 59 (2 serious)
Citation history
Health deficiencies cited at Bay Crest Care Center during CMS and state inspections, most recent first.
A resident with type 2 DM, hemiplegia, hemiparesis, and severely impaired cognition had an order for glipizide with parameters to hold the dose if CBG was below 120, but an LVN repeatedly administered the medication despite CBG readings under that threshold and did not recognize the ordered parameters. Review of records showed multiple days where glipizide was given contrary to orders, with no documentation of a change in condition, no medication error report, and no notification to the physician or the resident’s responsible party, despite facility policies requiring immediate notification and reporting of such errors.
A resident with type 2 DM and severe cognitive impairment had a physician’s order for daily glipizide 2.5 mg with parameters to hold the dose if CBG was less than 120. Over multiple days, nursing staff documented CBG values below 120 yet still administered glipizide each time. An LVN acknowledged giving the medication outside the ordered parameters, stating he was unaware of and did not see the complete order, and was unfamiliar with glipizide having hold parameters. An RN confirmed the repeated administrations despite low CBG readings and the absence of documentation of these medication errors, while another RN confirmed the original telephone order included the hold instruction.
A resident with dementia, severe cognitive impairment, prior rib fractures, and a documented history of falls was identified as a high fall risk and required substantial/maximal assistance with ADLs. Despite a physician’s order for bed rails with fall precautions and repeated requests from the resident’s family, staff did not timely install bed rails or implement additional fall-prevention interventions such as bed alarms or floor mats after multiple falls. The care plan and facility policies on falls and bed rails called for identifying and implementing interventions to prevent subsequent falls, but no new interventions were added after repeated incidents, including a witnessed fall from bed. The resident ultimately sustained a possible nondisplaced lateral malleolus fracture of uncertain chronicity and was transferred to an acute care hospital.
A resident with dementia, prior rib fractures, and a documented history of falls was identified as having severely impaired cognition and multiple fall risk factors, including confusion, poor safety judgment, and impaired balance. After the resident was found on the floor and at the end of the bed on multiple occasions, a physician ordered side rails with fall precautions, and the family repeatedly requested bed rails. Despite this, staff did not complete a required bed rail assessment, did not obtain informed consent from the resident’s representative, and did not implement the physician’s order without delay. Interviews with a CNA, an LVN, an RN supervisor, the DON, and the maintenance director showed that maintenance was not notified to install the bed rails until several days after the order, and bed rails were not installed until after additional falls, contrary to facility policies on falls, restraints, and bed rail use.
A resident with dementia and atrial fibrillation, documented as having severely impaired cognition and needing maximal assistance with ADLs, repeatedly refused showers, meals, medications, and vital signs according to nursing notes and IDT documentation. Despite these ongoing refusals, staff did not develop an individualized care plan with measurable goals, timeframes, and interventions to address the refusal of care. An LVN and the DON both acknowledged that a care plan should have been created to guide staff response, and the facility’s own comprehensive care plan policy requiring inclusion of identified problem areas and related risk factors was not followed.
A resident with dementia, anxiety, prior left rib fractures, and moderately impaired cognition experienced a documented fall from her wheelchair, after which the existing fall risk care plan was not revised to reflect the actual fall or to add new interventions. Although the IDT noted the fall and discussed specific measures such as keeping the bed in the lowest position, implementing a toileting schedule, encouraging fluids while the resident self-propelled in a w/c, and educating staff on care plan adherence, these were not incorporated into an updated care plan. The IP and DON both acknowledged that the fall risk care plan remained unchanged after the fall, and the resident later sustained another unwitnessed fall resulting in multiple left rib fractures, despite facility policy requiring individualized, comprehensive, and updated care plans based on assessments.
Staff failed to follow infection prevention and control practices for mask use during an influenza outbreak. An LVN was observed administering medications with a face mask worn below the nose and did not adjust it to cover the nose and mouth, despite acknowledging this was improper and could expose a resident to respiratory droplets. A CNA was also observed wearing a mask below the nose and acknowledged this violated facility policy requiring masks to fully cover the nose and mouth while on duty. The IP and DON confirmed that all staff must wear PPE, including properly fitted masks, during resident care, and facility policy states that face masks must cover the nose and mouth while performing treatment or services.
A resident with intact cognition did not receive required monthly personal fund account statements, and the facility failed to obtain necessary authorization signatures for personal fund management. Several withdrawal receipts lacked witness signatures, and there was no documentation that the resident had been given her account statements as required by policy.
Two residents with physical and cognitive impairments were unable to access their call lights, forcing them to yell for assistance and causing delays in care. In both cases, the call lights were found out of reach—one wedged between the mattress and side rail, and the other placed on a bedside table. Staff confirmed that call lights should have been accessible, and care plans required this intervention for safety.
A LVN failed to directly supervise a student nurse during a medication pass, resulting in a resident receiving another resident's medications and missing their own prescribed medications. The LVN did not accompany the student nurse to the bedside or verify the resident's identity, and the five rights of medication administration were not followed. The resident required hospital evaluation after the error was discovered.
A resident with multiple medical conditions received another resident's medications after an LVN failed to directly supervise a student nurse during medication administration. The student nurse, instructed to give medications to a resident by bed assignment, did not verify the resident's identity and administered the wrong medications. The resident experienced low blood pressure and increased sleepiness, leading to transfer to a hospital for evaluation. Interviews confirmed that the LVN did not follow facility policy requiring direct supervision and proper resident identification.
A resident with moderate cognitive impairment received the wrong medications, resulting in increased sleepiness and low blood pressure. The responsible party was not promptly notified of the medication error or the resident's change in condition, despite facility policy requiring immediate notification. The omission was confirmed through staff interviews and record review.
A resident with a history of heart and lung conditions, who required minimal assistance with a walker, was able to leave the facility through an unsupervised, non-alarmed front door after being inaccurately assessed as low risk for elopement. Staff failed to monitor the door after the receptionist's shift, and the door was sometimes propped open, allowing the resident to exit unnoticed. The resident was later found at a restaurant, experienced shortness of breath, and died after being transported to a hospital. Staff also failed to respond promptly to exit door alarms, and there was confusion about responsibilities for monitoring and responding to alarms.
A resident with multiple serious medical conditions was admitted without timely initiation or implementation of physician orders. Licensed staff were unaware of the resident's presence for over two hours, and no admission packet or orders were processed during that time, contrary to facility policy requiring immediate action upon admission.
A resident with multiple medical conditions and a history of psychosis was inaccurately assessed as non-ambulatory for elopement risk, despite physical therapy documentation showing the ability to ambulate with assistance. The inaccurate assessment was based on limited observation and incomplete information, leading to the omission of appropriate interventions to address the resident's risk for elopement.
A resident admitted with multiple serious conditions, including heart failure and psychosis, did not receive eight prescribed medications on time because an LVN could not locate the admission packet and failed to enter medication orders into the electronic system. The delay was confirmed by a nurse supervisor and the administrator, and was not in accordance with facility policy requiring prompt medication ordering and administration.
The facility did not maintain or implement an ongoing QAPI program, as there was no documentation of QAPI activities, committee meetings, or performance improvement projects since the last recorded QA committee meeting. The Administrator confirmed that required monthly meetings had not occurred, and a review of facility policy showed that such meetings and documentation were mandated to monitor and improve care quality.
A resident with paraplegia and muscle weakness sustained a second-degree burn to the thigh after using an unauthorized egg cooker in their room. Facility staff, including an LVN, DON, and Administrator, were aware of the appliance at different times but did not ensure its removal, assess its safety, or provide written approval as required by facility policy. The lack of oversight and failure to enforce the electrical appliance policy led to the resident's injury.
A resident who required moderate assistance was transported from the shower room to their bedroom with only a towel covering the front of their body, leaving their buttocks exposed and visible through the shower chair in the hallway. The CNA was unaware of the exposure, and the resident later reported feeling embarrassed. Facility policy requires staff to maintain residents' bodily privacy during personal care, which was not upheld in this case.
A resident with severe cognitive impairment and a history of behavioral issues entered a roommate's space, yelled, and struck her with a water bottle. Despite being informed, staff did not separate or supervise the residents, leaving the affected resident feeling unsafe. Facility leadership later acknowledged that policy requiring immediate separation and supervision was not followed.
A resident with severe cognitive impairment and a history of aggressive behaviors struck her roommate multiple times with a water bottle. Despite the incident being witnessed by a CNA and reported by the victim to staff and her responsible party, the event was not reported to the DON or administrator within the required timeframe, resulting in a delay in notifying CDPH and other authorities as mandated by facility policy.
A resident with severe cognitive impairment and a history of delusions, wandering, and aggressive behaviors repeatedly entered roommates' personal spaces, took belongings, and displayed physical and verbal aggression. Despite staff and administration being aware of these behaviors, the care plan was not updated to include interventions addressing these specific risks, resulting in repeated incidents and distress among other residents.
A resident with COPD and muscle weakness did not receive requested copies of their medical records after a written request was submitted by a law office. The Medical Record Director delayed the release, believing more time was allowed, and was waiting for additional documentation from nursing. Interviews revealed the facility lacked a clear policy or timeframe for releasing records, and key staff were unaware of the request until surveyors intervened.
Staff failed to consistently monitor and document the temperature of a resident refrigerator containing personal food items, resulting in the refrigerator being found at 60°F, well above the required 41°F. The refrigerator contained various foods, including eggs without resident identification, and staff interviews revealed lapses in following temperature check protocols.
A resident with multiple complex medical conditions did not receive their scheduled morning medications on time, with administration delayed by over three hours. The LVN responsible did not notify the physician of the delay, as required by facility policy. The DON confirmed that such notification is necessary when medication administration is late, especially for residents with significant health risks.
A resident with multiple chronic conditions received ten scheduled medications three hours late when an LVN administered them outside the required one-hour window, citing workload as the reason for the delay. The facility's policy and the resident's care plans required timely medication administration, but these protocols were not followed.
A resident with hypertension and congestive heart failure was left waiting outside after returning from an appointment because a doorbell at one entrance was not working. The resident had to knock repeatedly before staff noticed and let her in. Staff confirmed the doorbell was non-functional and acknowledged its importance for timely resident access.
Two residents with indwelling urinary catheters did not have individualized care plans addressing their catheter care, despite physician orders and facility policy requiring such plans. Staff confirmed that care plans should have included interventions for monitoring and reporting complications, but these were not documented, leaving catheter-related care needs unaddressed.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with quadriplegia and a sacral pressure ulcer was not turned or repositioned for about five hours, despite physician orders and the care plan requiring repositioning every two hours. Documentation was missing for the overnight shift, and a CNA reported not providing the care, while another CNA stated the resident never refused repositioning. Facility policy required regular repositioning for immobile residents to prevent skin breakdown.
The facility failed to maintain a plan that outlines the process for conducting QAPI and QAA activities, as required. Surveyors found no documentation or description of how these quality assurance activities are implemented.
A resident with orthopedic and mobility issues, requiring substantial assistance with hygiene, requested only female staff for personal care. Despite this preference being communicated by the family and supported by facility policy, male CNAs were assigned to the resident on multiple occasions, and staff confirmed the preference was not consistently honored.
A resident with mobility issues, muscle weakness, and a stage 3 pressure ulcer did not receive required toileting hygiene assistance every shift and as needed. Documentation and interviews confirmed that care was missed on multiple shifts, and the resident was left in soiled disposable underwear for an extended period, contrary to facility policy and standard practice.
A resident with multiple fractures and heart failure did not receive physician-ordered restorative nursing assistance (RNA) services, including active and assisted range of motion exercises, as documented in facility records and confirmed by staff interviews. The facility's policy required provision of these services to promote safety and independence.
A resident with a Foley catheter and a history of bladder dysfunction and UTIs did not have documented evidence of catheter care or urine monitoring for infection. Interviews with the treatment nurse and DON confirmed the lack of documentation, despite facility policies requiring such care for residents needing assistance with hygiene.
Two residents with special dietary needs did not receive meals at scheduled times or requested alternatives, resulting in missed or delayed meals. Documentation and staff interviews confirmed that meals were not consistently provided three times daily or within the facility's required timeframe.
A resident with severe cognitive impairment and a history of pulling out her G-tube did not receive required assessments of her G-tube site by nursing staff, despite facility policy and known risk behaviors. The G-tube became dislodged and was not identified until the resident complained of pain, resulting in a delay in care and the need for emergency reinsertion.
A resident with chronic kidney disease and hypertension received two doses of temazepam 15 mg within a short interval after two nurses failed to follow the required protocol of verifying medication administration timing in the electronic charting system before giving the controlled medication. The error was discovered when the system alerted the second nurse after the medication had already been administered.
A nurse administered temazepam 15 mg to a resident for insomnia but recorded the wrong date on the Controlled Drug Record, contrary to facility policy requiring immediate and accurate documentation of controlled medication administration. The resident had chronic kidney disease, hypertension, and required moderate assistance with daily activities. The error was identified through record review and staff interview.
A resident with schizophrenia and cognitive impairment, who had a care plan requiring a 1:1 sitter due to wandering and behavioral issues, entered another resident's room and attempted to take a cell phone. The facility failed to implement the care plan, as the assigned sitter was not present, leading to a breach of privacy and distress for the affected resident.
A resident with a history of wandering and behavioral issues entered another resident's room without consent, attempting to take a cell phone. The resident was supposed to be under 1:1 supervision due to their diagnoses, but the facility failed to ensure this, resulting in a privacy violation. The DON could not determine who was assigned as the sitter, highlighting a lapse in supervision.
Three residents in an LTC facility experienced deficiencies in their living environment, including non-functioning call lights, inaccessible lighting, and malfunctioning TV remotes and overbed tables. These issues were observed and confirmed through interviews, causing frustration and impacting the residents' quality of life. Staff acknowledged the deficiencies, emphasizing the importance of a homelike environment.
The facility failed to accurately document PASARR screenings for five residents with mental health diagnoses, leading to potential inappropriate placements and delayed services. The Registered Nurse Supervisor admitted to not reviewing PASARRs upon admission, and the Director of Nursing emphasized the importance of accurate documentation. The facility's policy requires PASARR completion for all admissions, but this was not adhered to, resulting in the deficiency.
The facility failed to provide adequate nail care for five residents, resulting in untrimmed and dirty fingernails with dark deposits. Residents with various medical conditions and cognitive impairments expressed dissatisfaction with their nail hygiene. Staff interviews revealed inconsistencies in performing and documenting nail care, despite facility policies requiring such care as part of ADLs.
A resident with a history of falls and dementia experienced multiple falls due to the facility's failure to reassess fall risk and update the care plan. Despite recommendations for a sitter, the resident was often left unsupervised, leading to repeated incidents and injuries. The facility did not follow its fall management policy, resulting in inadequate fall prevention measures.
A resident with a history of stroke and dysphagia was not provided with the prescribed nectar thick liquid during a medication pass, leading to difficulty swallowing and coughing. Nursing staff interviews revealed a lack of adherence to standard practices, with one nurse admitting to not having a liquid thickener ready. Facility policies require staff to follow specific instructions for fluid intake, which were not followed in this instance.
The facility's QAA failed to effectively oversee and implement corrective actions for previously identified deficiencies, leading to repeat issues in resident rights, care plans, pharmacy services, and infection control. The Administrator admitted to a lack of diligence in the QAPI program, which is designed to measure care outcomes and improve quality of life for residents.
The facility failed to maintain resident dignity by not providing a privacy curtain for a resident with cognitive impairment and not covering another resident's urine collection bag. The first resident's privacy was compromised when the housekeeping staff removed the curtain for cleaning without a replacement, while the second resident's dignity was affected due to the lack of a dignity bag for their urine collection. The facility's policy emphasizes the importance of promoting and protecting resident privacy, which was not followed in these cases.
A resident requiring substantial assistance with personal care was left exposed during care due to a failure to draw the privacy curtain. Staff interviews confirmed the importance of maintaining privacy, as outlined in the facility's policies. This oversight violated the resident's right to privacy.
A resident's bed was positioned against the wall, restricting movement and considered a restraint. The resident, who was severely cognitively impaired, did not have a care plan addressing this setup. Staff acknowledged the issue but were unsure of the reasoning, and the facility's policy indicated that such positioning should be considered a restraint.
Failure to Notify Physician and Responsible Party After Repeated Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party after repeated medication administration errors and a significant deviation from ordered treatment parameters. The resident, who had type 2 DM, hemiplegia, hemiparesis, and severely impaired cognition, had a physician’s order for glipizide 2.5 mg once daily with instructions to hold the medication if the capillary blood glucose (CBG) was less than 120. Review of the Medication Administration Record showed that on multiple dates in March, the resident’s CBG levels were below 120, yet glipizide was administered at 9 a.m. on each of those days contrary to the physician’s order. The resident’s History and Physical and MDS documented that the resident lacked capacity to understand and make decisions and required extensive assistance with activities of daily living. During interviews, the LVN who administered the glipizide acknowledged giving the medication when the CBG was less than 120 and stated he had not noticed the parameters on the order. He further stated he did not notify the physician of the medication administration errors. Review of the Order Summary Report, MAR, nursing progress notes, and change of condition reports confirmed there was no documentation of the errors, no change of condition report, and no notification to the physician or the resident’s family/responsible party. This failure occurred despite facility policies requiring immediate notification of the physician and resident representative for significant changes in condition or treatment, and immediate reporting and documentation of all medication errors, including notification of the attending physician, resident, and responsible party.
Failure to Follow Glipizide Hold Parameters for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to administer a hypoglycemic medication according to the physician’s ordered parameters for a resident with type 2 DM and severe cognitive impairment. The resident, who required significant assistance with activities of daily living and lacked decision-making capacity, had a care plan goal to remain free of signs and symptoms of hypoglycemia, with an intervention for staff to administer hypoglycemic medications as ordered. A physician’s order dated 3/4/2026 directed that the resident receive glipizide 2.5 mg once daily for DM, with instructions to hold the dose if the resident’s CBG was less than 120. Review of the MAR for the month showed that on eight separate days the resident’s CBG levels were below 120 (ranging from 96 to 119), yet glipizide 2.5 mg was administered at 9 a.m. on each of those days. During interview, the LVN who administered the medication acknowledged giving glipizide outside the ordered parameters multiple times, stated he was unaware the order included a hold parameter for CBG less than 120, and reported he did not see the complete order when administering the medication. He also stated he was not familiar with glipizide having parameters and that he should not have assumed the medication did not have parameters. RN 1 confirmed that glipizide was administered when CBG was less than 120 and that there was no documentation in nursing progress notes or change of condition reports regarding these medication errors. RN 2 confirmed that when the telephone order was taken, the hold parameter for CBG less than 120 was included and read back to the physician. The facility’s medication error policy defined a medication error as administration of a medication that is not currently prescribed or given at the wrong dose or time.
Failure to Implement Ordered Bed Rails and Fall-Prevention Measures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow fall-prevention measures, including timely installation of ordered bed rails, for a resident with severe cognitive impairment and a high fall risk. The resident was admitted with dementia, multiple rib fractures, a history of falls, and was documented as lacking capacity to understand and make decisions. The care plan identified confusion and decreased safety awareness related to dementia, with goals for the resident to remain free of falls and return to a previous level of activity. Interventions listed included cueing for safety and educating the resident and representative on proper ambulation and transfer techniques. Nursing documentation and the MDS showed the resident had multiple fall risk factors, including a history of falls in the last six months, disorientation/confusion, poor safety judgment, impaired balance, and a need for substantial/maximal assistance with toileting, bathing, and showering. On one date in February, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she had hit her left ribs and back and was experiencing pain, for which pain medication was given. A physician’s order for side rails with fall precautions was entered a few days later. A PT evaluation indicated the resident required moderate assistance to ambulate 10 feet with a two-wheeled walker. Subsequently, another change of condition note indicated the resident was found sitting on the floor near her doorway after attempting to get up without assistance. An IDT care conference note recorded that the resident had a recent fall resulting in a rib fracture, as well as another fall, and that the resident had decreased safety awareness and attempted to ambulate independently. During one of these incidents, a CNA placed the resident on a shower chair and briefly left to gather supplies, returning to find the resident on the floor. Interventions noted at that time included cueing for safety and placing bilateral mats at the bedside. Despite the physician’s order for bed rails and the resident’s repeated falls, interviews and record reviews showed that bed rails and other fall-prevention interventions were not implemented in a timely manner. A CNA stated the resident was dependent in ADLs, used a wheelchair, was considered a fall risk, and did not have bed rails installed until after the resident was admitted to the hospital. The CNA and LVN both indicated that residents at fall risk should have interventions such as low beds, floor mats, side rails, bed alarms, and frequent monitoring, and the LVN confirmed that the resident’s family member had repeatedly requested bed rails since the initial fall. The LVN reported witnessing the resident fall from the bed to the floor on a later date, noting that at that time the resident had no floor mats, bed rails, or bed alarm, and that no new interventions were implemented after that incident. The RN supervisor and DON both acknowledged that a physician’s order for bed rails with fall precautions existed, that bed rails should be installed without delay after assessment, order, and consent, and that no new interventions or physician orders were implemented following the resident’s subsequent falls. The maintenance director stated he was first informed to install the bed rails at a stand-up meeting in early March, and installed them that same day. The facility’s policies on Falls-Clinical Protocol and Bed Rails required staff and physicians to identify and implement interventions to prevent subsequent falls and address the risks of clinically significant consequences of falling, but these were not followed for this resident, who ultimately sustained a possible nondisplaced lateral malleolus fracture of uncertain chronicity and was transferred to a general acute care hospital.
Failure to Assess, Obtain Consent, and Timely Implement Physician-Ordered Bed Rails for a High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to complete required assessments, obtain informed consent, and timely implement physician-ordered bed rails for a resident identified as a high fall risk. The resident was admitted with dementia, multiple rib fractures, and a history of falls. A History & Physical dated 9/28/2025 documented that the resident lacked capacity to understand and make decisions. The care plan dated 1/13/2026 identified confusion and decreased safety awareness secondary to dementia, with goals for the resident to be free of falls and return to previous activity level, and interventions including cueing for safety and education on ambulation and transfer techniques. A nursing evaluation dated 2/12/2026 documented fall risk factors including a history of falls in the last six months, disorientation/confusion, poor safety judgment, and impaired balance. An MDS dated 2/20/2025 indicated severely impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and showering. On 2/20/2026, a change of condition note documented that the resident was found lying on her back at the end of the bed, reporting that she hit her left ribs and back, with pain rated 4/10 and pain medication administered. An order summary dated 2/23/2026 showed a physician’s order for side rails with fall precautions. Despite this order, a subsequent change of condition on 2/27/2026 recorded that the resident was found sitting on the floor near the doorway after attempting to get up without assistance. An IDT care conference note on 2/27/2026 documented that the resident had a recent fall on 2/20/2026 resulting in a rib fracture and another fall on 2/27/2026, and that the resident had decreased safety awareness and attempted to ambulate independently. On 3/1/2026, an x-ray of the left tibia and fibula showed a possible nondisplaced lateral malleolus fracture of uncertain chronicity. On 3/6/2026, surveyors observed bed rails present on both sides at the head of the bed, but no floor mats at the bedside, and the resident was reported to have been admitted to an acute care hospital. Staff interviews and record reviews showed that the facility did not follow its own process and policies for bed rail use. A CNA stated the resident was a fall risk and did not have bed rails installed until after hospital admission. An LVN reported that the resident’s family member had repeatedly requested bed rails since the initial fall on 2/20/2026, that staff had asked for the necessary paperwork, and that she did not know why bed rails were not installed after the 2/20/2026 fall or after the 2/23/2026 physician order. The LVN described the facility’s process as requiring a bed rail assessment, a physician’s order, and informed consent after education on risks, benefits, and alternatives, with immediate installation once consent and order were obtained, and physician notification if there was any delay; she confirmed these steps were not completed in a timely manner and could not explain the delay. The RN supervisor similarly stated that the process required a bed rail assessment, physician order, and consent prior to implementation, and that bed rails should be installed without delay and the physician notified of any delay, but could not explain why side rails were not installed until 3/2/2026. The DON stated the family had requested bed rails since the initial fall, that the resident was a fall risk due to dementia and prior falls, and that additional interventions such as a bed alarm and bed rails should have been implemented; she stated policy required a bed rail assessment, physician order, and consent, and that bed rails should be installed within 24 hours, but maintenance was not contacted until 3/2/2026. The maintenance director confirmed he first learned of the need for bed rails on 3/2/2026 and installed them that day. Review of facility policies on falls, restraints, and bed rails showed requirements for pre-restraint assessment, identification of interventions to prevent subsequent falls, and assessment-based decisions regarding bed rail use, which were not carried out for this resident prior to bed rail installation.
Failure to Develop Care Plan for Resident’s Refusal of Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop an individualized comprehensive care plan addressing a resident’s refusal of care and treatment. The resident was admitted with dementia and atrial fibrillation, and an MDS dated 1/5/2026 documented severely impaired cognition and a need for maximal assistance with toileting, bathing, and showering. Nursing documentation showed that on 11/15/2025 the resident refused to be showered, an IDT care conference note on 11/24/2025 recorded refusals of meals and medications, and a follow-up note on 12/26/2025 documented refusal of vital signs. Despite these documented refusals across multiple care areas, there was no corresponding care plan problem, goal, or interventions developed to address the resident’s refusal of care. During an interview and concurrent record review on 2/20/2026, an LVN confirmed that there was no care plan in place for the resident’s refusal of care and stated that such a care plan should have been developed so staff would be aware of the resident’s needs and know how to respond appropriately. The LVN also stated that a care plan addressing refusal of care was important because the lack of one could place the resident at risk for skin breakdown and that the care plan serves as a communication tool for staff. In a separate interview, the DON stated that when a resident refuses care, a care plan should be developed to guide staff in directing care. The facility’s written policy on comprehensive care plans indicated that each resident’s care plan is to incorporate identified problem areas and associated risk and contributing factors, with interventions designed after consideration of the relationship between the resident’s problem areas and their causes, which was not followed in this case.
Plan Of Correction
Corrective Action for Deficient Practice: On 2/25/26, the Director of Nursing (DON) developed the care plan for Resident 1 on refusal of care and treatment and included goals and interventions. Identification of Other Affected Residents: On 2/24/26, the DON conducted staff interviews to identify residents who had exhibited episodes of refusal of care. 8 residents were identified as having instances of refusal of care. On 2/25/26, the DON developed/updated a care plan for the identified residents to address the refusal of care. Systemic Changes: On 3/2/26, the DON initiated an in-service to licensed nurses on the policy and procedure titled "Care Plan Comprehensive" with a focus that each resident's care plan is designed to incorporate identified problem areas and incorporate risk and contributing factors associated with identified problems. Interventions in the care plans are designed in relationships between the residents' problem areas and their causes. Monday through Friday, during the Clinical Meeting, the clinical team (Director of Nursing, Director of Staff Development, Infection Preventionist, Director of Rehab, Social Service Director) will review Change of Conditions as well as the progress notes from the day prior to identify any episodes of refusal of care. The clinical team will conduct an audit of the resident's care plans for refusal of care. Negative findings will be corrected immediately. Monitor to Ensure Ongoing Compliance and Responsible Individuals:DON and/or designee will report findings of the care plan audits monthly x 3 months to QAA committee for further evaluation and recommendations.Compliance Date: 3/2/26
Failure to Revise Fall Risk Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s fall risk care plan after an actual fall and change in condition. The resident was admitted with diagnoses including multiple left rib fractures, dementia, and anxiety. A History and Physical dated 9/28/2025 documented that the resident did not have capacity to understand and make decisions. A Minimum Data Set dated 2/8/2026 showed moderately impaired cognition and a need for substantial/maximal assistance with ADLs such as toileting and bathing. A Change of Condition evaluation dated 1/11/2026 documented that the resident was found sitting on the floor next to her wheelchair, indicating an actual fall. The resident’s existing care plan, titled "Risk for Falls secondary to confusion/decreased safety awareness and history of falls," dated 1/13/2026, included general interventions such as determining the resident’s ability to transfer, educating the resident/representative on ambulation and transfer techniques, ensuring call light availability, evaluating the environment for fall risks, and notifying the provider and initiating neuro checks and bleeding evaluation if a fall occurred. An Interdisciplinary Care Conference note dated 1/16/2026 recorded that the resident had a fall on 1/11/2026 and continued to be at risk for falls due to cognitive changes and dementia, and it identified specific measures such as keeping the bed in the lowest position, providing a toileting schedule, providing a cup with holder to encourage fluids as the resident propelled herself in the wheelchair, and educating staff to adhere to the care plan. Despite these findings and discussions, the fall risk care plan dated 1/13/2026 was not revised to reflect that the resident had an actual fall on 1/11/2026 or to incorporate new or adjusted interventions following that event. The Infection Preventionist stated that the care plan should have been revised after the 1/11/2026 fall and acknowledged that it was not. The DON also confirmed that the resident had an actual fall on 1/11/2026, that the fall risk care plan had not been revised to reflect this incident, and that no new interventions were added after the fall. Subsequently, a Change of Condition report dated 2/20/2026 documented that the resident was found lying on her back on the floor in front of her bed, and a General Acute Care Hospital record for the same date indicated the resident was admitted after an unwitnessed fall that resulted in multiple fractures to the left ribs. The facility’s own care plan policy required individualized comprehensive care plans with measurable objectives and timeframes, developed and implemented by the IDT and revised based on identified needs from assessments.
Plan Of Correction
Corrective Action for Deficient Practice: On 2/23/26, the Director of Nursing (DON) revised Resident 1's care plan to reflect the resident's current physical and cognitive status. On 2/23/26, the DON revised the "At risk for fall" care plan for Resident 1. Identification of Other Affected Residents: On 3/2/26, the DON reviewed the care plans for 5 residents with recent falls. There were no other residents identified to have been affected by the alleged deficient practice. Systemic Changes: On 3/2/26 the DON initiated an in-service to licensed nurses on the policy and procedure titled "Care Plan Comprehensive" with a focus on developing an "individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs." In addition, care plan interventions should be designed after careful consideration between the problem and it's cause. Interventions should address the underlying source of the problem rather than addressing only the symptoms. Monday through Friday, during the Clinical Meeting, the clinical team will review Change of Conditions from the day prior to identify any incidents of fall. The clinical team (Director of Nursing, Director of Staff Development, Infection Preventionist, Director of Rehab, Social Service Director) will conduct an audit of each resident's care plan that both the "Actual Fall" and the at "Risk for Fall" care plan are present and reflective of the resident's current condition and needs. The audit will also verify that a new intervention has been added as appropriate to address the relationship between the resident's problem areas and the cause of the fall. Negative findings will be corrected immediately. Monitor to Ensure Ongoing Compliance and Responsible Individuals: DON and/or designee will report findings of the care plan audits monthly x 3 months to QAA committee for further evaluation and recommendations. Compliance Date: 3/2/26
Improper Mask Use During Influenza Outbreak
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control practices for mask use during an influenza outbreak. During an observation and interview on 1/30/2026 at 8:20 a.m., an LVN was seen administering medications while wearing a face mask positioned below her nose and did not adjust it to fully cover her nose during the medication pass. The LVN acknowledged that the mask was worn improperly and stated that it should fully cover both the nose and mouth during resident care, and that not wearing it properly could potentially expose residents to respiratory droplets and increase the risk of infection transmission. At 8:33 a.m. the same day, a CNA was observed wearing a face mask positioned below her nose, leaving her nose exposed. The CNA acknowledged that her mask was worn improperly and stated that wearing the mask below the nose could potentially expose residents to respiratory droplets and increase the risk of infection transmission if she entered a room or interacted with a resident, and confirmed that facility policy requires masks to fully cover both the nose and mouth while on duty. In interviews later that morning, the IP and DON both stated that all staff are required to wear PPE, including masks that fully cover the nose and mouth, while providing resident care, and that improper mask use increases the risk of influenza transmission. Review of the facility’s 2025 PPE policy for face masks indicated that masks must cover the nose and mouth while performing treatment or services for residents.
Failure to Provide Required Personal Fund Statements and Obtain Authorization Signatures
Penalty
Summary
The facility failed to properly manage and document a resident's personal funds by not providing the required monthly personal fund account statements and by failing to obtain the necessary authorization signatures. Record review showed that the resident, who had intact cognition and was able to make herself understood, did not receive periodic statements detailing deposits, withdrawals, and current balances. Additionally, the personal funds authorization form was incomplete, lacking both the resident's and the required staff witness signatures. Several personal fund withdrawal receipts were also missing witness signatures, and there was no documentation that the resident had been given her account statements as required by facility policy. During interviews, the resident reported that she had repeatedly requested her account statements and was dissatisfied with the facility's response, leading her to contact law enforcement. The Office Manager confirmed that the resident had the right to receive monthly and quarterly statements, especially given her cognitive status, but was unable to provide documentation that these statements had been provided or that proper authorization procedures had been followed. The facility's policy required that residents be presented with a copy of their ledger, sign for receipt, and have the signed copy placed in their trust folder, but this process was not followed for this resident.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of three sampled residents, resulting in both residents being unable to use their call lights to request assistance. For one resident with convulsions and muscle weakness, the call light was found wedged between the mattress and side rail, out of reach, causing the resident to yell for help and experience frustration due to difficulty moving and inability to reposition himself. The resident reported that this was a recurring issue and that he had to yell to get staff attention. A CNA confirmed that staff should have checked the call light's accessibility before leaving the room. Another resident, with diagnoses including fibromyalgia, back pain, and dementia, was observed sitting on the edge of her bed with her call light placed on a bedside table out of her reach. This resident also reported having to yell for assistance and expressed frustration both at her own inability to access the call light and at the frequent yelling from a neighbor, which disrupted her rest. The care plan for this resident specifically required the call light to be within reach due to her fall risk. Staff interviews confirmed that call lights should be accessible and that failure to do so could increase the risk of residents attempting to get up on their own.
Failure to Supervise Student Nurse Leads to Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed a cup containing multiple tablets to the student nurse, instructing the student to administer all the medications to a specific resident. The LVN did not accompany the student nurse to the resident's bedside and did not observe the administration of the medications. The student nurse administered the medications without verifying the resident's identity or reviewing the medications with the resident, and the LVN was not present to ensure the five rights of medication administration were followed. As a result of this lack of supervision and failure to follow established medication administration protocols, the resident received medications intended for another resident, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide. The resident did not receive his prescribed medications, which included Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The error was discovered after the resident exhibited symptoms, and it was reported that the resident's wife noticed something was wrong. The resident was subsequently transferred to a general acute care hospital for evaluation, where he underwent blood tests and radiological studies. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the LVN did not follow facility policy or professional standards, which require direct supervision of student nurses and verification of resident identity using at least two identifiers. The facility's consultant pharmacist also confirmed that the five rights of medication administration were not followed, and the LVN failed to supervise the student nurse during the medication pass. The facility's policies and job descriptions require licensed nurses to provide nursing services in accordance with professional standards and to verify resident identity before administering medications.
Failure to Supervise Student Nurse Results in Significant Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to provide direct supervision to a student nurse (SN) during a scheduled medication pass, resulting in a significant medication error. The LVN prepared medications at the medication cart and handed them to the student nurse, instructing the student to administer them to a resident identified only by bed assignment. The LVN did not accompany the student nurse to the resident's bedside or verify the resident's identity, and the student nurse administered the medications without confirming the resident's name or identity. As a result, the resident received another resident's medications, including Valsartan, multivitamin and minerals, Guaifenesin ER, Eliquis, Carvedilol, Keppra, and Magnesium Oxide, instead of their prescribed medications such as Glipizide, Metformin, Baclofen, vitamin D, Iron, Finasteride, and Lacosamide. The resident involved had a history of hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes, and was assessed as having moderate cognitive impairment. Following the medication error, the resident became unusually sleepy, had low blood pressure, and was unable to recall events from the day. The resident's responsible party noticed the change in condition and requested a blood pressure check, which revealed hypotension. The Director of Nursing (DON) was notified and assessed the resident, who was then transferred to a general acute care hospital for evaluation, where blood tests and radiological studies were performed to rule out adverse drug effects. Interviews with the student nurse, another student nurse, the LVN, and the DON confirmed that the LVN routinely failed to provide direct supervision during medication administration by student nurses and referred to residents by bed assignment rather than by name. The facility's policy required verification of resident identity and direct supervision of student nurses during medication administration, which was not followed. The failure to adhere to these protocols led to the resident receiving the wrong medications and being exposed to unnecessary medical interventions.
Failure to Notify Responsible Party After Medication Error
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident when there was a significant change in the resident's condition following a medication error. The resident, who had diagnoses including hemiplegia, hemiparesis, atrial fibrillation, and type 2 diabetes mellitus, was assessed as having moderate cognitive impairment and lacked capacity to make certain decisions. On the day of the incident, the resident was administered multiple medications that were not prescribed for him by a new nurse who did not verify his identity or review his medications with him. As a result, the resident became unusually sleepy and had low blood pressure, which was first noticed by his RP during a visit. Despite facility policy requiring immediate notification of the resident and responsible party in the event of a medication error or significant change of condition, the assigned LVN did not inform the RP after being instructed to do so by the DON. The LVN stated she was focused on monitoring the resident and forgot to call the RP. The RP only learned of the medication error when the DON entered the room later that day. Facility records and staff interviews confirmed that the required notification was not made in a timely manner, contrary to facility policy.
Resident Elopement Due to Inadequate Door Monitoring and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident who required minimal assistance with ambulation using a front wheel walker was able to exit the facility through an unsupervised, non-alarmed front door without staff knowledge. The facility did not have a system in place to monitor the front door after the receptionist left for the day, and the door could be freely opened from the inside, allowing residents to leave undetected. Staff were observed propping the front door open with a box of gloves to facilitate staff entry, leaving the entrance unsupervised and accessible to residents and unauthorized individuals. Multiple staff interviews confirmed that the front door was not consistently monitored, and there was no alarm system to alert staff if someone exited through it. The resident in question had a medical history including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. Despite being assessed as low risk for elopement due to an assumption of non-ambulatory status, therapy records and staff interviews indicated the resident was able to ambulate with minimal assistance using a walker. The resident was last seen in his room in the evening and was later found at a local restaurant approximately one mile away, after which he experienced shortness of breath, was transported to a hospital, and subsequently died from cardiac arrest. The inaccurate assessment of the resident's mobility and elopement risk, as well as the lack of appropriate interventions and monitoring, directly contributed to the resident's ability to leave the facility unnoticed. Additional observations revealed that staff did not respond promptly to exit door alarms, with alarms sounding for several minutes without investigation. Staff interviews indicated confusion about responsibilities for responding to alarms and a lack of clear procedures for monitoring exit doors, especially during times when the front lobby was unsupervised. The facility's policy required identification and care planning for residents at risk of elopement, but this was not followed in the case of the resident who eloped. The combination of inadequate assessment, lack of monitoring systems, and failure to respond to alarms resulted in a serious lapse in resident safety.
Removal Plan
- The Elopement Evaluation for active residents was completed by the Director of Staff Development (DSD), Infection Prevention Nurse (IPN) and Case Manager (CM). Residents identified to be at risk for elopement. The Elopement Evaluation will be completed upon admission, readmission, quarterly, annually, and as needed by the Minimum Data Set Nurse (MDSN)/ Designee. Upon completion of elopement evaluation by the licensed nurse, the Director of Nursing (DON)/Designee will review for accuracy. Resident centered care plans with emphasis on elopement interventions will be reviewed, updated, and completed to ensure resident safety upon completion of the Elopement Evaluation. After completion of Elopement Evaluation, the Licensed Nurse will initiate interventions/measures such as one to one (1:1) monitoring, sitter, hourly rounding, place resident in a supervised area when in wheelchair, re-route resident when attempting to seek exit, engage resident in activities of choice.
- The care plan for residents identified to be at risk for elopement was reviewed and updated by DON/Designee. The care plan interventions included measures such as: hourly rounding, placed in supervised area, redirection / rerouting. Residents placed on 1:1 monitoring for 24 hours and will be evaluated by the Interdisciplinary Team (IDT) for continuation or discontinuation. Residents in the same room were placed on a sitter for 24 hours and will be evaluated by the IDT for continuation/discontinuation.
- The IDT initiated a care plan meeting for residents identified to be at risk for elopement with a follow up call to the resident's representative by the IP Nurse.
- The Maintenance Director checked facility egress doors and tested all audible door alarms for functionality. There were no negative findings identified in all exit doors. Egress tests and checks will be maintained daily for four weeks then weekly thereafter by the Maintenance Director. Exit Door Audit logs will be completed by Maintenance Director /Designee daily. The Administrator will perform validation rounds on door and alarm testing once a week. If the alarm is not working, maintenance will be notified via TELS, Maintenance department will fix and if more time needed, a staff member will be assigned to monitor door until it is fully operational. If a resident is observed attempting to leave using the egress door, staff will redirect and prevent the resident from leaving and notify the Licensed Nurses for further action / interventions.
- The DON/Designee initiated skills competency to licensed nurses on resident admission and elopement with emphasis on identifying risks, prevention, interventions, and door security procedures to ensure all exit doors are attended and checked for resident safety. The DSD/Designee initiated in-service training to Certified Nursing Assistant (CNA) on elopement policy with emphasis on prevention, interventions, monitoring of all exit doors and alarm system, identification of elopement risk residents, location of elopement binders and pink wristbands as elopement identifier. Staff training provided by the DSD/Designee on monitoring all exit doors and ensuring all exit doors are secured and alarm in place. Staff training with emphasis on ensuring all exit doors are secured and an alarm in place: a. The front door will be unlatched, and the alarm will be turned off by the receptionist on duty to allow entrance and exit of facility staff and visitors. b. The front door activity will be monitored by the receptionist on duty. c. The receptionist, before leaving for the day, will inform the licensed nurse to ensure continuity of monitoring of the front door. The licensed nurse will ensure the front door is fully latched, and the alarm is turned on. d. An assigned staff from 3p.m. to 11 p.m., and 11-7 p.m., will monitor the exit doors. The DSD/Designee is responsible for preparing the daily assignment for checking the exit doors that are latched and alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of all doors and alarms as assigned hourly. e. Any licensed nurse on leave will receive training on their next scheduled workday prior to their shift.
- The DON/Regional Clinical Resource initiated an in-service to the nursing staff regarding the updated resident elopement binder which is located at each nurse's station and reception area that has the following information: a. List of residents that are elopement risk b. Guide for staff on steps to take in case of elopement: Refer to Elopement Policy included in the binder as well as the list of the local police and fire department, and nearby acute hospitals in the area. c. Each resident packet includes demographic information which includes a copy of the resident's latest photograph, face sheet, elopement risk identification, most recent elopement evaluation, and updated elopement care plan.
- The DON/Designee is responsible for updating the content of the Elopement Binder for any newly identified and or changes in resident elopement evaluation and plan of care. Any new information, updates or changes with the list of residents in the Elopement Binder will be communicated by the DON / Designee with the nursing staff during the shift huddle and Point Click Care Communication Home Page. A pink wristband will be applied to a resident by the DON/Designee and to be worn by a resident determined to be an elopement risk based on evaluation. The pink wristband will include the resident name, date of birth identification, facility address, and telephone number. The department managers will check out the resident pink wristband during the daily Patient Centered Rounds to ensure wristbands are in place and worn per plan of care. Registered Nurse (RN) Supervisors responsible for checking the wristbands on weekends. If pink wristbands are not in place, Department Managers will notify the DON/Designee for replacement. On weekends, the Registered Nurse Supervisor (RNS) will replace the pink wristbands which are available at Station 1.
- The Medical Director was informed by DON regarding the incident. No new orders were given.
- The Elopement Binder was reviewed and updated by the DSD/Designee and placed at each nursing station and the reception area.
- The DSD/Designee placed pink wristbands to residents as an elopement identifier.
- The Maintenance Director initiated daily checks on all exit doors to ensure they were properly latched and alarms functioning.
- Nursing staff from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., shifts. The DSD/ Designee is responsible for preparing the daily assignment for checking the egress doors and alarms of exit doors and if properly latched with alarms on. An exit door and alarm monitoring log will be completed by the assigned Nursing staff to document the checking of exit doors as assigned hourly.
- The facility installed an alarm on the front lobby door, with a key in a red key holder located inside the reception area.
- The receptionist hours were increased, with the expectation to monitor the front door lobby for residents leaving or attempting to leave unattended. In case of receptionist is not available during break, another staff will cover to ensure continuity of monitoring is in place.
- The Administrator and Regional Nurse Consultant provided 1:1 in service training to RNS 1 and reviewed elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures. Inservice and education with the licensed nurses was also initiated regarding accurate assessment and elopement policy with emphasis on accurate assessment of a resident determined to be at risk for elopement which includes reviewing records from GACH, initiating care plan interventions to maintain resident safety and facility's elopement policy and procedures.
- The Administrator will report findings to the Quality Assurance and Performance Improvement (QAPI) Committee on the outcome of resident elopement evaluation and system implementation status update for review and further action as needed.
- The facility's policies and procedures regarding elopement and wandering residents were reviewed by IDT. Interventions such as 1:1 monitoring, providing a sitter, and hourly safety checks as needed.
- The facility revised its facility's new admission decision tree to include questions about history and frequency of wandering and elopement prior to resident admission to the facility. The admissions coordinator will inquire about additional information regarding elopement, history of wandering- and will be discussed with the team: Administrator, DON, and Social Service Director (SSD). DON will audit new admissions daily.
- DSD/Designee will train new hires in wandering, elopement, and resident safety procedures during orientation.
- All findings will be discussed at the monthly Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of three months or until the pattern of compliance is maintained.
Failure to Timely Initiate Admission Orders for New Admission
Penalty
Summary
The facility failed to ensure that admission orders were entered and implemented in a timely manner for a newly admitted resident with multiple serious medical conditions, including acute myocardial infarction, coronary angioplasty implant and graft, heart failure, COPD, and psychosis. Upon arrival at approximately 9:00 p.m., the resident was not acknowledged or assessed by licensed staff for over two hours. The assigned LVN was unaware of the resident's admission until discovering the individual in bed during rounds at approximately 11:30 p.m. No admission packet or hospital orders were available or processed during this time, and no admission orders were entered into the electronic system. Interviews with staff revealed that admissions frequently occurred during shifts without an RN supervisor present, contributing to lapses in the admission process. The facility's policy required immediate initiation of admission orders and assessment upon a resident's arrival, including reconciliation of medications and communication with the attending physician. The administrator confirmed that the expectation was for admission orders to be initiated within 30 minutes of arrival and acknowledged that this protocol was not followed in this instance.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's risk for elopement. A review of the resident's physical therapy assessment indicated the resident was alert and able to ambulate with a front-wheeled walker, though with a slow gait and complaints of fatigue. The resident's medical history included acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis. The joint mobility screening showed full range of motion in all extremities. However, the elopement risk assessment documented that the resident could not walk or self-propel a wheelchair independently. Interviews with the Physical Therapy Director confirmed the resident could walk to the bathroom with minimal assistance but required frequent safety cues due to impulsivity. The Registered Nurse Supervisor, who completed the elopement risk assessment, based her assessment on limited observation and the resident's selective responsiveness, concluding the resident was non-ambulatory. The nurse later acknowledged the assessment was inaccurate and that the resident was at high risk for elopement. The facility's policy required comprehensive assessment upon admission to inform care planning, but this was not followed, resulting in the failure to identify and address the resident's elopement risk.
Failure to Timely Administer Admission Medications Due to Order Processing Delay
Penalty
Summary
The facility failed to ensure that a newly admitted resident received timely and appropriate medication administration upon admission. The resident, who was admitted with multiple serious medical conditions including acute myocardial infarction, coronary angioplasty, heart failure, COPD, and psychosis, had physician orders for eight prescribed medications to address these conditions. Upon arrival, the Licensed Vocational Nurse (LVN) on duty was unable to locate the resident's admission packet containing hospital orders and did not enter any of the resident's medications into the electronic system. As a result, the resident's medication orders were not processed or administered as required. The delay in entering and processing the medication orders was confirmed by the Registered Nurse Supervisor (RNS), who began entering the orders the following day, and by the facility Administrator, who acknowledged that medications should be ordered immediately upon a resident's arrival. Review of the facility's policy indicated that medications are to be ordered and received from the pharmacy on a timely basis, with accurate records maintained. The failure to follow this policy resulted in a delay in administering essential medications for the resident's serious medical conditions.
Failure to Maintain Ongoing QAPI Program and Documentation
Penalty
Summary
The facility failed to maintain and implement an ongoing Quality Assurance and Performance Improvement (QAPI) program as required. Documentation and evidence of QAPI activities, committee meetings, or performance improvement projects were not available for review since 07/17/2025. The last recorded meeting of the Quality Assurance (QA) committee was on that date, and no subsequent meetings or activities were documented. During an interview, the Administrator confirmed that the QA committee was expected to meet monthly to review concerns, discuss current issues, and revise care plans as needed, but acknowledged that no meetings had occurred since the last documented date. A review of the facility's QAPI policy and procedure indicated that the facility was required to develop, implement, and maintain an ongoing, facility-wide QAPI plan, with the QA committee meeting monthly to monitor and evaluate the quality and safety of resident care. The policy outlined objectives such as identifying and resolving negative outcomes, correcting deficiencies, and maintaining documentation of QAPI activities. The lack of ongoing QAPI activities and documentation demonstrated noncompliance with the facility's own policy and regulatory requirements.
Failure to Prevent Burn Injury Due to Unauthorized Appliance
Penalty
Summary
A resident with paraplegia and generalized muscle weakness sustained a second-degree burn to the left thigh after using an unauthorized egg cooker in their room. The resident, who was cognitively intact and required partial to moderate assistance with activities of daily living, reported burning themselves while cooking eggs. The burn was not immediately reported to staff, and the resident waited several days before seeking treatment, at which point a partial thickness wound was identified and treated per physician order. Facility staff, including an LVN, DON, and Administrator, were aware at various times that the resident possessed an egg cooker in their room. The LVN observed the egg cooker during routine care but did not report its presence until after the burn occurred. The DON believed the egg cooker had been removed but did not verify this, and the Administrator instructed the resident not to keep the appliance but did not confirm its removal due to the resident's behavior and concealment of the device. No staff member assessed the egg cooker for safety, provided written approval for its use, or ensured the resident received instruction on safe operation of the appliance. The facility failed to follow its own policy and procedure regarding electrical appliances, which required written authorization and safety checks for any such devices in resident living areas. The policy specifically prohibited residents from maintaining heating or cooking devices in their rooms unless approved in writing by the Administrator or designee. The lack of enforcement and oversight of this policy directly contributed to the resident's injury.
Resident Exposed During Post-Shower Transfer
Penalty
Summary
A resident with a diagnosis of generalized weakness, who required partial to moderate assistance with showering and toilet hygiene, was observed being transported by a CNA in a shower chair from the shower room to his bedroom. During this transfer, the resident had a bath towel covering the front of his body, but his uncovered buttocks was visible and hanging through the shower chair as they moved through the hallway. The CNA stated he usually wrapped a towel around the resident's entire body but was unaware that the resident's buttocks was exposed during this instance. The resident later reported feeling something cold on his buttocks and realized it was uncovered, expressing concern and embarrassment about the possibility of being seen. The DON confirmed that the resident should have been fully covered after the shower to prevent exposure. Facility policy requires staff to promote and protect residents' privacy, including bodily privacy during personal care, but this was not followed in this instance.
Failure to Separate and Supervise Residents After Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by not separating, supervising, or monitoring after an incident involving another resident with a known history of delusions, severe cognitive impairment, and behavioral disturbances. The resident with dementia and major depressive disorder had a documented pattern of wandering, invading others' personal spaces, and exhibiting both verbal and physical aggression. On the evening in question, this resident entered her roommate's space, yelled, and struck her multiple times on the leg with a water bottle. The affected resident reported feeling unsafe and fearful, and stated that previous complaints to staff about similar behaviors had not resulted in any action. Despite being informed of the incident, the CNA and LVN who responded did not remove the aggressive resident from the shared room or provide additional supervision. The LVN did not consider the event to be abuse since there were no visible injuries, and left the residents unsupervised together after the incident. Other residents in the room also expressed fear and concern about the aggressive resident's behavior, noting a pattern of wandering and intruding into their spaces. The responsible party for the affected resident called the police due to concerns about the facility's lack of response. Interviews with facility leadership confirmed that the facility's policy requires immediate separation and supervision following allegations of abuse, but this was not followed. The DON and Administrator both acknowledged that the aggressive resident should have been moved and provided with one-on-one supervision after the incident. The facility's own policies and procedures, as well as federal and state regulations, guarantee residents' rights to be free from abuse and to be treated with dignity and respect, which were not upheld in this situation.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within the required two-hour timeframe after an incident involving two residents. One resident, who had severe cognitive impairment, a history of delusions, and physical and verbal behaviors directed toward others, reportedly approached her roommate, yelled at her, threw water, and struck her with a water bottle multiple times while the roommate was in bed. The incident was witnessed by a CNA, who heard yelling and observed the resident standing close to the roommate, with a water pitcher on the ground nearby. Despite these observations and the roommate's report of being hit, the CNA did not report the incident, believing no one was hurt and assuming the administrator was already aware of ongoing issues between the two residents. The roommate, who was the victim in this incident, stated that she had previously informed nursing staff about repeated invasions of her personal space and taking of her belongings by her roommate, but no action had been taken. On the night of the incident, she used her call light and yelled for help, but no staff responded. She also contacted her responsible party, who, upon hearing the commotion over the phone, called the police for a wellness check. The police report confirmed the details of the incident, including the physical altercation and the lack of immediate staff intervention. The Director of Nursing (DON) only became aware of the incident the following day during a staff huddle and confirmed that the incident should have been reported immediately to the administrator, police, Ombudsman, and CDPH. The administrator was present in the building at the time of the incident but was not informed until the next day. The facility's policy required reporting all allegations of abuse within two hours, but this protocol was not followed, resulting in a delay in notifying authorities and initiating an investigation.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable goals and interventions for a resident with severe cognitive impairment, a history of delusions, and behavioral symptoms such as wandering, hitting, threatening, and screaming. The resident was known to enter roommates' personal living spaces, take their belongings, and display aggressive behaviors, but the care plan only addressed the risk of elopement and did not include interventions specific to these behaviors. Multiple incidents were reported where the resident invaded the personal space of roommates, leading to feelings of violation, anxiety, and, in one case, an allegation of bodily harm when the resident hit a roommate with a water bottle. Interviews and record reviews revealed that staff and administration were aware of the resident's behaviors but did not update the care plan to address the specific risks posed to other residents. Roommates and their responsible parties reported these incidents to staff and administration, but no effective measures were taken to prevent recurrence. Staff members described difficulty redirecting the resident and noted that the behaviors persisted over time, affecting multiple roommates and requiring intervention from more than one staff member on several occasions. The facility's own policy required the interdisciplinary team to develop and revise care plans as residents' conditions changed, including the implementation of person-centered interventions with measurable objectives. However, the care plan for this resident was not revised to address the ongoing behavioral issues, resulting in repeated incidents where the resident's actions negatively impacted the safety and well-being of other residents.
Failure to Timely Release Medical Records Upon Written Request
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon written request, violating the resident's right to access their own records. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and muscle weakness, had a record release request submitted by a law office on their behalf. The Medical Record Director (MRD) received the request and forwarded it to the facility's legal department, but did not release the records, believing she had additional time to fulfill the request. The MRD was still waiting for the nursing department to complete their section of the records and had not yet provided the requested documents. Interviews with facility staff revealed a lack of clear policy and procedure regarding the timeframe for releasing medical records. The Administrator and Director of Nursing (DON) both acknowledged that there was no specific policy guiding the release of records or the associated costs, and were unaware of the delay until it was brought to their attention by surveyors. The DON also indicated that requests for records typically go through the front office and administration, and he was not informed of the request until the day of the survey.
Failure to Monitor and Maintain Resident Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and maintain the temperature of the resident refrigerator containing personal food items, as required by its policy and procedure. Review of the Resident Refrigerator Temperature Log showed that temperature checks were not documented on multiple days throughout the month. During an observation, the refrigerator thermometer was found to read 60 degrees Fahrenheit, significantly above the policy requirement of 41 degrees Fahrenheit or below. The refrigerator contained various food items, including a carton of eggs without resident identification, cake, and other bagged or sealed foods. Interviews with staff revealed that the charge nurse responsible for checking the refrigerator had forgotten to do so and was unsure of the appropriate temperature standard. The DON confirmed the elevated temperature and that the food items were present in the refrigerator at the time of the check. The facility's policy specified that refrigerator temperatures should be checked daily when first opening and closing in the evening, and that refrigerators should be maintained in good working condition.
Failure to Notify Physician of Delayed Medication Administration
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) administered a resident's scheduled 9 a.m. medications at 12:08 p.m., resulting in a delay of over three hours. The LVN did not notify the resident's physician about the late administration, despite facility policy requiring immediate consultation with the physician when there is a significant need to alter treatment. The LVN acknowledged that medications should be administered as ordered due to their time-sensitive nature and admitted that the physician should have been informed of the delay, as the resident might require further treatment or monitoring. The resident involved had multiple complex medical conditions, including hemiplegia, hemiparesis, diabetes, hypertension, a history of cerebrovascular accident (CVA), and was at risk for cardiovascular complications, hypo/hyperglycemia, and bleeding due to anticoagulant therapy. The resident's care plans specifically required medications to be administered as ordered, with monitoring for effectiveness and side effects, and prompt reporting of abnormalities to the physician. The medications delayed included those for stroke prophylaxis, diabetes management, hypertension, and supplements. During interviews, the LVN explained that the delay was due to being occupied with other residents' needs, and confirmed that no notification was made to the physician regarding the late administration. The Director of Nursing (DON) stated that in cases of late medication administration, the nurse should complete a change in condition report, update the care plan, monitor the resident, and notify both the physician and the resident's family. Review of facility policy confirmed the requirement for immediate physician notification when treatment is significantly altered.
Late Medication Administration by LVN
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) administered ten medications to a resident three hours after the scheduled 9 a.m. administration time, with the medications being given at 12:08 p.m. The medications included treatments for diabetes, hypertension, stroke prophylaxis, and supplements, all of which were ordered to be administered at specific times according to the resident's physician orders and care plans. The LVN stated the delay was due to being occupied with other residents' needs, including addressing family concerns and managing a gastrostomy tube for another resident. The resident involved had a medical history of hemiplegia, hemiparesis, diabetes, hypertension, hyperlipidemia, congestive heart failure, and a history of cardiac arrest and stroke. The resident was cognitively intact but dependent on staff for activities of daily living. The care plans for this resident specifically required timely administration of medications to manage risks related to blood pressure, blood sugar, and anticoagulant therapy, with interventions including administering medications as ordered and monitoring for side effects. Facility policy and the LVN's job description both required medications to be administered within one hour of the prescribed time unless otherwise specified. The Director of Nursing confirmed that late administration should be documented, and the physician and family should be notified. However, in this instance, the medications were administered late without adherence to these protocols, resulting in a failure to meet the pharmaceutical service needs of the resident as required.
Non-Functioning Doorbell Delays Resident Re-Entry
Penalty
Summary
The facility failed to ensure that one of three doorbells, specifically at hallway 2's entrance, was functioning properly. This deficiency was identified when a resident, who had diagnoses including hypertension and congestive heart failure and was cognitively intact, returned from an appointment and attempted to use the doorbell to gain entry. The doorbell did not work, resulting in the resident having to knock several times and wait several minutes outside before staff heard and let her in. The resident expressed frustration about the wait and the non-functioning doorbell. Multiple staff members, including an LVN, the Registered Nurse Supervisor, the Maintenance Director, and the Director of Nursing, confirmed through observation and interviews that the doorbell was not working and acknowledged its importance for resident access. The Maintenance Director was unaware of the doorbell's existence prior to the incident. Review of facility policy indicated that the maintenance department is responsible for keeping equipment in safe and operable condition at all times.
Failure to Develop Care Plans for Residents with Indwelling Urinary Catheters
Penalty
Summary
The facility failed to develop and implement care plans with specific interventions for two residents who had indwelling urinary catheters in place. For both residents, medical records and physician orders documented the presence of indwelling urinary catheters, including details such as catheter size, reason for use, and instructions for changing the catheter and drainage bag. However, a review of their care plans revealed no documentation or individualized plans addressing the care and monitoring of the catheters. This omission meant that care needs related to catheter use, such as monitoring for infection, displacement, or blockage, were not formally identified or documented in the residents' care plans. Interviews with facility staff, including an LVN and the DON, confirmed that care plans should have been created to guide staff in monitoring, documenting, and reporting any signs of infection or complications associated with catheter use. The facility's own policy required comprehensive care plans with measurable objectives and timetables to address each resident's needs, but this was not followed for the two residents with indwelling catheters. As a result, the care needs related to the use of these catheters were unknown and undocumented.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Reposition Resident with Pressure Ulcer as Ordered
Penalty
Summary
A resident with a history of cervical spine fracture, quadriplegia, and a sacral pressure ulcer was not turned or repositioned for approximately five hours, contrary to physician orders and the resident's care plan, which required repositioning every two hours. Documentation for turning and repositioning during the overnight shift was missing, and a CNA reported not providing this care after midnight, citing the resident being asleep and claiming the resident always refused to be turned. However, another CNA stated the resident never refused repositioning and was always willing to participate in care. The facility's policies required regular repositioning for immobile residents to prevent skin breakdown and maintain skin integrity. The Director of Nursing confirmed that turning and repositioning are essential for both comfort and assessment of skin condition, and that care should have been provided and documented. The lack of adherence to the care plan and physician's orders resulted in the resident not receiving necessary care to prevent complications related to pressure injuries.
Lack of Documented QAPI/QAA Process
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or a described process outlining how QAPI and QAA activities are to be carried out within the facility.
Failure to Accommodate Resident's Gender Preference for Personal Care Staff
Penalty
Summary
The facility failed to accommodate a resident's request to have only female staff provide personal hygiene care. The resident, who was admitted with orthopedic aftercare needs, abnormalities of gait and mobility, muscle weakness, and a stage 3 pressure ulcer in the sacral region, had intact cognitive skills and required substantial assistance with toileting hygiene and showering. The resident's family member communicated the preference for female caregivers for personal hygiene tasks. Despite this request, a review of assignment sheets showed that male CNAs were assigned to the resident on several occasions. Staff interviews confirmed that the resident's preference was not consistently honored. The facility's policy stated that residents' preferences would be accommodated to the extent possible, but this was not followed in practice for this resident.
Failure to Provide Toileting Hygiene Assistance Every Shift
Penalty
Summary
A deficiency occurred when a resident who was admitted with orthopedic aftercare needs, mobility issues, muscle weakness, and a stage 3 pressure ulcer in the sacral region did not receive assistance with toileting hygiene at least every shift and as needed. The resident's Minimum Data Set indicated intact cognitive skills and a requirement for substantial assistance with toileting hygiene and showering. Documentation reviewed by a registered nurse showed that toileting hygiene was not provided on all three shifts on multiple days, and on one specific day, the resident received assistance on only one shift instead of the required three. A family member reported that the resident was left in soiled disposable underwear without personal care until the afternoon on a particular day. Both the registered nurse and the Director of Nursing confirmed that facility policy and standard practice require toileting hygiene to be provided every shift and as needed. The facility's policy on supporting activities of daily living also states that residents unable to perform these tasks should receive necessary services to maintain good grooming and personal hygiene.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
A deficiency was identified when a resident with multiple fractures of the pelvis, orthopedic aftercare, and heart failure did not receive Restorative Nursing Assistance (RNA) services as ordered by the physician. The resident's Minimum Data Set indicated intact cognitive skills and independence in all activities of daily living. Physician orders specified that the resident was to receive active assisted and active range of motion exercises to the right lower extremity and bilateral upper extremities every day, three times a week or as tolerated. Record review and staff interviews confirmed that the resident did not receive the ordered RNA services during the months reviewed. The Registered Nurse acknowledged that the restorative services were not provided as ordered, and the Director of Nursing stated that all residents should receive RNA services as ordered, with refusals documented and addressed. The facility's policy required that residents receive restorative nursing services as needed to promote optimal safety and independence.
Lack of Documented Foley Catheter Care and Urine Monitoring
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular bladder dysfunction and previous urinary tract infections was admitted with a Foley catheter. Review of the resident's admission record and Minimum Data Set indicated the resident required substantial assistance with toileting hygiene. However, there was no documentation in the medical record of Foley catheter care being provided or of monitoring the urine for signs and symptoms of infection. During interviews, the treatment nurse confirmed the absence of documentation regarding Foley care and urine monitoring. The Director of Nursing also stated that residents with Foley catheters should receive catheter care and have their urine assessed every shift for infection indicators. Facility policies reviewed indicated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene, but there was no evidence these services were documented or provided in this case.
Failure to Provide Timely and Appropriate Meals to Residents
Penalty
Summary
The facility failed to provide scheduled meals and requested alternatives to two out of three sampled residents, resulting in missed or delayed meals. One resident, admitted with orthopedic aftercare, muscle weakness, and a stage 3 pressure ulcer, required set-up assistance for eating and had a regular diet order with a large portion of protein for breakfast. This resident did not receive a requested alternative sandwich after disliking the breakfast meal and ultimately received the sandwich much later than the scheduled mealtime. Another resident, admitted with multiple fractures and heart failure, was independent in eating and had a regular diet order with the option for double portions upon request. Record reviews and staff interviews confirmed that both residents did not consistently receive three meals per day as required, and that meals were not always provided within the facility's policy timeframe of 45 minutes from request or scheduled mealtime. The DON acknowledged that all residents should receive their scheduled meals, and documentation showed that the deficiency occurred over a period of time, affecting the residents' access to timely and appropriate nutrition.
Failure to Assess and Monitor G-Tube Placement in Resident with Known Risk Behaviors
Penalty
Summary
A deficiency occurred when nursing staff failed to assess and check the placement of a resident's gastrostomy (G-tube) as required by facility policy. The resident, who had diagnoses including Alzheimer's disease, severe protein calorie malnutrition, anorexia, and was fully dependent on staff for all activities of daily living, had a history of agitation and repeatedly attempting to pull out her G-tube. Despite these known behaviors and the facility's policy requiring G-tube site assessment every four hours and at the start of each shift, staff did not perform the required checks. On the morning in question, both the LVN and RN on duty did not assess the G-tube site at the start of their shifts, citing that the resident was sleeping and the abdominal binder was in place. The LVN only became aware of the dislodged G-tube after being notified by a CNA, who discovered the issue when the resident complained of stomach pain. The delay in assessment meant it was unclear how long the G-tube had been dislodged, and the resident required an emergency room visit for reinsertion of the tube. Interviews with staff and the resident's responsible party confirmed that the resident had a known pattern of pulling at her G-tube and that the responsible party had previously requested increased monitoring. The facility's policy on enteral feedings clearly stated the need for frequent assessment of the G-tube site, but this was not followed, resulting in a delay in care and the resident experiencing discomfort and pain during the reinsertion procedure.
Medication Error: Double Dosing of Temazepam Due to Failure to Follow Verification Protocol
Penalty
Summary
A medication error occurred when a resident with chronic kidney disease stage 3, hypertension, and muscle weakness received two doses of temazepam 15 mg within a short interval, contrary to the prescriber's order of one capsule by mouth every 24 hours as needed for insomnia. The resident's Minimum Data Set indicated intact cognition and a need for partial to moderate assistance with activities of daily living. The error took place when one nurse administered temazepam to the resident after a complaint of insomnia, and a second nurse, a few hours later, also administered the same medication after the resident again reported difficulty sleeping. The second nurse relied on the resident's statement that no sleep medication had been given previously and proceeded to administer the dose, only discovering the error when the electronic charting system (Point Click Care) alerted her that the previous dose had been given too recently. Facility policy required nurses to check the electronic charting system before administering controlled medications to ensure correct timing and prevent errors. Both the second nurse and the Director of Nursing confirmed that the correct process was not followed, as the medication was administered and documented on the controlled drug record before verifying in the electronic system, resulting in the resident receiving two doses within a two-hour and twenty-four-minute interval.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
Facility staff failed to accurately document the administration of temazepam 15 mg for one resident. Specifically, a Licensed Vocational Nurse (LVN) administered temazepam to the resident after the resident complained of an inability to sleep, but the LVN recorded the date of administration incorrectly on the Controlled Drug Record (CDR), entering the previous day's date instead of the actual date the medication was given. This error was identified during a review of records and confirmed in an interview with the LVN, who acknowledged the importance of accurate documentation to prevent confusion for subsequent staff. The resident involved had been admitted with chronic kidney disease stage 3, essential hypertension, and muscle weakness. The Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact and that they required partial to moderate assistance with certain activities of daily living. The medication order for temazepam specified administration as needed for insomnia, with a start date documented in the resident's Order Summary Report. Facility policy and procedure for controlled medications required that the licensed nurse immediately document the date and time of administration, the amount administered, and provide their signature on the accountability record at the time the medication is removed from supply. The nurse was also required to initial the Medication Administration Record (MAR) after administration. The failure to document the correct date on the CDR was contrary to these established procedures.
Failure to Implement 1:1 Sitter for Resident with Wandering Behavior
Penalty
Summary
The facility failed to implement a care plan for a resident with a history of wandering and behavioral issues, which included the provision of a one-to-one (1:1) sitter. This deficiency resulted in the resident entering another resident's room without consent and attempting to take a cell phone. The resident in question had been admitted with diagnoses including schizophrenia, a mood disorder, and an anxiety disorder, and was noted to have moderate cognitive impairment and a history of delusions and physical and verbal behaviors directed toward others. The care plan, dated over a year prior, specified the need for a 1:1 sitter to ensure the resident's safety and prevent intrusion into other residents' privacy. Despite the care plan and a physician's order for a 1:1 sitter, the facility did not ensure that this intervention was consistently implemented. On the day of the incident, the Director of Nursing (DON) responded to a call for help and found the resident in another resident's room, which was against the care plan's directives. The DON acknowledged that the resident should have had a 1:1 sitter at all times, but upon reviewing the staff assignment sheet, could not determine who was assigned as the sitter for the resident at the time of the incident. This lack of implementation of the care plan led to a breach of another resident's privacy and caused distress to the affected resident.
Inadequate Supervision Leads to Resident Privacy Violation
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of wandering and behavioral issues, resulting in an incident where the resident entered another resident's room without consent. The resident, who had diagnoses including schizophrenia, mood disorder, and anxiety disorder, was supposed to be under constant supervision by a 1:1 sitter as per their care plan and physician's orders. However, on the day of the incident, the resident was able to enter another resident's room and attempted to take a cell phone, causing distress to the resident whose privacy was invaded. The Director of Nursing confirmed that the resident should have been supervised at all times, as indicated in the care plan and physician's orders. However, upon reviewing the staff assignment sheet, the Director could not determine who was assigned as the sitter for the resident at the time of the incident. This lack of supervision and failure to adhere to the care plan and physician's orders led to the violation of the other resident's privacy and safety, as outlined in the facility's policy and procedure for resident safety.
Facility Fails to Provide Homelike Environment for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents, resulting in a deficiency. Resident 16 experienced multiple issues, including a non-functioning call light, a missing cord for the overhead light, and a TV remote control with only one battery. These deficiencies were observed during a room inspection and confirmed through interviews with Resident 16, who expressed frustration over these issues. Resident 16 required substantial assistance with daily activities due to fractures and muscle weakness, making the functionality of these items crucial for their comfort and safety. Resident 51 faced difficulties with the overhead light cord, which was too short for them to reach. This issue arose after the room was painted, and Resident 51 had to rely on staff assistance to operate the light, causing frustration. Resident 51 had moderate cognitive impairment and used a wheelchair, highlighting the importance of accessible lighting for their independence and safety. During a Resident Council Meeting, Resident 51 expressed their dissatisfaction with the situation. Resident 65 encountered problems with a malfunctioning overbed table and a TV remote without batteries. Despite informing the staff upon arrival, these issues persisted, affecting Resident 65's ability to use the TV and the overbed table effectively. Resident 65 was dependent on assistance for daily activities due to muscle weakness and a history of falling. Interviews with staff, including a CNA, LVN, and the Director of Nursing, confirmed the deficiencies and acknowledged the impact on the residents' quality of life, emphasizing the need for a homelike environment.
Inaccurate PASARR Documentation for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate documentation of the Preadmission Screening and Resident Review (PASARR) for five residents, which is a federal requirement to prevent inappropriate placement in nursing homes. The deficiency was identified during a review of the records and interviews with staff. The Registered Nurse Supervisor (RNS) acknowledged that the PASARR Level I screenings for these residents were either inaccurately documented or not completed as required. For instance, Resident 5 had a positive Level I screening indicating the need for a Level II evaluation, which was not conducted. Similarly, Resident 12's PASARR Level I screening inaccurately indicated no mental illness despite a diagnosis of psychosis. The deficiency involved residents with various mental health diagnoses, including major depressive disorder, PTSD, psychosis, schizophrenia, and schizoaffective disorder. These residents were on psychotropic medications, highlighting the need for accurate PASARR documentation to ensure they receive appropriate care and services. The RNS admitted to not reviewing the PASARRs upon admission, which contributed to the oversight. The Director of Nursing (DON) emphasized the importance of accurate PASARR documentation to ensure residents are in the appropriate setting and receive necessary services. The facility's policy and procedure on PASARR completion, dated September 30, 2024, mandates that all admissions have the appropriate PASARR completed. However, the failure to adhere to this policy resulted in the deficiency. The RNS and DON both acknowledged the importance of accurate documentation for the residents' quality of care, but the inaction in reviewing and completing the PASARRs as required led to the identified deficiency.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for five residents, leading to untrimmed fingernails with dark brown deposits underneath. This deficiency was observed in residents with various medical conditions, including diabetes mellitus, major depressive disorder, encephalopathy, dementia, Parkinson's disease, psychosis, hypertension, and hemiplegia. These residents required varying levels of assistance with activities of daily living (ADLs), such as bathing, grooming, and personal hygiene, due to their medical conditions and cognitive impairments. Resident 6, who was dependent on two or more persons for ADLs, expressed dissatisfaction with the appearance of her fingernails, which were long and unclean. Similarly, Resident 69, who required one-person assistance, was unhappy with his untrimmed nails. Resident 13, who needed assistance from two or more persons, also had long fingernails with irregular edges and dark deposits. Resident 34, with moderate cognitive impairment, and Resident 68, who required partial assistance, both had long, jagged, and dirty fingernails. Interviews with staff, including CNAs and the Director of Nursing Services, revealed that nail care was supposed to be part of ADL care but was not consistently documented or performed. The facility's policy indicated that residents unable to perform ADLs independently should receive necessary services to maintain grooming and personal hygiene. However, the lack of specific interventions and documentation for nail care contributed to the deficiency, potentially leading to infection and skin injuries.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate fall prevention measures for a resident identified as high risk for falls. The resident, who had a history of falls, dementia, and generalized weakness, experienced multiple falls within a short period. Despite these incidents, the facility did not conduct fall risk reassessments or update the resident's care plan to address the effectiveness of current preventative measures or to develop new interventions. The resident experienced falls on several occasions, resulting in injuries such as skin abrasions and cuts. After each fall, the facility did not evaluate the resident's condition or follow the Interdisciplinary Team's (IDT) recommendations, which included providing a sitter for constant supervision. The facility's policy on fall management, which requires reassessment and care plan updates after falls, was not implemented, leading to repeated incidents. Observations and interviews revealed that the resident was often left without a sitter, despite recommendations for close monitoring. Nursing staff acknowledged the lack of reassessment and care plan updates, and the Director of Nursing Services confirmed that fall risk safety precautions were not adequately discussed or implemented. This lack of action contributed to the resident's continued risk of falls and injury.
Failure to Provide Prescribed Liquid During Medication Pass
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 19, was provided with the prescribed liquid during a medication pass. Resident 19, who has a medical history of cerebral infarction with right hemiplegia and dysphagia, was observed in bed with a 45-degree head elevation when a Registered Nurse Supervisor administered medications crushed and mixed in applesauce without offering the prescribed nectar thick liquid. This oversight led to Resident 19 coughing vigorously and producing whitish/yellowish secretions, indicating difficulty in swallowing the medication effectively. Interviews with nursing staff revealed a lack of adherence to standard practices regarding medication administration. Registered Nurse Supervisor 1 admitted to not having a liquid thickener ready during the medication pass, while Registered Nurse Supervisor 2 emphasized the importance of having prescribed liquids and thickeners prepared. The Director of Nursing Services confirmed that licensed nurses are expected to provide prescribed liquid hydration to prevent aspiration. The facility's policies on encouraging fluids and administering medications were reviewed, highlighting the requirement for nursing staff to follow specific instructions concerning residents' fluid intake.
Repeat Deficiencies in QAPI Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to provide effective oversight and implementation of the plan of correction for deficiencies identified in the previous recertification survey. This resulted in repeat deficiencies in several areas, including resident's rights, comprehensive resident-centered care plans, pharmacy services, quality assurance and performance improvements, and infection control. During an interview and record review, the Administrator acknowledged the need for improvement in the facility's Quality Assurance Performance Improvement (QAPI) program, admitting a lack of diligence in its execution. The facility's policy and procedure for the QAPI program, dated February 2020, outlines the implementation and maintenance of a data-driven program focused on care outcomes and quality of life for residents. The program aims to measure indicators, establish performance improvement projects, and reinforce effective systems for quality care delivery. However, the Administrator is responsible for ensuring compliance with regulatory requirements, and the QAPI committee reports directly to the Administrator, indicating a lapse in fulfilling these responsibilities effectively.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity by not providing a privacy curtain for Resident 34 and not covering Resident 45's urine collection bag with a dignity or privacy bag. Resident 34, who was admitted with diagnoses including psychosis and hypertension, had moderate cognitive impairment and required substantial assistance with daily activities. During an observation, it was noted that the Housekeeping Supervisor removed the privacy curtain in Resident 34's room for cleaning, but there were no spare curtains available to replace it, compromising the resident's privacy and dignity. Resident 45, admitted with quadriplegia, anxiety, and depression, was cognitively intact but dependent on assistance for activities of daily living. During an interview, a CNA confirmed that Resident 45's urine collection bag was not covered with a dignity or privacy bag, which is important for maintaining the resident's dignity. The facility's policy on dignity, dated February 2021, emphasizes the importance of promoting and protecting resident privacy, which was not adhered to in these instances.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The nursing staff at the facility failed to protect the privacy of Resident 14, a resident who requires substantial assistance with personal care due to conditions such as type 2 diabetes mellitus and anxiety. During an observation, it was noted that the privacy curtain was not drawn while Certified Nurse Assistant (CNA 11) was providing personal care and repositioning Resident 14, leaving the resident visually exposed to roommates and others. This oversight was acknowledged by CNA 11, who admitted that the privacy curtain should have been closed to maintain the resident's dignity and privacy. Interviews with other staff members, including a Licensed Vocational Nurse (LVN 5) and the Director of Nursing (DON), confirmed that it is the staff's responsibility to ensure privacy curtains are drawn during personal care to protect residents' dignity and prevent potential embarrassment. The facility's policies on dignity and resident rights emphasize the importance of maintaining bodily privacy during personal care. The failure to adhere to these policies resulted in a violation of Resident 14's right to privacy.
Failure to Ensure Resident is Free from Unnecessary Restraints
Penalty
Summary
The facility failed to ensure that Resident 61 was free from unnecessary physical restraints. Resident 61's bed was positioned against the wall on the right side with an upper side rail on the left side, which restricted the resident's freedom of movement. This setup was identified as a potential restraint, as it inhibited the resident's ability to move freely and could pose a risk of entrapment. The resident, who was severely cognitively impaired and required partial assistance with daily activities, did not have a care plan addressing the bed's positioning against the wall. During interviews, both a CNA and an LVN acknowledged the bed's positioning but were unsure of the reasoning behind it. The LVN confirmed that the bed against the wall should be considered a restraint and should have been addressed in the care plan. The DON also stated that the bed's positioning was considered a restraint and emphasized the need for ensuring the resident's safety if such positioning was preferred. The facility's policy on restraints indicated that restraints should only be used for safety and well-being after other alternatives have been tried unsuccessfully, and any device that restricts a resident's ability to change position is considered a restraint.
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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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