Bel Vista Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, California.
- Location
- 5001 East Anaheim Street, Long Beach, California 90804
- CMS Provider Number
- 555805
- Inspections on file
- 31
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Bel Vista Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a need for assistance with activities of daily living was discharged to a recuperative care facility instead of a Board and Care as ordered by the physician and preferred by the resident. Miscommunication among staff led to the resident being placed in an environment that did not meet their care needs, and the facility did not verify the appropriateness or safety of the discharge location.
A resident with multiple medical conditions was discharged to a board and care facility without receiving the required 30-day written notice of proposed discharge. Instead, the notice was provided and signed on the same day as the discharge. Interviews with an LVN and the DON revealed that the facility's practice was to give discharge notices on the day of discharge, contrary to both federal regulations and facility policy.
A resident with multiple medical conditions and a care plan for constipation did not receive prescribed bowel regimen interventions after three days without a bowel movement. Staff failed to monitor and report the resident's condition, and no medications for constipation were administered as ordered. Facility policies required CNAs to report changes and LVNs to review and act on such information, but these steps were not followed.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with multiple medical conditions was sent to a medical appointment wearing a hospital gown instead of personal clothing, despite having 'street clothes' provided by a family member. The CNA offered the resident the option to change only once, did not document the refusal, and failed to notify nursing staff, resulting in the resident feeling embarrassed and not being treated with dignity as required by facility policy.
Surveyors found that access to two fire alarm pull stations was blocked by portable nurse worktables and a dirty linen cart, with the Maintenance Supervisor confirming staff awareness of proper storage procedures. The facility's policy requires maintenance of safe and accessible equipment, but these obstructions were not removed as required.
Surveyors found that multiple sprinkler deflectors in various areas of the facility had dust buildup, paint, or mildew, indicating a failure to maintain the automatic sprinkler system as required by NFPA 25. The maintenance supervisor acknowledged these findings during observations and interviews, and facility policy assigns responsibility for such maintenance to the maintenance department.
Surveyors found that the door to the electrical panel room, a designated hazardous area, was propped open and not maintained in a closed position as required. The Maintenance Supervisor acknowledged the issue during the survey, and facility policy indicates responsibility for compliance with safety regulations.
Surveyors found that sprinkler deflectors in several rooms had accumulations of dust and mildew, and the electrical panel room was being used for storage and as an office, with items placed too close to the electrical panel. The maintenance supervisor acknowledged these deficiencies, which were not in compliance with facility policy and relevant safety codes.
A facility failed to maintain the required distinctive color markings on an emergency electrical receptacle in the dining room, as most of the red coloring had been worn off by residents' wheelchairs. The Maintenance Supervisor confirmed the deficiency, noting the receptacle should be red to indicate its connection to the life safety emergency system.
Surveyors observed that phone charging cords were plugged into emergency red outlets in a resident room, which the Maintenance Supervisor confirmed were connected to the life safety emergency system. This practice allowed non-essential equipment to be connected to the emergency power supply, contrary to regulatory requirements that restrict such outlets to critical functions only.
Two residents did not receive care as ordered by their physicians: one was not provided a dermatology consult for hand lesions due to incomplete consent and lack of follow-up, and another was found without a required dressing on a surgical wound, despite orders for daily wound care. Staff interviews confirmed awareness of the deficiencies and the importance of following physician orders to prevent complications.
Two residents did not have their admission and readmission assessments completed by an RN as required, with LVNs performing these assessments instead. Staff interviews confirmed that LVNs typically handled admissions, and RNs were not consistently involved or verifying assessments, contrary to facility policy and federal regulations.
Two residents experienced deficiencies in medication management, including failure to follow up on a pharmacist's MRR recommendation, lack of communication of a new medication order to the pharmacy, and improper administration and removal of a Lidoderm patch. These actions resulted in discrepancies between physician orders and medication administration, with staff failing to ensure orders were accurately followed and documented.
A medication error rate of 8% was identified when a nurse administered a chewable aspirin tablet to a resident without ensuring it was chewed, and gave hydrocodone-acetaminophen based on outdated pain parameters. The pharmacy had not received the updated order, and staff did not clarify discrepancies between orders and medication packaging, resulting in medications not being administered as prescribed.
Two residents did not receive pain medication according to the most current physician-ordered pain level parameters. An LPN administered hydrocodone-acetaminophen for a pain level outside the prescribed range, and the pharmacy was not notified of the updated order, resulting in repeated administration errors. Staff interviews confirmed that medication orders and packaging were not properly updated or followed.
A deficiency was identified when staff failed to use required PPE, including gowns and gloves, during high-contact care activities for a resident with a Foley catheter. Despite facility policy and physician orders mandating Enhanced Barrier Precautions for residents with indwelling devices, a nurse was observed handling the resident's Foley catheter and administering a Lidocaine patch without proper PPE. Interviews revealed inconsistent understanding among staff regarding EBP requirements, and facility policies confirmed that PPE should have been used in these situations.
A resident with known allergies to banana, avocado, and strawberries, as well as dysphagia and asthma, was served a breakfast tray containing banana despite clear allergy documentation and facility policies requiring allergy checks. The dietary aide failed to notice the allergy tag, and the dietary supervisor confirmed the process for checking trays was not followed, resulting in the resident being exposed to an allergenic food item.
The facility's QAA Committee did not ensure effective oversight or timely implementation of its QAPI plan, as evidenced by missing documentation of QAPI meetings, delayed response to ongoing call light issues, and lack of follow-through on identified trends. The ADM acknowledged that earlier QAPI intervention could have addressed persistent problems, but actions were not taken until trends continued, and documentation was lacking.
Two resident bedrooms did not meet the required minimum square footage per resident, with multi-bed rooms measuring less than 80 sq. ft. per resident and single-bed rooms less than 100 sq. ft. per resident. This was confirmed by facility documentation and direct measurement, with both the Maintenance Supervisor and DON acknowledging the rooms' inadequate size and potential for clutter.
A resident with mild cognitive impairment and significant physical needs reported inappropriate touching by a male staff member. Although facility policy required 72-hour monitoring and documentation for every shift after such an allegation, only sporadic progress notes were found. Staff interviews confirmed that consistent monitoring was expected but not completed, resulting in a failure to follow professional standards and facility policy.
A resident was transferred to a GACH without the facility providing a required written notice of a seven-day bed hold to the resident and their responsible party. The resident, who lacked decision-making capacity, was admitted with conditions including cerebral infarction and dementia. The responsible party was informed of the transfer but was misinformed about the necessity of signing the bed hold document. The facility's policy requiring written notice was not followed, and the Director of Nursing acknowledged the oversight.
A resident's clothing was lost after being sent to an outside laundry vendor due to the facility's failure to maintain an inventory log. The resident, with hemiplegia and hemiparesis, relied on staff for daily living activities. Interviews revealed the absence of a tracking system for laundered clothing, and the facility's policy on personal property inventory was not adhered to.
A facility failed to accurately document a resident's family concerns in the IDT Conference Notes. The resident, with hemiplegia and hemiparesis, was dependent on staff for daily activities. Although family concerns were discussed, they were not recorded in the IDT notes, contrary to facility policy. The DON acknowledged the omission, which could affect the resident's care plan implementation.
A resident with type 2 diabetes mellitus did not receive weekly CBC and CMP tests as ordered, and their blood sugar was not checked during a significant change in condition, leading to hospitalization with critically high blood sugar levels. The facility failed to follow physician orders and notify the physician of the resident's condition and critical lab results.
The facility failed to lock medication and IV carts when unattended, leaving them accessible to unauthorized individuals. Additionally, keys to a medication cart were left unattended, and two residents' medications were not labeled with open dates as required by facility policy. These deficiencies were confirmed by staff and observed during a survey.
The facility failed to assess, care plan, and obtain physician's orders for bed positioning against the wall for three residents, potentially leading to unnecessary physical restraints. Observations revealed that residents with various medical conditions had their beds against the wall without proper documentation or assessment, contrary to the facility's restraint policy.
The facility failed to ensure proper documentation and administration of medications, leading to a discrepancy in controlled medication counts and inappropriate sharing of medications between residents. An LVN did not document the administration of Hydrocodone-Acetaminophen for a resident, and Refresh Tears Ophthalmic Solution was improperly given to another resident due to unavailability. The Director of Nursing confirmed that these actions were against the facility's policies.
The facility failed to accurately document medication administration for two residents, leading to discrepancies in the MAR. A resident did not receive Ipratropium-Albuterol Solution as documented, and another resident did not receive Refresh Tears Ophthalmic Solution, despite records indicating otherwise. The DON confirmed that proper procedures were not followed, increasing the risk of adverse reactions.
The facility failed to implement individualized care plans for two residents, one with a pressure injury and another with an anxiety disorder. The care plan for the resident with a pressure injury did not address non-compliance with turning and repositioning, while the resident with anxiety was not monitored for symptoms or medication side effects. Staff interviews confirmed the absence of necessary care plans, contrary to facility policy.
A resident with a G-Tube did not receive proper medication administration as the nursing staff failed to flush the tube with water before and after medications, and did not check gastric residuals. The resident, with a history of cerebral infarction and dysphagia, received 560 mL of fluids during medication administration, contrary to facility policy. Interviews revealed staff were unaware of the physician's orders and facility protocols.
A resident with severe cognitive impairment and mobility issues was not assisted out of bed as ordered, preventing participation in facility activities. Despite a physician's order and care plan for substantial assistance with transfers, the resident remained in bed due to reported equipment and space constraints. Interviews and observations revealed a lack of appropriate equipment and sufficient space for care, contrary to facility policy.
The facility failed to assist two residents with their hearing needs, leading to frustration and potential delays in care. One resident was not helped with recharging her hearing aid, while another was not scheduled for necessary hearing assessments. Staff interviews confirmed the lack of assistance, and no care plans were in place to address these issues.
A resident with a history of falls and on anticoagulant medication did not have fall mats placed on both sides of their bed, as required by their care plan. Facility staff confirmed the absence of these safety measures, which are crucial to prevent falls and potential injuries. The facility's policies on fall prevention and safety were not followed in this instance.
A facility failed to monitor a dialysis resident's fluid intake and output as per physician's orders, risking fluid overload. The resident, with conditions including diabetes and end-stage kidney disease, was on a fluid restriction, but there was no documentation of adherence or monitoring. Interviews revealed that staff did not document the fluid restriction or output monitoring, and the DON highlighted the importance of these actions to prevent complications.
A facility failed to assess and address PTSD in a resident, who was non-verbal and had modified independence in cognitive skills. Despite having a care plan for trauma-informed care, the facility did not conduct a trauma assessment to identify potential triggers. The Social Service Designee and nursing staff were unaware of the resident's trauma history, contrary to the facility's policy on individualized care plans for past trauma.
The facility failed to properly assess and document the use of bed rails for residents, leading to potential risks of entrapment and injury. Observations and interviews revealed that residents with cognitive and mobility impairments had siderails up without proper assessments or care plans. Staff were unaware of orders or consents for siderail use, and the Director of Nursing confirmed the lack of necessary documentation.
A resident with PTSD and depression did not receive individualized trauma-informed care due to the facility's failure to assess the resident's trauma history and provide staff training. The DON acknowledged the lack of assessment, and the LVN and DSD were not trained in trauma-informed care, despite the facility's policy requiring such training.
A facility failed to monitor a resident prescribed Lorazepam for anxiety, neglecting to document behavior prior to administration and monitor for side effects. The resident's care plan lacked a strategy for the medication, and staff interviews confirmed the absence of necessary monitoring, contrary to the facility's policy on psychotropic medication management.
The facility failed to prevent ice buildup in the walk-in freezer, which was observed during a survey. A kitchen staff member expressed concern about potential food supply damage, while the Maintenance Director noted the issue was due to the freezer's age. The Registered Dietician acknowledged the problem had been addressed multiple times, but it persisted, indicating non-compliance with the facility's food storage policies.
The facility failed to include the Infection Prevention Nurse in a recent assessment and did not adequately evaluate a resident's needs with PTSD, leading to potential inadequate care. The Admin acknowledged the oversight, and the facility's policy mandates annual assessments to ensure resources meet residents' needs.
The QAA and QAPI committee failed to maintain systems for feedback and data analysis on issues like trauma-informed care and abuse. The Administrator and DON admitted to lacking evidence of monitoring and not following QAPI policy for performance indicators.
A resident on Vancomycin for C-diff was prematurely removed from isolation, and staff did not use PPE, risking infection spread. The resident had diabetes, kidney cancer, and used a gastrostomy tube. The Infection Preventionist ended isolation due to no diarrhea symptoms, but the resident was still on antibiotics. Facility policy on infection control was not properly followed.
The facility failed to provide adequate room size for two residents, with rooms measuring 149.80 sq. ft. for two residents, below the required 80 sq. ft. per resident. Despite a waiver, staff reported difficulties in maneuvering equipment and providing care, although no resident complaints were noted.
A facility failed to verify the competencies and backgrounds of caregivers provided by a resident's family, who were not subjected to background checks or competency verification before rendering care. The resident, with severe disorientation and dependency on assistance for daily activities, was at risk due to the lack of facility orientation for these caregivers. The facility's policies required verification of nurse aides' skills and certifications, which was not adhered to in this instance.
A resident with severe cognitive impairment alleged physical aggression by CNAs, which was reported by a family member to the Operations Manager. The manager did not consider it abuse and failed to report it to authorities within the required timeframe, violating facility policy.
A resident with dementia and other health issues had laboratory tests ordered, but the results were not communicated to the MD until three days after they were received. Interviews with staff confirmed that the facility's policy requires prompt communication of lab results to the MD, which was not followed in this case.
Failure to Ensure Safe and Appropriate Discharge Placement
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident by not following the physician's order and the resident's stated preference for discharge to a Board and Care facility. The resident, who had diagnoses including hypertension, glaucoma, lack of coordination, and protein-calorie malnutrition, required supervision or assistance with activities of daily living such as bathing, dressing, transferring, and toileting. The care plan and physician's order specified discharge to a Board and Care with home health services for physical and occupational therapy, as well as nursing support for medication compliance. However, the resident was instead discharged to a recuperative care facility, which is intended for individuals recovering from illness and experiencing homelessness, and does not provide the level of care or services required by the resident. Interviews and record reviews revealed that there was miscommunication between the facility's social worker, the Director of Patient Care, and other staff regarding the discharge destination. The Director of Patient Care and the case manager both confirmed that the resident was discharged to a recuperative care facility rather than a Board and Care, and that the facility did not verify whether the placement met the resident's needs or was safe. The resident expressed discomfort and fear upon arrival at the recuperative care facility, noting concerns about safety and the environment, and subsequently left the facility on his own. The facility's own policy required that discharges meet specific criteria, including resident notification, orientation, and documentation. The Director of Nursing and the administrator acknowledged that the discharge did not follow the physician's order or the resident's preference, and that the facility failed to screen the discharge location to ensure it was appropriate and safe for the resident. This resulted in an inappropriate discharge that did not meet the resident's needs or preferences.
Failure to Provide 30-Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a written 30-day notice of proposed discharge to a resident prior to their transfer, as required by federal regulations and the facility's own policy. The resident, who had diagnoses including hypertension, glaucoma, lack of coordination, and protein-calorie malnutrition, was admitted on a specified date and required supervision or assistance with activities of daily living. Documentation showed that the resident was discharged to a board and care facility, and the formal written notice of proposed transfer/discharge was given and signed on the same day as the discharge, rather than at least 30 days in advance. Interviews with facility staff, including an LVN and the DON, confirmed that the practice was to provide the discharge notice on the day of discharge. The DON was not aware that the notice should be given at least 30 days prior, as outlined in the facility's policy and federal requirements. Review of the facility's policy confirmed that residents or their representatives are to be notified of an impending discharge at least 30 days in advance, and the notice should be provided in a manner understandable to the resident.
Failure to Monitor and Treat Constipation According to Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary care and services for a resident with a history of metabolic encephalopathy, atrial fibrillation, hypertension, and acute osteomyelitis. The resident was identified as being at risk for complications related to constipation due to immobility and medication side effects. The care plan included interventions to administer medications for constipation as ordered by the physician. Despite physician orders for a bowel regimen that included Milk of Magnesia, Dulcolax suppository, and Fleet Saline Enema to be administered as needed for constipation, the resident did not have a bowel movement for three consecutive days. Documentation showed that the resident's Activities of Daily Living (ADL) records indicated no bowel movement on those days, but no medications for constipation were administered as required by the orders. Interviews with staff revealed that the Certified Nursing Assistant (CNA) did not notify the charge nurse of the resident's constipation, and the Licensed Vocational Nurse (LVN) did not recall receiving an alert or being notified. As a result, the resident did not receive the prescribed interventions for constipation. Further review of facility policies and job descriptions confirmed that CNAs are required to report changes in residents' conditions to the nurse supervisor, and LVNs are responsible for reviewing charts and evaluating residents' conditions. The Director of Staff Development and the Director of Nursing both acknowledged that the staff should have monitored the resident's bowel movements and administered the prescribed medications for constipation according to the care plan and physician orders.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Assist Resident with Dressing for Appointment
Penalty
Summary
A facility failed to ensure that a resident was treated with respect and dignity by not assisting him with getting dressed in his personal clothing prior to leaving for a medical appointment. The resident, who had diagnoses including acute kidney failure, type 2 diabetes, and a colostomy, was cognitively intact and had 'street clothes' provided by a family member for the appointment. Despite this, the resident was sent to the appointment wearing a hospital gown, which led to feelings of embarrassment. The family member reported the incident, expressing concern about the resident's emotional well-being. Interviews and record reviews revealed that the CNA offered the resident the option to change into his clothes only once, and upon the resident's refusal, did not document the refusal or notify the charge nurse as required by facility policy. The facility's policies emphasized the importance of treating residents with dignity and supporting their rights, including the right to wear preferred clothing. There was no documentation in the clinical record of the resident's refusal or any communication to responsible parties regarding the incident.
Plan Of Correction
F-tag 557 1. Corrective Action for residents found to have been affected: • Resident 1 was discharged from the facility and admitted to Long Beach Memorial Medical Center on 5/30/2025. Resident did not return to the facility. DSD held a 1:1 verbal counseling with responsible CNA on 05/30/2025. The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 6/18/2025, the DON conducted a visual audit of residents who went out for appointments to ensure they were dressed in their own personal clothing. On 6/18/2025, one resident went out for an appointment, and she was wearing her own personal clothing when she went to the appointment. No findings were identified. • The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. • The DSD conducted an additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. • The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. III. Facility measures and systemic changes to ensure the deficient practice does not recur: The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. The DSD conducted additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON, and the DON/designee will provide an in-service to staff including certified nursing assistants and licensed vocational nurses. IV. Facility's plan to monitor corrective actions to achieve and sustain compliance; integrate the POC into the QA process: The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON immediately. Thereafter, the DON/designee will provide immediate re-education through an in-service to staff including certified nursing assistants and licensed vocational nurses, and implement progressive discipline if repeated to ensure compliance. The DSD/designee will report findings from the conducted weekly/monthly audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing during the monthly QAA meeting for 3 months. Compliance Date: 07/07/2025
Obstructed Access to Fire Alarm Pull Stations
Penalty
Summary
Surveyors observed that access to fire alarm pull stations was obstructed in two separate locations within the facility. Specifically, two rolling portable nurse worktables were found blocking one pull station across from the nurse's station, and a dirty linen cart was left unattended in front of another pull station. These obstructions were identified during concurrent observations and interviews with the Maintenance Supervisor (MS), who acknowledged that staff were aware not to leave items in front of the pull stations and that such items should be stored on the opposite wall. A review of the facility's Maintenance Service Policy and Procedure indicated that the Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, including compliance with federal, state, and local regulations. The failure to keep the pull stations accessible was noted as a deficiency, as it could potentially delay the activation of the fire alarm system in the event of an emergency.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. Corrective Action Taken: On 05/19/2025, the facility's policy is to comply with all applicable federal and state regulations regarding fire alarm system initiation requirements as specified in NFPA Life Safety Code sections 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, and 9.6.2.5. Maintenance Supervisor immediately removed the rolling portable nurse worktables and dirty linen cart that were blocking pull stations 1 and 2. The Maintenance Department conducted a facility-wide inspection of all pull stations to ensure clear access and visibility. New "Keep Clear" floor markings were installed in front of all pull stations on 05/20/2025 to designate required clearance zones. Identification of Other Areas with Potential to be Affected: On 05/20/2025, the Maintenance Director conducted a comprehensive facility-wide assessment of all fire alarm pull stations to identify any additional access issues or potential obstructions. This assessment included all four smoke compartments and verification of proper pull station placement per NFPA requirements. Systemic Changes and Measures Implemented: 1. In-service training was conducted for staff on 05/21/2025 regarding: • Proper placement of equipment and furniture • Importance of maintaining clear access to pull stations Monitoring and Quality Assurance: The Director of Maintenance/designee will conduct daily rounds to ensure pull stations remain accessible and unobstructed. The Maintenance Director will conduct weekly comprehensive fire safety inspections, including verification of pull station accessibility, and document findings on a checklist. The Director of Maintenance will compile monthly reports of monitoring results for review by the QAPI committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. Any identified issues will be addressed immediately with additional staff education and corrective measures as needed. Date of Completion: 06/12/2025
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 25 standards, as evidenced by multiple sprinkler deflectors throughout the building that were found with dust buildup, paint, and a green mildew-like substance. During a series of observations and interviews, surveyors identified these deficiencies in several locations, including the kitchen dry goods storeroom, social service storeroom, administrator's office, CNA storeroom, resident rooms, and the shower room. In each instance, the maintenance supervisor acknowledged the presence of dust, paint, or mildew on the sprinkler deflectors. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring the building and equipment are kept in a safe and operable condition at all times, including compliance with federal, state, and local regulations. Despite this policy, the observed conditions showed that the sprinkler system components were not being properly maintained, as required by NFPA 25, which mandates that sprinklers be free of corrosion, foreign materials, paint, and physical damage, and be installed in the correct orientation.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, specifically section 5.2.1.1.1 concerning sprinkler maintenance and testing. Corrective Action Taken: On 05/19/2025, the Maintenance Director initiated immediate cleaning and restoration of all affected sprinkler heads. A licensed fire protection contractor was engaged to properly clean and inspect all sprinkler deflectors throughout the facility, with special attention to those identified in the survey findings. All painted sprinkler heads were replaced with new, properly rated sprinkler heads. The shower room sprinkler head showing mildew was replaced and the surrounding ceiling area was treated for mold prevention. Identification of Other Areas with Potential to be Affected: On 05/20/2025, the Maintenance Director and Fire Safety Officer conducted a comprehensive facility-wide inspection of all sprinkler heads and deflectors in all smoke compartments. This inspection documented the condition of each sprinkler component and identified any additional heads requiring cleaning or replacement. Systemic Changes and Measures Implemented: 1. A new monthly sprinkler inspection checklist has been implemented that specifically addresses cleanliness, paint, corrosion, and proper orientation of all sprinkler heads. 2. The preventive maintenance schedule has been updated to include quarterly deep cleaning of all sprinkler heads by qualified maintenance staff. Monitoring and Quality Assurance: The Maintenance Director will conduct weekly inspections of randomly selected sprinkler heads throughout the facility for the next 90 days. The Director of Maintenance will oversee all monitoring activities and report findings to the quarterly Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters. Date of Completion: 06/12/2025
Hazardous Area Door Not Maintained Closed
Penalty
Summary
Surveyors observed that the facility failed to maintain the doors of hazardous areas, specifically the electrical panel room, in a closed position when not in use. During an observation with the Maintenance Supervisor, the door to the electrical panel room was found propped open. The Maintenance Supervisor acknowledged this condition at the time of the survey. The facility's own policy and procedure for maintenance services states that the Maintenance Department is responsible for maintaining the building in compliance with all applicable laws and regulations, including ensuring that hazardous areas are properly enclosed. The deficiency was identified in one of four smoke compartments and involved a room classified as a hazardous area due to its use for storage of combustible supplies and equipment. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was based on direct observation, interview, and review of facility policy, with no mention of corrective actions or follow-up steps taken at the time of the survey.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding hazardous areas enclosure requirements as specified in NFPA 101 Life Safety Code sections 19.3.2.1 and 19.3.5.9. Corrective Action Taken: On 5/20/2025, the Maintenance Supervisor immediately removed the door prop and verified proper door closure and latching operation for the electrical panel room door. The door's self-closing mechanism and latching hardware were inspected and confirmed to be functioning properly. A facility-wide inspection of all hazardous area doors was completed on 5/20/2025 to ensure proper operation of self-closing mechanisms and latching hardware. Identification of Other Areas with Potential to be Affected: On 5/20/2025, the Maintenance Director conducted a comprehensive facility-wide assessment of all hazardous areas including electrical rooms, storage rooms over 50 square feet, mechanical rooms, and other areas requiring fire-rated separation. This assessment included verification of door closure mechanisms, and latching hardware functionality. 1. Daily rounds to verify doors are unobstructed and properly closing • Monthly documented inspections of all fire-rated door assemblies. • Prohibition of door stops or other devices that prevent proper door closure. 2. Staff education was provided on 5/21/2025 regarding: • The importance of maintaining closed doors in hazardous areas. • Proper operation of fire-rated doors. • Reporting procedures for malfunctioning door hardware. Monitoring and Quality Assurance: The Maintenance Director or designee will conduct daily rounds to ensure all hazardous area doors are maintained in the closed position and functioning properly. The Maintenance Director will review compliance data monthly and report findings to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. Date of Completion: 6/12/2025
Deficient Maintenance of Sprinkler Systems and Improper Storage in Electrical Panel Room
Penalty
Summary
Surveyors observed multiple deficiencies related to the maintenance of fire safety equipment and electrical panel access. During several walkthroughs with the maintenance supervisor (MS), it was noted that sprinkler deflectors in various rooms, including resident rooms, a restroom, and a shower room, had significant buildups of dust and, in one case, a green mildew-like substance. The MS acknowledged these findings during the observations. The facility's maintenance policy states that the maintenance department is responsible for keeping the building and equipment in a safe and operable manner and in compliance with applicable regulations. Additionally, the electrical panel room was found to be used for storage and as an office space for the case manager. Items such as binders, blank paper, and a floor polishing machine were stored within three inches of the electrical panel, which is not compliant with NFPA 70 requirements for clear working space around electrical panels. The MS confirmed that the room had been used in this manner for years due to limited space in the building and acknowledged the findings during the survey.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding electrical safety requirements as specified in NFPA 101 Life Safety Code (2012 Edition) and NFPA 70 National Electrical Code (2011 Edition), specifically regarding maintaining clear working spaces around electrical panels. Corrective Action Taken: On 05/20/2025, the Maintenance Supervisor immediately removed all stored items, including binders, paper, and floor polishing machine from the electrical panel room. The Case Manager's office was relocated to an alternative space within the facility. The electrical panel room was secured with appropriate signage indicating "Electrical Room - No Storage Permitted." The Maintenance Supervisor conducted a complete inspection of all electrical panel rooms facility-wide to ensure compliance with NFPA requirements for clear working spaces. Identification of Other Areas with Potential to be Affected: The Maintenance Supervisor, in conjunction with the Safety Committee, completed a facility-wide assessment on 05/20/2025 to identify any other electrical panels or utility rooms that could potentially be affected by improper storage or space utilization. This assessment included all four smoke compartments and documentation of current space utilization near all electrical equipment. Systemic Changes and Measures Implemented: 1. The facility's Maintenance Service Policy and Procedure has been revised to specifically address electrical room safety requirements, including: • Prohibition of storage within 36 inches of electrical panels • Required monthly inspections of all electrical rooms and panels 2. Implementation of a facility-wide space utilization assessment to ensure appropriate allocation of office and storage areas. Monitoring and Quality Assurance: The Maintenance Director will conduct weekly inspections of all electrical rooms for the first month, then monthly thereafter. The Director of Maintenance will conduct independent monthly audits to ensure continued compliance. Results will be documented and reviewed during monthly Safety Committee meetings and quarterly QAPI meetings. The QAPI Committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive quarters. Any identified issues will
Emergency Electrical Receptacle Markings Worn Off
Penalty
Summary
The facility failed to ensure that all emergency electrical receptacles supplied from the life safety and critical branches had distinctive color markings, as required by NFPA 99 standards. During an observation in the dining room, a receptacle located next to the exit sliding door was found to be missing most of its red coloring, which is used to indicate its connection to the emergency power system. The Maintenance Supervisor confirmed that the outlet was designated as an emergency outlet and should be red in color, but stated that the red coloring had been worn off due to contact with residents' wheelchairs. A review of the facility's Maintenance Service Policy and Procedure indicated that the Maintenance Department is responsible for maintaining the building and equipment in compliance with federal, state, and local regulations. The policy also outlines that maintenance personnel are tasked with ensuring the building remains safe and operable at all times. Despite these requirements, the emergency receptacle in question was not properly marked, resulting in noncompliance with regulatory standards.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding electrical systems and essential electric system receptacles as specified in NFPA 99 codes 6.4.2.2.6, 6.5.2.2.4.2, and 6.6.2.2.3.2. Corrective Action Taken: On 5/20/2025, the Maintenance Director immediately replaced the emergency receptacle located in the dining room next to the exit sliding door with a new red-colored receptacle that clearly identifies it as being connected to the life safety emergency system. Additionally, all emergency receptacles throughout the facility were inspected for proper color identification and marking. Identification of Other Areas with Potential to be Affected: The Maintenance Director conducted a facility-wide assessment on 5/20/2025 of all emergency receptacles connected to life safety and critical branches to identify any other receptacles with worn or missing distinctive color markings. This assessment included all four smoke compartments of the facility. Systemic Changes and Measures Implemented: 1. A preventive maintenance schedule has been implemented requiring monthly inspections of all emergency receptacles for proper color identification. Monitoring and Quality Assurance: The Maintenance Director will conduct monthly audits of all emergency receptacles to ensure proper identification markings are maintained. Results will be documented on the Emergency Receptacle Inspection Log. The Director of Maintenance will review these logs monthly and report findings to the quarterly Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for a minimum of three consecutive quarters. Date of Completion: 5/20/2025
Non-Essential Equipment Connected to Life Safety Emergency Outlets
Penalty
Summary
The facility failed to ensure that only permitted electrical equipment was connected to the Life Safety emergency system, as required by NFPA 99 and related codes. During an observation and interview, it was found that phone charging cords were plugged into the emergency red outlets located behind beds in room 19. The Maintenance Supervisor confirmed that these red outlets are connected to the life safety emergency system, which is intended only for specific, critical functions as outlined in the regulations. The report specifies that, in the event of a prolonged normal electrical failure, unessential equipment such as phone chargers should not be continuously connected to the emergency system. This is to prevent power overload and potential failure of the alternative power source. The deficiency was identified during a concurrent observation and interview, and the findings were acknowledged by the Maintenance Supervisor. A review of the facility's Maintenance Service Policy and Procedure indicated that the Maintenance Department is responsible for maintaining the building and equipment in compliance with all applicable laws and regulations. However, the observed practice of allowing non-essential equipment to be plugged into the life safety emergency outlets was not in compliance with these requirements.
Plan Of Correction
BEL VISTA HEALTHCARE CENTER makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. BEL VISTA HEALTHCARE CENTER is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes BEL VISTA HEALTHCARE CENTER's written credible allegation of compliance for the deficiencies noted. It is the facility's policy to comply with all applicable federal and state regulations regarding NFPA 99 Health Care Facilities Code 2012 Edition, specifically section 6.4.2.2.3.5 concerning the proper use of Life Safety emergency system electrical outlets. Corrective Action Taken: On 05/20/2025, the Maintenance Director immediately removed all phone charging cords from the emergency red outlets in Room 19. The Maintenance Director conducted a facility-wide inspection of all emergency red outlets to ensure no unauthorized equipment was connected. Identification of Other Areas with Potential to be Affected: The Maintenance Director completed a comprehensive audit of all emergency power outlets throughout the facility on 05/20/2025 to identify any similar instances of improper use. This included inspection of all four smoke compartments and documentation of all emergency power circuits and their current usage. Systemic Changes and Measures Implemented: 1. Installed clear signage at all emergency outlets identifying proper usage restrictions. 2. Conducted in-service training for staff on 05/21/2025 regarding emergency power systems and proper outlet usage. 3. Added emergency outlet inspection to daily maintenance rounds checklist. Monitoring and Quality Assurance: The Maintenance Director will conduct daily rounds to ensure compliance with emergency outlet usage requirements. Results will be documented on a standardized audit tool. The Administrator will review audit results monthly. The Maintenance Director will report monitoring results to the quarterly Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months. Additional education and monitoring will be implemented as needed based on audit findings. Date of Completion: 06/12/2025
Failure to Follow Physician Orders for Consults and Wound Care
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with physician orders. For one resident with a history of Parkinson's disease, rheumatoid arthritis, and chronic kidney disease, there was a physician order for a dermatology consult and treatment for right hand lesions. The dermatologist requested a face sheet and a photograph of the lesions, and later required a signed consent form to schedule a biopsy. However, the consent form was not signed or dated, and there was no documentation that the consent was faxed to the dermatology clinic. There were no follow-up notes in the resident's record for several months, and the resident reported that the facility had not provided any treatment for her skin issue, which had persisted for about six months. Staff interviews confirmed that the required steps for the dermatology consult were not completed, and the resident was not seen by a dermatologist as ordered. Another resident, with diagnoses including type 2 diabetes mellitus, diabetic neuropathy arthropathy, hypertension, and a right above-the-knee amputation, had physician orders for daily wound care and dressing changes to the surgical site. During observation, the resident was found in bed without a dressing on the surgical site. The nurse present was aware that the dressing was missing and acknowledged the importance of keeping the wound covered to prevent infection. Another nurse was not aware that the dressing was missing but also stated the importance of following the physician's order to keep the wound covered. The DON confirmed that the facility must follow physician orders and keep the wound covered to prevent infection. The facility's policies and procedures were reviewed and indicated that residents have the right to quality care, dignity, and respect, including care that honors their goals, choices, and preferences. The policies also state that residents are entitled to equal access to quality care. Despite these policies, the facility did not ensure that the two residents received care in accordance with physician orders, resulting in one resident not receiving a dermatology consult and another resident not having their surgical wound properly dressed.
Plan Of Correction
This plan of correction constitutes the facility's written credible allegation of compliance. Preparation and/or execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth of the facts alleged, or the conclusion set forth on the Statement of Deficiencies. This plan of correction is prepared and/or executed solely because of the provisions of the health and safety code section 1280 and 42 CFR 483. F-tag 684 I: Corrective Action for residents found to have been affected: • Resident 2 lesion was reassessed by the RN on 5/18/2025. The attending physician was made aware of the dermatology follow-up appointment and orders were given by the physician on 5/20/2025 for a Dermatology consult on June 18, 2025, at 0930. • Resident 28's treatment for right AKA was completed by the RN on 5/18/25. • Resident 28 was reassessed by RN on duty for any signs or symptoms of infection such as drainage, pain, foul smelling odors, etc. Resident 28 wound remains stable at this time. • No other residents have been affected. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/06/2025, the MRD completed an audit of residents' specialist consult orders in the past 30 days to ensure that residents with orders are seen per physician orders. • The DON/designee performed an audit on 5/18/25 on residents' treatments and verified that treatment orders were followed per physician. III: Facility measures and systemic changes to ensure the deficient practice does not recur: • DON/designee conducted an in-service to facility licensed nurses regarding following physician orders for treatment, including follow-up of needed consult orders of residents as ordered by the physician. The goal is to ensure that residents receive treatment and needed services per the physician's order. • MRD will conduct audits that residents' consult orders are followed per physician orders weekly for 1 month then bi-monthly for 2 months. • DON/designee will conduct random audits of 5 residents' treatments weekly for orders to ensure that each order is followed by physician orders X 90 days. IV: Facility's plan to monitor corrective actions, achieve, and sustain compliance: • Integrate the POC into the QA Process. • The Medical Record Director/designee will report on the findings and trends of weekly audits of new psychotropic medications for informed consent during the monthly QA meeting for the next 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025
Failure to Ensure RN Completion of Admission and Readmission Assessments
Penalty
Summary
The facility failed to ensure that admission and readmission assessments for two residents were completed by Registered Nurses (RNs) as required. Instead, Licensed Vocational Nurses (LVNs) performed these assessments, including head-to-toe and skin assessments, without RN verification or involvement. Interviews with staff confirmed that LVNs typically conducted admission assessments, and RNs were not routinely involved in this process, contrary to facility policy and federal regulations. For one resident, the admission record showed initial admission and subsequent readmission with multiple diagnoses, including lumbar fracture, spinal stenosis, and obstructive uropathy. The resident was sent to the hospital for evaluation of skin tears and returned the same day, but no readmission assessment was completed by either an LVN or RN upon return. Staff interviews revealed that assessments were not always performed after hospital returns, and the importance of such assessments was acknowledged by the staff. Another resident was admitted and later readmitted with diagnoses such as Parkinson's disease, diabetes, and dementia. The admission/readmission evaluation was completed by an LVN, and staff interviews confirmed that LVNs generally performed these assessments. The Director of Nursing stated that RNs do not usually do admissions, and if an LVN completes the assessment, the RN should verify it, but this was not consistently done. Facility policies indicated that RNs are responsible for comprehensive assessments and oversight of care plans, but these procedures were not followed in practice.
Plan Of Correction
F-tag 727 (1) Corrective Action for residents found to have been affected: • Resident 21 was no longer in the facility as of 05/22/2025. • Resident 28 admission/readmission evaluation was completed by the licensed nurse on 05/13/2025 and reviewed by the DON on 05/19/2025. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • The MRD completed an audit on 06/06/2025 for the past 14 days, that an admissions/readmission evaluation was completed by licensed nurses. No other residents are affected by the deficient practice. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, the DON conducted an in-service to facility licensed nurses regarding completion of admission/readmission evaluation of residents. The goal is to ensure that there is no delay of care and services due to missed or inaccurate identification of problems. • The MRD will conduct daily audits for completion of admissions/readmission evaluation of residents by licensed nurses and validated by RN. Findings will be reported to the Director of Nursing during daily stand-up meetings for follow-up. IV. Facility's plan to monitor corrective actions, achieve, and sustain compliance; integrate the POC to QA process: • The Medical Record Director/designee will report the findings and trends of weekly audits of admissions/readmission evaluation of residents completed by a licensed nurse during the monthly QA meeting for the next 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Failure to Ensure Accurate Medication Administration and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals as required by regulation. For one resident, there was a failure to follow up on the Medication Regimen Review (MRR) recommendations made by the pharmacist. The MRR had identified a discrepancy between the physician's order for hydrocodone-acetaminophen for moderate pain and the medication blister pack and reconciliation count sheet, which were labeled for severe pain. The nursing staff did not ensure that the medication order on the pain assessment flow sheet matched the reconciliation sheet, and the updated order was not communicated to the pharmacy. As a result, the resident was at risk of not receiving the appropriate medication for pain management. Additionally, the facility did not communicate a new medication order to the pharmacy for the same resident. When the parameters of the hydrocodone-acetaminophen order were changed, the updated order was not faxed to the pharmacy as required. Nursing staff acknowledged that it was their responsibility to ensure the medication blister pack matched the current physician order, but this was not done. The Director of Nursing confirmed that discrepancies between the order and the medication packaging could lead to medication errors and that the resident could be under or over medicated. For another resident, the facility failed to follow physician orders regarding the administration and removal of a Lidoderm (lidocaine) patch. The order specified that the patch should be applied in the morning and removed at bedtime, but documentation did not indicate that the patch was removed as ordered. The resident reported that the patch had not been removed for two days, and observation confirmed the patch was still in place without a date. Nursing staff and supervisors acknowledged that the patch should be on for 12 hours and off for 12 hours, and that leaving it on longer could cause skin irritation. The facility's policy required medications to be administered as prescribed, including adherence to required time frames, but this was not followed in this case.
Plan Of Correction
F-tag 755 I: Corrective Action for residents found to have been affected: • Resident 21 was no longer in the facility as of 05/22/2025. • Resident 1 was reassessed by RN on duty for any negative effects due to not administering medication as per physician's order. Resident remains stable at this time. • Clarification of Resident 1 medication was made by RN with physician on 5/18/2025. Resident 1's order for hydrocodone-acetaminophen was communicated and clarified by the licensed nurse to the pharmacy and delivered on 05/18/2025. • Resident 1's MRR was communicated to attending physician on 5/17/2025 by the RN and on 5/18/2025 an order clarification was given by the attending physician. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • The facility's Medication Regimen Review (MRR) for the current residents was requested from Pharmacy by the DON on 05/21/2025. Recommendations and follow-up were completed on 05/28/2025 by the DON. • The RN performed an audit for residents with lidocaine patch orders on 5/17/2025 to ensure orders are followed per the physician orders. • The DON/designee conducted a facility-wide audit on 5/28/2025 for all narcotic medications orders for accuracy. No further findings. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication to the residents. • The Medical Records Director/designee will conduct a daily audit of the MRRs for the new admissions and the DON to follow-up for the monthly MRR provided by the pharmacist consultant. • The Medical Records Director/designee shall conduct a monthly audit that the Medication Regimen Review (MRR) pharmacy recommendations are completed and will report the findings to the DON for follow-up. • The Medical Records Director/designee will conduct daily audits of residents' new physician's orders to ensure physician's orders are accurate and being followed. IV. Facility's plan to monitor corrective actions to achieve & sustain compliance; Integrate the POC to QA Process: • The DON/designee will report issues or trends from the weekly audits conducted for Lidocaine orders are followed per physician orders during the monthly QAA meeting x 3 months to ensure compliance. • The MRD/designee will report issues or trends from the weekly audits of new medication orders are communicated to the pharmacy and the Medication Regimen Review (MRR) are completed during the monthly QAA meeting x 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Medication Error Rate Exceeds 5% Due to Improper Administration and Order Discrepancies
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with three medication errors identified out of 25 observed opportunities, resulting in an 8% error rate. During a medication pass, a nurse administered 11 medications to a resident, including a chewable aspirin tablet and a hydrocodone-acetaminophen tablet. The resident swallowed the chewable aspirin whole instead of chewing it as ordered, and the nurse confirmed this deviation from the prescribed method. The nurse acknowledged that not chewing the medication could alter its effectiveness. Additionally, the hydrocodone-acetaminophen was administered based on outdated pain level parameters, as the medication blister pack and reconciliation count sheet did not match the updated physician order for pain management. The pharmacy had not received the updated order, and the nurse did not clarify the discrepancy with the physician. The resident involved had a history of cerebral infarction and osteomyelitis and was assessed as having moderate cognitive impairment, requiring significant assistance with daily activities. Interviews with nursing staff and the DON confirmed that medications were not administered as ordered and that discrepancies between medication orders and packaging were not addressed. Facility policy required medications to be administered according to prescriber orders, but this was not followed in the observed instances.
Plan Of Correction
F-tag 759 I: Corrective Action for residents found to have been affected: • Resident 1 order for aspirin chewable was clarified with physician by the RN on 5/28/2025. • Resident 1's pain observation/assessment was completed by RN on 5/18/2025. • A 1:1 in-service education was provided by the DON to LVN 4 regarding the Policy and Procedure on administering medication to ensure that residents received their medication per physician orders. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 5/28/2025, the Medical Records Director/designee conducted a facility-wide audit of residents on aspirin chewable tablets and hydrocodone-acetaminophen orders to ensure that residents are provided medication per physician orders. • No other residents have been affected by the deficient practice. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication as prescribed by the physician. • The Pharmacy Nurse consultant will conduct a 3-way medication cart audit on a monthly basis for the presence of medications and accuracy of orders. Findings will be reported to the DON for follow-up. • The Medical Records Director/designee will conduct a daily audit for new physicians' orders for accuracy and will report findings to the DON during the daily stand-up meeting for follow-up. IV: Facility's plan to monitor corrective actions are achieve & sustain compliance; Integrate the POC to QA Process: • DON/designee will report issues or trends per the weekly random audits made on residents on pain management during the monthly QAA meeting x 3 months to ensure compliance. • The Pharmacy consultant will report issues or trends of monthly medication administration given by the pharmacy nurse consultant and monthly in-service educations provided regarding medication administration and review of residents on pain management. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025
Failure to Administer Pain Medication per Ordered Parameters
Penalty
Summary
The facility failed to administer pain medication according to the ordered pain level parameters for two residents. For one resident with a history of cerebral infarction and osteomyelitis, the Licensed Vocational Nurse (LVN) administered hydrocodone-acetaminophen 5-325 mg for a reported pain level of 7/10, despite the current physician order specifying the medication should be given for moderate pain (4-6). The medication blister pack and reconciliation count sheet still reflected the previous order for severe pain (6-10), and the pharmacy had not received the updated order. Review of the Medication Administration Record (MAR) showed that this resident received the medication outside the ordered pain parameters on seven occasions. Interviews with nursing staff and the pharmacist confirmed that when medication orders are changed, the new parameters should be communicated to the pharmacy and reflected on the medication packaging. The staff acknowledged that it is their responsibility to ensure medications are administered according to the most current orders. The facility's policy requires medications to be administered in accordance with prescriber orders, including any specified parameters, but this was not followed in these instances.
Plan Of Correction
F-tag 760 I: Corrective Action for residents found to have been affected: Resident 21 is no longer in the facility as of 05/22/2025. • Resident 1 was reassessed by RN and duty on 05/18/2025 for any negative effects due to an incorrect hydrocodone-acetaminophen order. Resident remains stable at this time. • A one-on-one in-service education was provided to LVN 4 on 05/18/2025 by the DON regarding hydrocodone-acetaminophen administration within the pain level parameters per the physician order. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/06/2025, the DON conducted an audit to review residents on pain management to ensure residents are receiving pain medication based on pain level parameters as ordered by the physician. • No other residents have been affected by the deficient practice. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • On 05/18/2025, DON/designee conducted an in-service regarding the policy and procedure for administering medication, to licensed nurses. The goal is to ensure proper, timely, and safe administration of medication as prescribed by the physician. • The Pharmacy Nurse consultant will conduct a 3-way medication cart audit on a monthly basis for the presence of medications and accuracy of orders. Findings will be reported to the DON for follow-up. • The Pharmacy Nurse consultant will continue monthly medication pass skills competency to licensed nurses. Any findings will be reported to the DON for follow-up. • The Medical Records Director/designee will conduct a daily audit for new physician orders for accuracy and will report findings to the DON during the daily stand-up meeting for follow-up. IV: Facility's plan to monitor corrective actions to achieve & sustain compliance; integrate the POC to QA process: • DON/designee will report issues or trends from the weekly random audits made on residents on pain management during the monthly QAA meeting for 3 months to ensure compliance. • The Pharmacy consultant will report issues or trends of monthly medication administration given by the pharmacy nurse consultant and monthly in-service educations provided regarding medication administration and review of residents on pain management. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the improper implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling Foley catheter. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as urinary catheters, to prevent the spread of multidrug-resistant organisms (MDROs). However, observations revealed that a nurse did not wear the required personal protective equipment (PPE) when exposing and administering a Lidocaine patch to the resident's lower back and when handling the resident's Foley catheter drainage bag. The resident involved had a history of lumbar vertebra fracture, spinal stenosis, and obstructive and reflux uropathy, and was dependent on staff for multiple activities of daily living. The resident utilized a wheelchair and had bilateral upper and lower extremity impairments. Physician orders and facility policy indicated that EBP should be implemented for this resident due to the presence of a Foley catheter, with specific instructions for PPE use during high-contact care activities. Interviews with nursing staff, the infection preventionist, and the director of nursing revealed inconsistent understanding and application of EBP requirements. Staff provided varying explanations regarding when gowns should be worn, with some indicating that gowns were only necessary when there was a risk of fluid exposure or direct skin contact, and others acknowledging that gowns should be worn for any contact with the Foley catheter or during medication administration involving direct resident contact. Facility policies reviewed by surveyors confirmed the expectation for PPE use in these scenarios, but the observed practices did not align with these requirements.
Plan Of Correction
F-tag 880 1. Corrective Action for residents found to have been affected: • Resident 21 is no longer in the facility as of 05/22/2025. • The IP Nurse will conduct direct observation of • LVN 1 was provided one-on-one in-service by the IP Nurse on 5/18/2025 regarding donning and doffing of PPE with residents on Enhanced Barrier Precaution (EBP). II. Facility's Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 5/28/2025, the IP Nurse conducted a direct observation on random facility staff in regard to proper donning and doffing of PPE with residents on EBP. 5/5 facility staff were observed and all are compliant. • No other residents were affected by the deficient practice. III. Measures and systemic changes put in place to ensure deficient practices do not recur: • The IP Nurse provided in-service to facility staff on 05/18/2025, regarding the policy and procedure for Enhanced Barrier Precaution (EBP). The goal is to prevent and control the risks of spreading infectious microorganisms to residents. • Facility staff will be observed for 1 month, then monthly, with 5 staff observations to ensure proper donning and doffing of PPE when in contact with residents on EBP. • Audit findings will be reported to the DON for follow-up. IV. Facility's plan to monitor corrective actions to achieve & sustain compliance: • The IP Nurse will report findings of donning and doffing observations during the monthly QAA meeting for 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Resident with Documented Food Allergy Served Allergenic Food Item
Penalty
Summary
A deficiency occurred when a resident with documented allergies to avocado, banana, and strawberries was served a breakfast tray containing half a banana. The resident's admission record and order summary report clearly indicated these allergies, and the resident was also noted to have dysphagia, asthma, and a history of repeated falls. The resident's cognitive status was moderately impaired, and they required significant assistance with daily activities. During the tray line observation, the dietary aide admitted to missing the allergy sign on the tray due to nervousness and acknowledged the importance of checking for allergy tags, which are written in red, to prevent such errors. The dietary supervisor confirmed that both the dietary aide and supervisor are responsible for checking meal trays to ensure residents with food allergies do not receive restricted items. Facility policy requires identification of food allergies upon admission and mandates that meals for residents with severe allergies be specially prepared to avoid exposure and cross-contamination. Despite these procedures, the resident was still served a food item to which they were allergic, as observed and confirmed during the survey.
Plan Of Correction
F-tag 800 I: Corrective Action for residents found to have been affected: • On 05/17/2025, a banana was removed from Resident 194's meal tray by the dietary supervisor prior to meal tray delivery. II: Facility's Identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • Residents with food allergies were audited by the dietary supervisor on 5/17/2025. No other residents identified with the same deficient practice. • An immediate in-service education was provided by the dietary supervisor on 5/18/2025 to dietary staff to ensure that residents' identified allergies are not provided in the resident's meal tray. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • The Registered Dietitian will conduct a tray line observation on a weekly basis for 1 month, then monthly for 3 months to ensure residents will not receive identified food allergy items on the food tray. IV. Facility's plan to monitor corrective actions are achieve & sustain compliance: • Integrate the POC to QA Process. • The result of tray line observation conducted by the RD will be reported by the Dietary Supervisor during the monthly QAA meeting for 3 months to ensure compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/25
Failure to Implement and Document Effective QAPI Oversight
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to implement and ensure effective oversight of the Quality Assurance and Performance Improvement (QAPI) plan. The Administrator (ADM) reported that while QAPI meetings were held monthly, there was no documentation of these meetings prior to March. Issues regarding call light response times were identified at the end of February, and these issues persisted into March, as noted during resident council meetings. However, a QAPI initiative addressing call light response times was not implemented until March, despite the presence of ongoing trends. The ADM acknowledged that earlier intervention through QAPI could have been beneficial but was delayed due to reliance on the previous Director of Nursing's (DON) opinions. Further review revealed that there was no QAPI activity documented for April, even though the call light response issue remained unresolved. The ADM stated that no complaints about call lights were raised during the resident council meeting in April, and attempts to locate previous QAPI documentation in the DON's office were unsuccessful. The ADM recognized that failure to implement QAPI in a timely manner could allow negative trends to continue, increasing risks to residents and failing to enhance care. The QAPI process was described as ongoing and monitored daily, with new issues added as trends were identified, but the lack of documentation and timely action was evident. The facility's policies and procedures outlined a comprehensive QAPI program, including regular data tracking, performance measurement, root cause analysis, and corrective action monitoring. The QAPI committee was responsible for overseeing these activities, meeting monthly to review reports and make necessary adjustments. However, the lack of documentation, delayed initiation of QAPI projects, and incomplete follow-through on identified issues demonstrated a failure to adhere to these established policies and procedures, resulting in the cited deficiency.
Plan Of Correction
F-tag 867 I: Corrective Action for residents found to have been affected: • On May 2025, four QAPI's were initiated: - Wound Management (05/06/2025) - Informed Consents for initiation and renewal of Psychotropic Drugs (05/06/2025) - Risk Management Process (05/06/2025) - Pharmacy Recommendation Compliance (05/13/2025) II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • QAPI's were initiated based on the identified issues will be presented during the monthly QA meeting. III: Measures and systemic changes put in place to ensure deficient practices do not recur: • An in-service education were provided by the Assistant Regional Director of Clinical Services (ARDCS) to the Administrator and Department Members on 6/09/2025 regarding the QAPI/QAA Activities, roles and responsibilities of each member of the QAPI/QAA Committee members to ensure a system and processes are in place for reporting/identifying problems in the facility, establishing corrective actions by the committee, establishing methodology for analysis of the action plans, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and the committee members' responsibilities in reporting findings to the administrator and the governing body. • The Administrator/designee shall initiate posted information monthly to the residents and staff regarding projects that the QAPI committee is working on, including the progress of each project. IV: Facility's plan to monitor corrective actions, achieve & sustain compliance, and integrate the POC to QA Process: • The Assistant Regional Director of Clinical Services (ARDCS) will review the quarterly activities of the QAPI program that is discussed in the quarterly QA Committee and posted in the facility. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V: Corrective Action Completion Date: 6/12/2025
Resident Bedrooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that two of its resident bedrooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, two multi-bed rooms were found to be below the 80 square feet per resident requirement, and two single-bed rooms were below the 100 square feet requirement. This was identified through a review of the facility's Client Accommodations Analysis form and confirmed by direct measurement during an observation with the Maintenance Supervisor, who acknowledged the rooms were small for two beds and was unaware of the correct measurement standards. The Director of Nursing also confirmed that rooms deemed too small could become cluttered, potentially leading to falls due to insufficient space.
Plan Of Correction
F-tag 912 I: Corrective Action for residents found to have been affected: • On 06/09/2025, the Social Services Director/designee conducted a room visit to residents in rooms 5 and 6. No signs or indications of any adverse effects from being in a room with more than occupancy required. Resident's feel safe, privacy not invaded, and no negative outcomes with care and treatment. Current needs are met. II: Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 06/09/2025, the Maintenance Director updated the room measurements for all rooms to ensure residents have adequate space for care, access and use of assistive devices and furniture and for visitors. • All other rooms are in compliance. III: Measures and systemic changes put in place to ensure deficient practices do not recur: Application for the room waiver was sent to Feven Isaac on 06/10/2025. Department managers will conduct room rounds daily to ensure resident satisfaction and validate through feedback. IV: Facility's plan to monitor corrective actions are achieve & sustain compliance; Integrate the POC to QA Process: • The Social Services Director/designee will report findings of the daily room rounds during the monthly QAA meeting x 3 months for compliance. • Trends and patterns will be discussed for further recommendations and interventions. • The administrator will monitor compliance. V. Corrective Action Completion Date: 6/12/2025
Failure to Monitor and Document Resident Status After Abuse Allegation
Penalty
Summary
The facility failed to ensure that the status of an alleged abuse allegation involving a resident was properly assessed and monitored. The resident, who had a history of stroke, mild cognitive impairment, and required significant assistance with activities of daily living, reported to a nurse practitioner that she had been inappropriately touched by a male staff member. Following this report, a Change in Condition (COC) evaluation was initiated, and facility policy required 72-hour monitoring with documentation for every shift. However, the progress notes only showed documentation on three occasions during the monitoring period, rather than for every shift as required. Interviews with facility staff confirmed that 72-hour monitoring should have been conducted and documented for every shift following a COC, especially in cases of alleged abuse. The Director of Nursing Covering Consultant and a Licensed Vocational Nurse both stated that this monitoring is necessary to observe any developments in the resident's condition and to ensure their safety and well-being. The facility's policy also specified that changes in a resident's condition or status must be recorded in the medical record. The lack of consistent monitoring and documentation represented a failure to follow professional standards and facility policy in response to the abuse allegation.
Plan Of Correction
a) How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 1 was discharged to home on May 20, 2025. b) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents who experience a Change of Condition, to include an allegation of abuse, have the potential to be affected. On 05/23/2025, the MRD (Medical Records Director) reviewed the facilities current residents noted to have Change of Condition within the past 30 days to ensure that they were assessed timely and placed on 72-hour alert charting/documentation. The audit identified other residents noted to be affected. Current residents identified to be affected were reassessed on 05/30/2025 by RN. In addition, the nurse who completed the COC has also been identified and has received 1:1 formal education on the Policy & Procedure titled "Change in a Resident's Condition or Status". c) What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. On 05/27/2025, the Director of Nursing conducted an in-service with the facility's licensed nursing staff on the Policy & Procedure titled "Change in a Resident's Condition or Status". The Medical Records Department (MRD) will audit the medical records of residents identified to have a change in condition, including allegation of abuse, during each workday to ensure timeliness of documentation and that residents are also placed on alert charting/documentation. Non-compliance identified will immediately be brought to the attention of the Director of Nursing for further follow-up. d) How the facility plans to monitor its performance to make sure that solutions are sustained. The MRD will summarize the audit findings and present during the Quarterly QAPI meeting for further recommendation by the QA Steering Committee, until compliance has been achieved for three consecutive quarters. Compliance Date: 05/30/2025
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a written notice of a seven-day bed hold to a resident and their responsible party when the resident was transferred to a General Acute Care Hospital (GACH). The resident, who was admitted with diagnoses including cerebral infarction, sick sinus syndrome, and dementia, did not have the capacity to understand and make decisions. The responsible party was informed of the transfer but was incorrectly told that signing the bed hold document was unnecessary. Upon review, it was found that no bed hold was placed for the resident, and the facility's policy requiring written notice of bed hold was not followed. The Director of Nursing acknowledged that a seven-day bed hold should have been placed and a written notice provided, as it was the resident's right to return to their room. The Business Office Manager confirmed that the facility's policy mandates providing written bed hold notices to residents and their representatives, which was not done in this case. The failure to issue a bed hold was attributed to ongoing complications between the facility and the resident's responsible party, as noted by the Director of Nursing.
Failure to Inventory Resident's Clothing Before Laundering
Penalty
Summary
The facility failed to ensure that a resident's clothing was properly inventoried before being sent to an outside laundry vendor, resulting in the loss of the resident's clothing. The resident, who was admitted with hemiplegia and hemiparesis, had moderately impaired cognition and was dependent on facility staff for activities of daily living. The facility did not maintain an inventory log of clothing sent out for laundering, which led to the inability to track and ensure the return of the resident's clothing. Interviews with facility staff and the resident's responsible party revealed that there was no system in place to document or track the clothing sent to the laundry vendor. The Director of Nursing confirmed the absence of an inventory list, acknowledging the facility's inability to ensure the return of laundered items. The facility's policy on personal property, which requires the inventory and documentation of residents' belongings, was not followed, contributing to the deficiency.
Inaccurate Documentation in IDT Conference Notes
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) Conference Notes for a resident accurately reflected the list of concerns and topics discussed during the IDT meeting. The resident, who was admitted with hemiplegia and hemiparesis, had a moderately impaired cognition and was dependent on facility staff for activities of daily living. During a review of the resident's Family Input/Concerns Interdisciplinary Care Plan Meeting Note, it was found that various topics, including nursing/medical conditions and dietary/nutrition plans, were discussed. However, the IDT Conference Note only mentioned pain medication and consulting with a pulmonologist, omitting the family's concerns. The Director of Nursing (DON) confirmed that the concerns were received via email and discussed in the IDT meeting but were not documented in the IDT Conference Note. This omission was contrary to the facility's policy and procedure, which encourages the participation of the resident's family in the development and revision of the care plan. The failure to document these concerns could lead to a lack of communication and implementation of the resident's plan of care.
Failure to Monitor Diabetic Resident's Condition
Penalty
Summary
The facility failed to ensure that a resident with type 2 diabetes mellitus received appropriate monitoring and care as per physician orders. The resident was supposed to have weekly complete blood count (CBC) and comprehensive metabolic panel (CMP) tests, which were not conducted. Additionally, the resident's blood sugar was not checked during a significant change in condition, which included increased confusion, slurred speech, and altered mental status over several days. These lapses in care led to the resident being transferred to a general acute care hospital with critically high blood sugar levels and other severe symptoms. The resident, who had a history of type 2 diabetes mellitus, cancer of the kidney, and a gastrostomy tube, was admitted to the facility with orders for Sitagliptin Phosphate and weekly CBC and CMP tests. Despite these orders, the facility did not perform the required tests, and the resident's blood sugar was not monitored during episodes of confusion and altered mental status. The staff failed to notify the physician of the resident's condition and critical lab results, which contributed to a delay in diagnosis and treatment. Interviews with facility staff revealed that there was a lack of communication and follow-up regarding the resident's condition and lab results. The Director of Nursing admitted to not ensuring that the ordered labs were conducted and acknowledged that the resident's hospitalization could have been prevented with proper monitoring and timely notification of the physician. The facility's policies and procedures for lab and diagnostic test results and changes in a resident's condition were not followed, leading to the resident's critical condition and subsequent hospitalization.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medication carts and an intravenous (IV) cart were locked when unattended, as observed during a survey. Two medication carts and one IV cart were found unlocked and unattended in the facility hallway. Licensed Vocational Nurse (LVN) 11 confirmed that the carts were unlocked because the lock button was popped out, allowing the drawers to be opened. The facility's policy and procedure (P&P) on medication storage, revised in November 2020, requires that drugs and biologicals be stored in locked compartments, and that medication carts should not be left unlocked and unattended. Additionally, the facility failed to secure the keys to medication cart 2, which were left unattended on top of the cart. LVN 11 admitted to accidentally leaving the keys on the cart and acknowledged that the keys should have remained with him until the medication count was completed with the incoming shift. The facility's P&P on controlled substances, revised in November 2022, states that only authorized personnel should have access to locked medications, and the charge nurse on duty is responsible for maintaining the keys to controlled substance containers. The facility also failed to label opened medications in accordance with its P&P. Resident 10's Vancomycin solution and Resident 15's Acetylcysteine solution, both stored in the medication refrigerator, were found without open date labels. LVN 2 confirmed that these medications should have been labeled with the open date. The Director of Nursing (DON) stated that licensed nurses are required to label new multi-dose medications with the open date and expiration date. The facility's P&P on medication storage, revised in January 2018, mandates that the date opened and new expiration date be recorded when the original seal of a manufacturer's container is broken.
Deficiency in Bed Positioning and Restraint Assessment
Penalty
Summary
The facility failed to properly assess, care plan, and obtain a physician's order for the positioning of beds against the wall for three residents, potentially leading to the unnecessary use of physical restraints. Resident 15, who was admitted with cerebral infarction and dysphagia, had severely impaired cognitive skills and was fully dependent on staff for various activities. During an observation, Resident 15's bed was found with one side against the wall and the opposite siderail up, without a documented care plan or physician's order. Resident 24, admitted with osteoarthritis and COPD, had fluctuating decision-making capacity but was cognitively intact according to the MDS. This resident required assistance for several activities and was observed with the bed against the wall and a siderail up. The LVN present was unaware of the reason for this arrangement and did not adjust the bed, indicating a lack of proper assessment and documentation. Resident 28, with a fracture and lack of coordination, also had their bed positioned against the wall without a care plan or physician's order. The RN confirmed that none of the residents had assessments or orders for their bed positioning, which could be considered a restraint. The facility's policy on restraints emphasizes that any device restricting movement without easy removal by the resident is considered a restraint, highlighting the deficiency in addressing the bed positioning in the residents' comprehensive assessments.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) properly documented the administration of a controlled medication for a resident, leading to a discrepancy in the medication count. LVN 11 did not immediately enter the date and time of administering Hydrocodone-Acetaminophen to Resident 16 on the Medication Administration Record (MAR) and the Controlled Medication Sheet, as required by the facility's policy and procedure. This oversight was discovered during an end-of-shift narcotic count, where it was found that the count of Hydrocodone-Acetaminophen tablets was off by one. LVN 11 admitted to forgetting to document the administration of the medication at 3 a.m., which he later corrected. Additionally, the facility failed to prevent the administration of a resident's medication to another resident. LVNs 11 and 12 administered Refresh Tears Ophthalmic Solution, prescribed for Resident 16, to Resident 139 due to the unavailability of the latter's medication. This practice was against the facility's policy, which clearly states that medications supplied for one resident should never be administered to another. The nurses involved justified their actions by the need to ensure Resident 139 did not miss his doses, but this resulted in inaccurate documentation and potential mismanagement of medication regimens. The Director of Nursing (DON) confirmed that the correct procedure for medication administration was not followed, emphasizing that documentation should occur immediately after administering medication. The facility's policies and procedures, which were reviewed, clearly outline the steps for handling controlled substances and the importance of adhering to the five rights of medication administration. The failure to document in real-time and the inappropriate sharing of medications between residents were identified as significant deficiencies in the facility's pharmaceutical services.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for two residents, leading to significant deficiencies in medication administration. For Resident 18, the Licensed Vocational Nurse (LVN) documented the administration of Ipratropium-Albuterol Solution for shortness of breath on specific dates, despite the medication not being delivered to the facility. This discrepancy was confirmed through a review of pharmacy delivery receipts and interviews with the LVN, who admitted to documenting the administration without verifying the medication's availability. Similarly, for Resident 139, licensed nurses documented the administration of Refresh Tears Ophthalmic Solution for dry eyes on multiple occasions, even though the medication was not available in the facility. This was corroborated by pharmacy delivery receipts and interviews with the resident, who reported inconsistencies in medication administration and a lack of eye drops, resulting in discomfort. The LVN admitted to signing the MAR for doses that were not administered. The Director of Nursing (DON) confirmed that the correct procedure for medication administration was not followed, as medications were documented as given without actual administration. The facility's policy requires verification of medication availability and accurate documentation post-administration, which was not adhered to in these cases. This failure to ensure accurate medical records increased the risk of adverse reactions and complications for the residents involved.
Failure to Implement Individualized Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans with measurable objectives, timeframes, and interventions for two residents, leading to deficiencies in care. Resident 24, who was admitted with diagnoses including diabetes mellitus and a pressure injury, was non-compliant with turning and repositioning, which are critical for wound management. Despite the increase in the size of the pressure injury, the care plan did not address this non-compliance, and there was no formulated plan to encourage compliance or involve the resident and family in care discussions. Resident 9, diagnosed with an anxiety disorder, was prescribed Lorazepam as needed for anxiety. However, the Medication Administration Record did not document any behavioral monitoring for anxiety symptoms before administering the medication. Additionally, there was no care plan in place to monitor the resident for side effects or adverse reactions to the medication, which is essential for evaluating the effectiveness of psychotropic medications. Interviews with staff, including a Licensed Vocational Nurse, a Registered Nurse, and the Director of Nursing, confirmed the absence of necessary care plans for both residents. The facility's policy requires comprehensive, person-centered care plans with measurable objectives, but this was not adhered to, potentially affecting the delivery of necessary care and services for the residents involved.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
The licensed nursing staff at the facility failed to adhere to professional standards of practice for a resident with a gastrostomy tube (G-Tube). The staff did not flush the G-Tube with 30 milliliters of water before and after administering medications, as required by the physician's orders. Additionally, the staff did not check the gastric residual volume prior to medication administration, which is necessary to ensure the resident's stomach can handle the medications and to prevent potential complications. The resident involved had a history of cerebral infarction, left hemiplegia, hemiparesis, dysphagia, and required tube feeding. The care plan for the resident indicated the need for specific interventions to prevent aspiration and ensure proper medication administration. However, during an observation, the Licensed Vocational Nurse (LVN) did not follow these protocols, resulting in the resident receiving 560 mL of fluids during medication administration, which was not in accordance with the facility's policy. Interviews with the LVN and the Director of Nursing (DON) revealed a lack of awareness of the physician's orders and facility policies regarding medication administration via the G-Tube. The facility's policy required medications to be mixed with 5-15 mL of water and the G-Tube to be flushed with 15-30 mL of water between each medication. The failure to follow these procedures was identified as a deficiency, with potential health risks for the resident.
Resident Not Assisted Out of Bed as Ordered
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including cerebral infarction, abnormalities of gait and mobility, and lack of coordination, was able to get out of bed as ordered. The resident's Minimum Data Set indicated severe cognitive impairment and total dependence on staff for activities of daily living (ADLs), requiring two or more staff for assistance. Despite a physician's order for the resident to get out of bed as tolerated and use wheelchair mobility, and a care plan indicating the need for substantial assistance for transfers, the resident remained in bed since admission. The resident expressed a desire to participate in Cinco de Mayo festivities, but staff reported an inability to transfer the resident due to room size constraints and lack of appropriate equipment. Interviews with staff and family members revealed that the facility did not have a Geri chair or a suitable wheelchair available for the resident, and staff found it challenging to maneuver the Hoyer lift in the resident's room. Observations confirmed the absence of a wheelchair in the resident's room and noted that there was sufficient space for care. The Director of Rehabilitation acknowledged the need for attempts to get the resident out of bed, emphasizing the benefits of engaging in out-of-room activities. The facility's policy on ADLs indicated that residents should receive necessary services to maintain or improve their ability to carry out ADLs, but this was not adhered to in the case of the resident.
Failure to Assist Residents with Hearing Needs
Penalty
Summary
The facility failed to provide necessary assistance to two residents, Resident 9 and Resident 18, in accessing vision and hearing services. Resident 9, admitted with anxiety disorder and a history of falls, was not assisted in recharging her hearing aid, leading to her frustration and inability to hear properly. Despite being able to make independent decisions, Resident 9 required assistance to get out of bed and was observed expressing frustration due to her non-functional hearing aid. Staff interviews confirmed that Resident 9 had difficulty hearing and needed her hearing aid to communicate effectively. Resident 18, admitted with chronic respiratory failure, was not scheduled for necessary ancillary services to assess her hearing needs. Although Resident 18 was able to make independent decisions, she required assistance with daily living activities and expressed frustration over her inability to hear staff. It was noted that Resident 18 had a pair of hearing aids at home but was not using them at the facility. Staff interviews revealed that Resident 18 was not identified as having a hearing impairment, and there was no care plan in place to address her hearing difficulties. The facility's policy required staff to assist residents with hearing impairments, but this was not adequately implemented for these residents.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to provide necessary safety interventions for a resident with a history of falls, specifically by not placing floor mats on both sides of the resident's bed. The resident, who was admitted with conditions including atrial fibrillation, dementia, and mobility abnormalities, was on anticoagulant medication, increasing the risk of injury from falls. The resident's care plan included interventions such as providing fall mats to prevent falls and minimize complications, but these were not in place during an observation. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing Services, confirmed the absence of fall mats and acknowledged the importance of following the care plan to prevent falls and potential injuries. The facility's policies on falls and safety emphasized the need for specific interventions to prevent accidents and promote resident safety, which were not adhered to in this case.
Failure to Monitor Dialysis Resident's Fluid Intake and Output
Penalty
Summary
The facility failed to ensure proper monitoring of a resident who required hemodialysis, specifically regarding the resident's fluid intake and output as per physician's orders. The resident, who was admitted with diagnoses including diabetes mellitus type 2, end-stage kidney disease, and pleural effusion, was placed on a 1000 mL fluid restriction. However, there were no orders to monitor the resident's output, and documentation revealed that the Certified Nurse Assistants and Licensed Nurses did not monitor the resident's intake and output. Interviews and record reviews indicated that from the specified dates, there was no documentation on the Medication Administration Record to demonstrate that the fluid restriction was adhered to, nor was the resident's output monitored. The Licensed Vocational Nurse acknowledged the lack of documentation and the potential risk of fluid overload. The Director of Nursing emphasized the importance of following physician's orders for fluid restriction and monitoring intake and output to prevent complications. The facility's policy indicated that fluid balance should be monitored, but this was not followed in the case of the resident.
Failure to Assess and Address PTSD in Resident
Penalty
Summary
The facility failed to ensure that a resident with a history of Post Traumatic Stress Disorder (PTSD) was properly screened and assessed for re-traumatization. The resident, who was admitted with diagnoses including PTSD and depression, was observed to be non-verbal and had modified independence in cognitive skills for daily decision-making. Despite these conditions, the facility did not conduct a trauma assessment to identify potential triggers or traumatic experiences that could lead to re-traumatization. The Social Service Designee (SSD) admitted to not knowing what a trauma assessment entails and was unaware of any specific triggers for the resident. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the care plan for trauma-informed care did not include an assessment of the resident's trauma history or potential triggers. The DON acknowledged that the facility staff were not informed about the resident's traumatic experiences, which could help in avoiding re-traumatization. The facility's policy on Trauma Informed Care and Culturally Competent Care emphasized the need for individualized care plans addressing past trauma, but this was not implemented for the resident in question.
Improper Use of Bed Rails in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of bed rails for two of three sampled residents, as per the facility's policy and procedure. The deficiency was identified through observation, interview, and record review, revealing that the facility did not assess, monitor, evaluate, or provide a care plan for residents with side rails. This oversight had the potential to result in inappropriate use of bed rails, which could lead to entrapment and/or injuries. Resident 15 was admitted with diagnoses including cerebral infarction and dysphagia, with severely impaired cognitive skills and functional limitations in both upper and lower extremities. The resident was fully dependent on staff for various activities, yet during an observation, the resident's bed was found with the left siderail up and the right side against the wall, without any documented assessment or care plan for the use of siderails. Resident 24, with diagnoses including left knee osteoarthritis and COPD, had fluctuating capacity to understand and make decisions. Despite requiring assistance for mobility, there was no documented assessment or care plan for the use of siderails. Similarly, Resident 28, with impairments in lower extremity mobility, was observed with both siderails up and the bed against the wall. Interviews with staff revealed a lack of awareness and documentation regarding the use of siderails, and the Director of Nursing confirmed the absence of necessary assessments and consents for these residents.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of PTSD and depression. The resident, who was admitted with these diagnoses, was observed to be non-verbal and in bed during an initial tour. The facility's Director of Nursing (DON) admitted that the resident's care plan did not include an assessment for trauma, and the facility was unaware of the resident's triggers or history. This lack of assessment and understanding of the resident's trauma history indicates a failure to provide an individualized approach to care. Interviews with staff revealed further deficiencies in the facility's approach to trauma-informed care. A Licensed Vocational Nurse (LVN) responsible for the resident was not trained or informed about trauma-informed care and was unaware of potential triggers for the resident. Additionally, the Infection Preventionist/Director of Staff Development (DSD) had not conducted in-service training on trauma-informed care due to being new in the role. The facility's policy on trauma-informed care, which mandates staff training on trauma screening and assessment tools, was not being followed, contributing to the deficiency in care for the resident.
Failure to Monitor Anxiolytic Medication Use
Penalty
Summary
The facility failed to ensure that a resident prescribed an anxiolytic for anxiety disorder was properly monitored for anxiety behaviors prior to medication administration and for side effects or adverse reactions every shift. The resident, who was admitted with a diagnosis of anxiety disorder, was prescribed Lorazepam to be taken as needed for anxiety. However, the Medication Administration Record (MAR) did not document any behavioral monitoring for anxiety prior to administering the medication. Additionally, the comprehensive care plan for the resident did not include a plan of care related to the use of the anti-anxiety medication. Interviews with the Registered Nurse and the Director of Nursing Services revealed that there was no documentation of behavior monitoring or side effect monitoring, which is necessary to determine the effectiveness of the medication and whether adjustments are needed. The facility's policy on psychotropic medication management requires such monitoring and documentation, which was not followed in this case.
Ice Buildup in Walk-In Freezer
Penalty
Summary
The facility failed to ensure the walk-in freezer in the kitchen did not have an ice buildup, which was observed during a survey. The ice buildup was located at the top portion of the freezer, and this issue was noted during an observation on May 18, 2024. During an interview, a kitchen staff member expressed concern that the ice buildup might leak and potentially destroy the residents' food supply. The Maintenance Director acknowledged the ice condensation as a normal occurrence due to the freezer's age and mentioned that the insulation line needed to be redone. The Registered Dietician confirmed that the ice buildup had been identified during kitchen audits and had been addressed by maintenance several times, although it was not considered ideal. The facility's Policy and Procedure on Food Receiving and Storage, revised in November 2022, indicated that refrigeration should be monitored daily to ensure food is not stored under leaking water lines or lines with condensation. Despite these guidelines, the issue persisted, indicating a failure to adhere to the facility's own policies and procedures regarding food storage and safety.
Deficiencies in Facility-Wide Assessment and Resident Needs Evaluation
Penalty
Summary
The facility failed to include the Infection Prevention Nurse (IPN) in the facility-wide assessment conducted on January 30, 2024, for a population of 39 residents. This omission was identified during a record review on May 18, 2024, and confirmed in an interview with the Director of Nursing (DON) and Administrator (Admin) on May 20, 2024. The Admin acknowledged forgetting to include the IPN, despite recognizing the importance of the IPN's role due to the presence of infectious diseases and the vulnerability of immunocompromised residents. Additionally, the facility did not adequately assess the needs of a resident admitted with a history of trauma, including PTSD, depression, and unspecified atrial fibrillation. The resident's Minimum Data Set (MDS) indicated modified independence in cognitive skills for daily decision-making. During an interview, the DON and Admin admitted that the facility assessment did not include PTSD under the psychiatric/mood disorder category, despite the resident's significant other having verbalized the condition. The facility's policy requires annual assessments to ensure resources meet residents' needs, but this was not reflected in the current assessment.
Deficiency in QAA and QAPI Committee's Monitoring and Feedback Systems
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee failed to maintain effective systems for obtaining and using feedback from direct care staff, residents, and resident representatives regarding trauma-informed care. Additionally, the committee did not monitor, review, or analyze data for performance improvement on issues such as abuse, the use of side rails or beds against the wall, and changes in residents' conditions. During an interview and record review, the Administrator and Director of Nursing admitted that the facility lacked evidence of monitoring these issues and did not have logs to track and trend facility issues. The Administrator acknowledged that while department heads address issues during their rounds, the facility was not following its QAPI policy for developing, monitoring, and evaluating performance indicators.
Inadequate Infection Control for Resident on Antibiotic Treatment
Penalty
Summary
The facility failed to maintain appropriate infection control measures for a resident who was on antibiotic treatment for Clostridioides difficile (C-diff). The resident, who had a history of type 2 diabetes mellitus, kidney cancer, and required a gastrostomy tube for nutrition and medication, was initially placed on strict single room isolation with contact precautions due to a positive C-diff diagnosis. However, the Infection Preventionist (IP) discontinued the isolation on February 8, 2024, because the resident showed no signs and symptoms of diarrhea, and there was no order for enhanced precautions. Despite the discontinuation of isolation, the resident was still on Vancomycin treatment until February 10, 2024. During this period, direct care staff, including Certified Nurse Assistants (CNAs) and Licensed Vocational Nurses (LVNs), were not wearing personal protective equipment (PPE) when providing care to the resident, as they were not on isolation. This oversight had the potential to expose other residents to infection. The facility's policy on infection surveillance indicated that the IP should collect data to determine the effectiveness of transmission-based precautions, but this was not adequately followed in this case.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that two resident rooms met the required square footage per resident, as observed during a survey. Rooms were found to be 149.80 square feet each, accommodating two residents per room, which does not meet the minimum requirement of 80 square feet per resident in multiple occupancy rooms. This deficiency was noted during an initial tour and confirmed through interviews and record reviews. The facility had been granted a waiver for these rooms in December 2021, which the Administrator believed would not adversely affect residents' health and safety. However, the deficiency led to practical challenges in providing care. A Certified Nurse Assistant reported difficulties in maneuvering a Hoyer lift in these rooms, making it challenging to provide necessary care for residents requiring extensive assistance. Observations confirmed that there was insufficient space for nursing staff to deliver care effectively, although no complaints were received from residents regarding room size. The Administrator mentioned adjustments in bed assignments to better accommodate residents' needs, but the space constraints remained a significant issue.
Failure to Verify Caregiver Competencies and Backgrounds
Penalty
Summary
The facility failed to ensure that caregivers for Resident 32 were properly identified, had their competencies verified, and were provided with an orientation to the facility's rules and regulations before being allowed to render care. Resident 32, who was admitted with diagnoses including anxiety disorder and senile degeneration of the brain, required assistance from two or more persons for activities of daily living. Despite this, the caregivers provided by the resident's family were not subjected to background checks or competency verification, and there was no physician order or contract for a private caregiver. The Director of Staff Development, Registered Nurse 1, and the Director of Nursing Services all confirmed that there was no facility orientation or checklist for the caregivers, posing a health and safety risk to Resident 32. The Administrator acknowledged the lack of a specific contract with the company providing the caregivers and admitted that it was the responsibility of the facility's staff to ensure the safety of residents, staff, and visitors. The facility's policies required that nurse aides possess appropriate skills and competencies, and that their certifications be verified through the state registry, which was not done in this case.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the California Department of Public Health (CDPH), Local Law Enforcement, and the State Long Term Care Ombudsman within the required two-hour timeframe. This deficiency involved a resident who was admitted with diagnoses including cerebral infarction and malnutrition, and who had severely impaired cognitive skills, requiring total dependence on staff for personal care. The resident's family member reported that the resident alleged physical aggression by three Certified Nurse Assistants, which was communicated to the Operations Manager. The Operations Manager did not consider the report as an allegation of abuse, viewing the conversation as informal and not indicative of physical abuse. Consequently, no thorough investigation was conducted, and the incident was not reported to the necessary authorities. The facility's policy, which mandates immediate reporting of suspected abuse within two hours, was not followed. This resulted in the CDPH being unaware of the abuse allegation until over a month later, hindering timely investigation.
Delayed Communication of Lab Results to MD
Penalty
Summary
The facility failed to ensure that laboratory findings were promptly communicated to the medical doctor (MD) for a resident diagnosed with dementia, generalized muscle weakness, and paroxysmal atrial fibrillation. The resident was admitted to the facility on February 24, 2024, and had a telephone order for monthly laboratory tests, including a complete blood count (CBC) and basic metabolic panel (BMP), dated May 8, 2024. The laboratory results were collected and received on May 10, 2024, but were not relayed to the MD until May 13, 2024. Interviews with the Registered Nurse (RN1) and the Director of Nursing (DON) confirmed that the laboratory results, whether normal or abnormal, should have been communicated to the MD as soon as they were available. The facility's policy and procedure (P&P) indicated that direct voice communication with the physician is preferred for presenting results requiring immediate notification, and a physician should respond within one hour regarding a lab test result requiring immediate notification. The delay in notifying the MD of the laboratory results was identified as a deficiency in the facility's practice.
Latest citations in California
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
