Berkley Post-acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Van Nuys, California.
- Location
- 6600 Sepulveda Blvd, Van Nuys, California 91411
- CMS Provider Number
- 056253
- Inspections on file
- 53
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Berkley Post-acute during CMS and state inspections, most recent first.
The facility failed to ensure that CNAs had the required competencies to provide colostomy care. The DSD reported that all nursing staff are expected to complete annual skills competencies, including colostomy care, and provided an attendance roster for a skills day that covered pressure injury prevention, incontinent care, colostomy care, and indwelling catheter care. Three CNAs confirmed their signatures were not on the roster, stated they did not attend the colostomy care competency, and cited part-time status or working an afternoon shift while training was held on the day shift. One CNA also reported being unsure whether she was allowed to change a resident’s colostomy. Facility documents, including the Facility Assessment Tool and the nursing staff competency policy, stated that staff must demonstrate specific competencies based on resident needs and receive competency evaluations on hire and annually, but these requirements were not met for the sampled CNAs regarding colostomy care.
A resident with COPD, heart failure, lack of coordination, severely impaired cognition, and dependence on staff for eating was observed being assisted with feeding by a CNA who stood over and hovered rather than sitting at eye level. The IP, present during the observation, confirmed the CNA's positioning and stated the CNA should be seated for safety and respect. The CNA later acknowledged she knew she was expected to sit in a chair and be at eye level while assisting. Facility policy on quality of life and dignity requires that residents, including those who are cognitively impaired, be treated with dignity and respect at all times.
The facility failed to follow its meal service policy by not documenting required food temperatures for multiple lunch and dinner meals, including regular, mechanical soft, and puree entrées, side dishes, beverages, and gravy. Review of temperature logs showed entire sections left blank on several days, and the Dietary Supervisor confirmed that cooks are responsible for checking and recording all food temperatures before meal service to ensure compliance with temperature regulations and to demonstrate that checks were performed. This lapse in documentation affected nearly all residents receiving meals during the affected services.
A resident admitted with type 2 DM, hemiplegia/hemiparesis after CVA, and glaucoma had physician orders for bedtime Atorvastatin and Semglee (insulin glargine) starting on the day of admission. The medications were not available at the scheduled bedtime dose and were delivered by the pharmacy early the following morning. The MAR showed the 9 p.m. doses were not administered and were coded as medication not available. Nursing staff did not notify the physician of the missed doses, and there was no documentation of any communication or clarification of orders, despite facility policies requiring timely pharmaceutical services and thorough charting.
A resident with multiple medical conditions, including diabetes and a gastrostomy, was not provided a comprehensive nutritional assessment within seven days of readmission, as required by facility policy. The assessment was completed on the twelfth day, despite documented weight loss and the resident's dependence on staff for daily care. Both the RD and DON confirmed the delay, which did not meet the facility's established protocols.
The facility did not document room temperature checks for three days, as required by their policy, potentially affecting residents' comfort. The Maintenance/Housekeeping Director confirmed the lack of documentation, and the responsible Maintenance Assistant admitted to not performing the checks due to forgetfulness and being busy.
Two unidentified and unlabeled medication tablets were found in a medication cart at Nursing Station 1, violating the facility's medication labeling and storage protocols. The IPN confirmed the labeling requirements, and LVN1 admitted to forgetting to discard the tablets. The DON emphasized the need for proper storage to ensure medication effectiveness.
The facility failed to manage medication administration and fall prevention, leaving medications unattended for two residents without proper assessments and not providing fall mats for a high-risk resident, increasing safety hazards.
The facility failed to document attempts of non-pharmacological interventions before administering PRN opioid medication to two residents, increasing the risk of adverse side effects. Despite care plans requiring such interventions, there was no evidence of their implementation before giving hydrocodone-acetaminophen. Interviews confirmed the lack of documentation and the importance of these interventions to potentially avoid unnecessary opioid use.
The facility failed to screen two visitors for COVID-19 symptoms, a dietary aide did not wash hands after touching a trash can lid, and several resident care items were not properly labeled or maintained, leading to potential infection risks.
A facility failed to ensure staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. The resident, with a history of muscle weakness, falls, and chronic kidney disease, had the capacity to make decisions. A nurse entered the room without knocking, acknowledging the oversight and the importance of respecting personal space. The facility's policy mandates knocking and requesting permission before entering.
A CNA failed to fully close a privacy curtain while assisting a resident with dressing, resulting in a privacy violation. The resident, who had intact cognition and required assistance with daily activities, was observed fully undressed with the curtain open. The CNA acknowledged the oversight, and the DON confirmed the expectation for full privacy during care.
A facility failed to maintain a comfortable environment in a resident room, where temperatures exceeded the acceptable range of 71 to 81 degrees Fahrenheit. Four residents, including those with end-stage renal disease and anemia, expressed discomfort due to the warm conditions. The Maintenance Supervisor and DON confirmed the importance of maintaining appropriate temperatures to prevent discomfort and dehydration.
A resident with conditions such as hypo-osmolality and kidney failure was on a strict fluid restriction of 1200 ml per day. Despite this, a water pitcher and additional cups were found at the bedside, contrary to the care plan and physician's orders. The Director of Staff Development confirmed the oversight, acknowledging the risk of fluid overload, while the DON stressed the importance of adhering to the fluid restriction to prevent electrolyte imbalance.
A facility failed to implement a scheduled toileting plan for a resident who was incontinent of bowel, despite being cognitively intact and requiring substantial assistance with walking. The care plan included regular intervals for offering a bedpan or urinal and assisting to the bathroom, but there was no documentation of scheduled bowel elimination. The facility's policy required a voiding diary, which was not maintained, as confirmed by staff interviews.
A facility failed to complete a post-dialysis assessment for a resident with end-stage renal disease, as required by their care plan. The Dialysis Assessment Form was left incomplete, and no vital signs or assessment notes were documented after the resident returned from dialysis. An LVN admitted to forgetting to fill out the necessary documentation, and the DON confirmed that licensed nurses are responsible for ensuring post-dialysis assessments are conducted to check for complications.
A facility failed to remove a lidocaine patch from a resident's knees after 12 hours as per the physician's order, leading to potential excessive dosing. The RN acknowledged the oversight, and the DON confirmed the risk of adverse effects due to prolonged application.
The facility failed to monitor side effects in two residents receiving anticoagulant therapy. One resident on apixaban for DVT prophylaxis had no documentation of monitoring for bleeding or bruising, despite the care plan's requirements. Another resident on heparin also lacked documentation of monitoring for side effects like bleeding and bruising. The facility's policy required such monitoring, which was not followed.
A facility failed to discard an expired vial of insulin lispro stored in a medication cart, which was past the 28-day usage period. A resident with diabetes mellitus had a physician's order for insulin administration, and the expired insulin posed a risk of ineffective blood glucose management. The deficiency was identified during an inspection, and the guidelines specify that opened insulin vials should be discarded after 28 days.
During a meal service, a cook failed to check the temperatures of pureed potatoes, chopped turkey, and chicken on the tray line, as required by the facility's policy. This oversight was observed and confirmed by the cook, posing a potential risk of foodborne illness to 110 medically compromised residents.
A facility failed to report an allegation of physical abuse involving a resident with COPD and respiratory failure to the State Survey Agency. The resident reported that a CNA was rough during care, causing bruises and throwing a teddy bear at them. The facility's administrator recognized this as an abuse allegation but did not report it, delaying an SSA inspection and potentially leaving other residents at risk.
The facility failed to complete Quarterly MDS assessments on time for six residents, including those with conditions like cellulitis and COPD. The assessments were not completed within the required 14-day period after the ARD, as per CMS guidelines. The delays were acknowledged by the RN, who noted potential negative impacts on residents. The DON highlighted the importance of timely assessments for effective care planning.
A resident with multiple health conditions received 13 incorrect doses of lisinopril-hydrochlorothiazide due to a transcription error by an RN. The RN used the less than symbol (<) instead of the greater than symbol (>) in the physician's order, leading to medication administration when the resident's blood pressure was below the specified threshold. The DON confirmed that the correct process involves reading back the order to the physician and avoiding the use of symbols.
Failure to Ensure CNA Competency in Colostomy Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated specific competencies and skill sets necessary to provide colostomy care, as required by resident assessments and plans of care. The Director of Staff Development (DSD) stated that the facility provides care to residents with colostomies and that all nursing staff are to receive annual competencies specific to colostomy care. A facility document titled “Class Attendance Roster” for an annual skills competency day conducted by the corporate nursing consultant listed colostomy care as a course topic, along with pressure injury prevention, incontinent care, and indwelling catheter care. During interviews and concurrent record reviews, three CNAs confirmed they had not attended this colostomy care competency training and their signatures were not on the attendance roster. CNA 1 stated she did not attend the skills competency for colostomy care because she works part time at the facility. CNA 2 likewise stated she did not attend the skills competency for colostomy care and explained that she also works part time. CNA 3 stated she did not attend the skills competency training, confirmed her signature was not on the roster, and reported she was unsure if she was allowed to change a resident’s colostomy. CNA 3 further explained that she works the 3:00 p.m.–11:00 p.m. shift and that the competency trainings are conducted during the 7:00 a.m.–3:00 p.m. shift. Review of the facility’s Facility Assessment Tool dated 4/9/2025 indicated that the facility provides sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and well-being, and that competency evaluation is checked on hire and annually thereafter. The facility’s policy and procedure titled “Competency of Nursing Staff” stated that all nursing staff must meet specific competency requirements, participate in a facility-specific, competency-based staff development and training program, and demonstrate specific competencies and skill sets necessary to care for residents’ needs as identified through assessments and plans of care. The policy also specified that facility- and resident-specific competency evaluations would be conducted upon hire and annually, including lecture with return demonstration and demonstrated ability to use tools and perform activities within the staff member’s scope of practice. Despite these stated requirements, the three sampled CNAs had not completed the annual colostomy care competency, resulting in the cited deficiency.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The deficiency involves staff failure to honor a resident's right to dignity and respect during assistance with eating. Surveyors reviewed the admission record of Resident 3, who was readmitted with COPD with exacerbation, heart failure, and lack of coordination, and whose MDS dated 1/7/2026 documented severely impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. During a meal observation in the resident's room, a CNA was observed assisting the resident with feeding while standing over and hovering over the resident. During a concurrent observation and interview, the facility's Infection Preventionist confirmed that the CNA was standing and hovering over the resident while assisting with feeding and stated that the CNA should be sitting and at eye level with the resident for safety and respect. In a subsequent interview, the CNA acknowledged that she had been standing while assisting with lunch and stated she knew she was supposed to sit in a chair and be at eye level with the resident to assist properly for the resident's safety and respect. Review of the facility's "Quality of Life – Dignity" policy indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that residents shall be treated with dignity and respect at all times, including cognitively impaired residents.
Failure to Document Required Food Temperatures for Multiple Meals
Penalty
Summary
Surveyors identified a deficiency in the facility’s meal service related to failure to document food temperatures as required by facility policy. Review of the food temperature logs showed that for lunch on 4/11/2026, all required temperature entries were blank, including the regular entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, gravy, dessert, milk, juice, and coffee. For dinner on 4/12/2026, the log again contained no documented temperatures for the entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, gravy, dessert, milk, juice, and coffee. For lunch on 4/15/2026, there were no documented temperatures for the entrée, mechanical soft entrée, puree entrée, vegetables, pureed vegetables, starch, pureed starch, or gravy. During an interview and concurrent record review with the Dietary Supervisor, it was confirmed that there were no food temperatures documented for the identified meals on 4/11/2026, 4/12/2026, and 4/15/2026. The Dietary Supervisor stated that cooks are responsible for checking the temperatures of all food items prior to meal service and that all food items served should be checked and documented to ensure they are within food temperature regulations. The Dietary Supervisor further stated that food temperatures need to be checked so residents do not get sick because bacteria can start growing if food is not at the right temperatures, and that documentation is important to show proof that temperatures were actually checked. The facility’s Meal Service policy indicated that meals will be served at appropriate temperatures, that Food and Nutrition Services staff will take food temperatures prior to service with a sanitized thermometer, and that these temperatures will be recorded on the daily therapeutic menu in the designated temperature columns. The deficient practice had the potential to affect 117 of 119 in-house residents.
Failure to Administer Ordered Atorvastatin and Insulin and Notify Physician for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide routine biologicals and pharmacy services, including administering medications as ordered, for a newly admitted resident. The resident was admitted from a general acute care hospital with diagnoses including type 2 DM, hemiplegia and hemiparesis following CVA affecting the right dominant side, and unspecified glaucoma. The resident’s MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On admission, the nurse practitioner and physician were notified, and the resident’s medication orders were faxed to the pharmacy. The physician’s orders included Atorvastatin 40 mg by mouth at bedtime for hyperlipidemia and Semglee (insulin glargine) 8 units subcutaneously at bedtime for DM, both with a start date of 1/6/2026. The facility’s pharmacy delivery manifest showed that these medications were delivered the following day at 3:22 a.m. Review of the resident’s January MAR revealed that the 9:00 p.m. doses of Atorvastatin and Semglee on the admission date were not administered, and code 8 (medication not available) was documented for both medications. RN 2 stated that the facility receives pharmacy deliveries three times a day and confirmed that the medications were not given at the scheduled time because they had not yet been delivered. RN 2 further stated that the charge nurse assigned to the resident should have called the physician to inform them of the missed doses and to clarify whether additional orders were needed, but review of the progress notes for that date showed no documentation that the physician was notified. The DON confirmed that for newly admitted residents, medication orders are sent to the pharmacy and that once medications are delivered, licensed nurses administer the first dose per the physician’s orders, and that the nurse should have clarified with the physician whether medications could be initiated the following day given the late admission time. Facility policies required regular and reliable pharmaceutical services, including that new medication or admission orders be available for administration of the next dose, and required documentation of services provided and changes in the resident’s condition in the medical record to facilitate communication among the interdisciplinary team.
Failure to Complete Timely Nutritional Assessment After Readmission
Penalty
Summary
The facility failed to conduct a comprehensive nutritional assessment within seven days of readmission for one resident, as required by its own policy and procedure. The resident, who had a history of diabetes mellitus, hypertension, gastrostomy, and anemia, was initially admitted and then readmitted after a hospital stay. Upon readmission, the resident's weight was recorded as unchanged from the time of transfer to the hospital, but a comprehensive nutritional assessment was not completed until the twelfth day after readmission, exceeding the facility's seven-day requirement. Interviews with the Registered Dietitian and the Director of Nursing confirmed that the nutritional assessment was delayed and not performed within the required timeframe. The facility's policies specify that a comprehensive nutritional assessment must be completed by a dietitian within seven days of admission or readmission, especially in cases of significant weight change. Despite these requirements and the resident's medical complexity, the assessment was not completed as stipulated, resulting in a deficiency.
Failure to Document Room Temperature Checks
Penalty
Summary
The facility failed to implement its policy on maintaining a homelike environment by not providing documented evidence of daily room temperature checks for residents from January 26 to January 28, 2025. The Maintenance/Housekeeping Director (MHD) stated that the facility is supposed to check and document room temperatures three times a day, with the first check by 9:00 a.m. However, during a review of the facility's Air Temperature Monitor Log, it was found that there was no documentation of temperature checks for the specified three days. Maintenance Assistant 1 (MA 1), who was responsible for checking the room temperatures, admitted to not performing the checks during this period because they forgot and were busy. The MHD emphasized the importance of daily temperature checks for residents' comfort and the necessity of documenting these checks to provide proof of compliance with the facility's policy. The facility's policy, dated May 2024, requires staff to ensure a safe, clean, comfortable, and homelike environment by maintaining comfortable room temperatures.
Unlabeled Medications Found in Medication Cart
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by the discovery of two unidentified and unlabeled medication tablets in one of the medication carts at Nursing Station 1. During an observation and interview with the Infection Prevention Nurse (IPN), it was noted that the medication cart contained one pink and one white tablet, both unlabeled. The IPN confirmed that all medications should be labeled with the resident's name, medication name, dose, and expiration date. This oversight was acknowledged by Licensed Vocational Nurse 1 (LVN1), who admitted forgetting to discard the unlabeled medications, which should have been removed immediately to prevent medication errors. The Director of Nursing (DON) reiterated the importance of storing medications according to the facility's policy and manufacturer's recommendations to maintain their effectiveness. A review of the facility's medication storage policy, last revised in August 2020, indicated that any outdated, contaminated, or deteriorated medications, as well as those in compromised containers, should be promptly removed and disposed of according to the established procedure. The failure to remove the unidentified tablets from the medication cart represents a breach of these protocols, potentially compromising the efficacy of medications administered to residents.
Medication Management and Fall Prevention Deficiencies
Penalty
Summary
The facility failed to ensure the safety of residents by not properly managing medication administration and fall prevention measures. For Resident 163 and Resident 164, medications were left unattended at their bedsides without a completed self-administration assessment. Resident 164, who was alert and oriented, had a Tylenol pill left at the bedside by a nurse, which was not in accordance with the facility's policy as the self-administration assessment was conducted after the incident. Similarly, Resident 163, who was severely impaired in cognition, had multiple pills left at the bedside without a prior self-administration assessment or physician's order, posing a risk of medication misuse. Additionally, the facility did not adhere to the care plan for Resident 29, who was at high risk for falls due to severe cognitive impairment and a history of falls. The care plan specified the use of bilateral floor mats to prevent injury from falls, but during an observation, no floor mats were found next to Resident 29's bed. This oversight increased the risk of injury for Resident 29, who had previously attempted to get out of bed unassisted. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential safety hazards for the residents involved. The Director of Nursing confirmed the lapses in procedure, acknowledging the importance of assessments and appropriate interventions to ensure resident safety. The failure to conduct timely assessments and implement care plan interventions contributed to the deficiencies observed.
Failure to Implement Non-Pharmacological Interventions Before Opioid Use
Penalty
Summary
The facility failed to ensure that licensed nurses provided non-pharmacological interventions before administering PRN opioid medication to two residents, which could increase the risk of adverse side effects from opioid use. Resident 11, admitted with diagnoses including encephalopathy, migraine headaches, and osteoarthritis, had a care plan that included non-pharmacological interventions such as maintaining proper body alignment, engaging in conversation, and using relaxation techniques. However, there was no documented evidence that these interventions were attempted before administering hydrocodone-acetaminophen on multiple occasions. Similarly, Resident 83, who was readmitted with cellulitis and had intact cognition, also had a care plan that required non-pharmacological interventions for pain management. Despite this, there was no documentation of such interventions being attempted before administering hydrocodone-acetaminophen on several occasions. Interviews with RN 4 and the DON confirmed the lack of documentation and emphasized the importance of non-pharmacological interventions to potentially avoid unnecessary opioid use. The facility's policy on pain management, last reviewed in May 2024, mandates following the resident's care plan for pain management. The DON acknowledged that non-pharmacological interventions should be attempted first, as they might suffice in managing the resident's pain without medication. The absence of documented attempts at these interventions before administering opioids represents a deficiency in the facility's adherence to its pain management policy.
Infection Control Deficiencies in Visitor Screening and Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures in several instances, leading to potential risks of infection among residents. Two visitors were not screened for COVID-19 symptoms or exposure on two separate days, contrary to the facility's policy requiring passive visitor screening. This oversight was acknowledged by the Director of Nursing, who emphasized the importance of screening to protect residents from potential illness. In the kitchen, a dietary aide did not wash their hands after touching a trash can lid before putting on gloves, which could lead to cross-contamination and foodborne illness. The dietary aide admitted to usually washing hands after touching contaminated surfaces, and the Dietary Supervisor confirmed that handwashing is required in such situations. The facility's handwashing policy underscores the importance of washing hands after handling soiled items to prevent infection spread. Additionally, several issues were noted with resident care items. A resident's oxygen nasal cannula was not labeled with the date it was last changed, which is necessary to prevent bacterial growth and respiratory infections. Another resident's urinal was not labeled with an identifier, increasing the risk of cross-contamination. Furthermore, a resident's oxygen tubing was observed touching the floor, which should be avoided to prevent infection. These observations were verified by staff, who acknowledged the lapses in following infection control protocols.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to ensure that staff knocked and asked permission before entering a resident's room, violating the resident's rights to respect and dignity. This incident involved a resident admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease. The resident had the capacity to understand and make decisions. During an observation, a registered nurse entered the resident's room without knocking and admitted to forgetting to do so, acknowledging that knocking is a sign of respect for the resident's personal space. The facility's policy on dignity, last reviewed in May 2024, requires staff to knock and request permission before entering residents' rooms.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, which resulted in a violation of the resident's right to privacy. The incident involved a Certified Nursing Assistant (CNA 1) who did not fully close the privacy curtain while assisting a resident, identified as Resident 96, with dressing. This oversight was observed during a survey when Resident 96 was found fully undressed and sitting on the edge of the bed with the privacy curtain open at the foot of the bed. Resident 96 had been admitted to the facility with diagnoses including difficulty in walking, generalized muscle weakness, and glaucoma. The resident's records indicated intact cognition and the ability to understand and make decisions, requiring supervision or assistance for most activities of daily living. During an interview, CNA 1 acknowledged the failure to close the privacy curtain, and the Director of Nursing confirmed the expectation for staff to provide full privacy during personal care. The facility's policy on dignity and privacy emphasized the importance of maintaining resident privacy during personal care and treatment procedures.
Room Temperature Exceeds Acceptable Range
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in Room A, as the room's temperature exceeded the acceptable range of 71 to 81 degrees Fahrenheit. This deficiency was identified through observations, interviews, and record reviews involving four residents: Resident 100, Resident 167, Resident 168, and Resident 363. The temperatures recorded in Room A were 87.1 F, 84.9 F, 83.3 F, and 82.7 F during the first measurement, and 81.3 F, 79.3 F, and 84.1 F during the second measurement. All four residents expressed discomfort due to the warm room conditions. Resident 100 was admitted with end-stage renal disease and required dialysis, while Resident 167 and Resident 168 had anemia, and Resident 363 had a urinary tract infection. The Minimum Data Set (MDS) assessments indicated varying levels of cognitive impairment among the residents, with some requiring assistance with eating. The Maintenance Supervisor and the Director of Nursing confirmed the importance of maintaining room temperatures within the specified range to prevent discomfort and potential dehydration. The facility's policy, last reviewed in May 2024, mandates daily temperature checks in multiple rooms to ensure compliance with the temperature guidelines.
Failure to Adhere to Fluid Restriction for a Resident
Penalty
Summary
The facility failed to adhere to a physician's order for a strict fluid restriction for Resident 317, who was diagnosed with conditions including hypo-osmolality, hyponatremia, hypokalemia, kidney failure, and muscle weakness. Despite the resident's care plan specifying no water pitcher at the bedside and a fluid restriction of 1200 milliliters per day, a water pitcher and additional cups were observed at the resident's bedside. This oversight occurred even though a sign above the resident's bed indicated that water pitchers should not be left at the bedside. The deficiency was identified during an observation on August 19, 2024, when the Director of Staff Development confirmed the presence of the water pitcher and acknowledged the risk of fluid overload for the resident. The Director of Nursing also emphasized the importance of following the physician's orders to prevent electrolyte imbalance and potential hospitalization. The facility's policy on fluid restriction guidelines, reviewed in May 2024, requires nursing to notify dietary services once a fluid restriction order is prescribed, ensuring the appropriate amount of fluid is managed by the nursing department.
Failure to Implement Scheduled Toileting Plan
Penalty
Summary
The facility failed to provide a scheduled toileting plan for a resident who was admitted with diagnoses including adult failure to thrive and extrarenal uremia. The resident was assessed as cognitively intact and required substantial assistance with walking. The Minimum Data Set (MDS) indicated that the resident was continent of bladder and incontinent of bowel. Despite this assessment, the facility did not implement a scheduled toileting plan as outlined in the resident's care plan, which included offering a bedpan or urinal at regular intervals and assisting the resident to the bathroom. During the review, it was found that the facility's policy required a voiding diary to be maintained and communicated among staff, but there was no documentation of scheduled bowel elimination for the resident. Interviews with the Minimum Data Set Nurse and the Director of Nurses confirmed the lack of adherence to the facility's policy. The Director of Nurses acknowledged the importance of maintaining continence or identifying reasons for incontinence to potentially place the resident on a bowel training program.
Failure to Complete Post-Dialysis Assessment
Penalty
Summary
The facility failed to complete a post-dialysis assessment for Resident 102, who was admitted with end-stage renal disease and required dialysis. The resident's care plan specified the need to assess the dialysis access site for complications such as bleeding, and to check for bruit and thrill. However, the Dialysis Assessment Form dated 8/20/2024 was not filled out, and there was no documentation of vital signs or an assessment in the resident's electronic chart after returning from dialysis. Licensed Vocational Nurse 3 confirmed that the post-dialysis assessment section was not completed and admitted to forgetting to fill out the form or write an assessment note. The Director of Nursing stated that licensed nurses are responsible for completing the post-dialysis assessment to ensure the resident's stability and absence of complications. The facility's policy on end-stage renal disease care requires licensed nurses to look for signs of infection and complications, but this was not adhered to in this instance.
Failure to Remove Lidocaine Patch as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of quality care by not ensuring the timely removal of a lidocaine patch as per the physician's order for a resident. The resident, who was admitted with diagnoses including muscle weakness, a history of falling, and chronic kidney disease, had a physician's order for a lidocaine patch to be applied to both knees for pain management, with instructions to keep the patch on for 12 hours and then remove it for 12 hours. However, during a medication administration observation, it was noted that the patch applied the previous day was not removed after 12 hours, as it was still attached to the resident's knees when the new patch was being applied. The Registered Nurse (RN) acknowledged that the patches should have been removed the previous day according to the physician's order. The Director of Nursing (DON) confirmed that the failure to remove the patch could lead to excessive dosing and potential adverse effects, as indicated in the medication's package insert. The DON agreed that the patch should have been removed after 12 hours to prevent discomfort and potential adverse side effects due to increased absorption of lidocaine.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure that licensed nurses monitored for side effects in residents receiving anticoagulant medications, specifically affecting two residents. Resident 73, who was readmitted with a diagnosis of atherosclerotic heart disease, was on apixaban for DVT prophylaxis. Despite the care plan indicating the need to monitor for bleeding or bruising, there was no documentation found to confirm that nurses were monitoring for these side effects. The Director of Nursing acknowledged the importance of monitoring for side effects due to the increased risk of bleeding associated with anticoagulants. Similarly, Resident 364, admitted with chronic obstructive pulmonary disease and other conditions, was on heparin for DVT prophylaxis. The care plan required monitoring for bleeding, bruising, and blood in the urine or stool. However, there was no documentation of such monitoring in the resident's medical record. The Licensed Vocational Nurse confirmed that side effects are usually documented on the MAR, but this was not done for Resident 364. The facility's policy on anticoagulation required monitoring for complications, which was not adhered to in these cases.
Expired Insulin Storage Deficiency
Penalty
Summary
The facility failed to ensure that a vial of insulin lispro, which was past its discard date, was not stored in one of the medication carts. This deficiency was identified during an inspection of Medication Cart A, where a vial of insulin lispro belonging to a resident with diabetes mellitus was found. The insulin vial had an open date that exceeded the 28-day usage period recommended by the manufacturer. Licensed Vocational Nurse 2 confirmed that the insulin should have been discarded after 28 days from opening, as it would lose its efficacy beyond this period. The resident involved had been admitted with a diagnosis of diabetes mellitus and required assistance for self-care. The physician's order for the resident included administering insulin lispro before meals and at bedtime. The manufacturer's guidelines and FDA recommendations specify that opened vials of insulin lispro should be discarded after 28 days, whether stored at room temperature or refrigerated. The failure to adhere to these guidelines resulted in the potential for expired insulin to be administered, which could lead to ineffective blood glucose management for the resident.
Failure to Check Food Temperatures During Meal Service
Penalty
Summary
The facility staff, specifically Cook 1, failed to check the temperature of all food items on the tray line during a mealtime service. This incident occurred on 8/21/2024 at approximately 12 p.m. when Cook 1 did not measure the temperatures of pureed potatoes, chopped turkey, and chicken. This oversight was observed during a kitchen tray line observation and later confirmed in an interview with Cook 1, who acknowledged missing the temperature checks for these specific food items. The facility's policy and procedure, titled 'Meal Service' and last reviewed on 5/22/2024, mandates that food and nutrition services staff must take food temperatures prior to meal service using a thermometer. The failure to adhere to this policy had the potential to result in harmful bacteria growth and cross-contamination, posing a risk of foodborne illness to 110 of the 114 medically compromised residents who received food from the kitchen.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with section 1150B of the Act. This deficiency was identified when the facility did not report an allegation of physical abuse involving a resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, to the State Survey Agency (SSA). The resident, who had the capacity to understand and make decisions, reported to a family member that a Certified Nursing Assistant (CNA) was rough while assisting them to a wheelchair, resulting in bruises on the arm and the CNA throwing the resident's teddy bear at them. The incident was documented in a grievance report, and the facility's administrator acknowledged that the rough handling should be considered an allegation of abuse. However, the facility did not report this allegation to the SSA, as required by their own Abuse Prevention Program policy. This failure resulted in a delay of an onsite inspection by the SSA to ensure the safety of other residents and had the potential to result in unidentified abuse.
Delayed MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure that the Quarterly Minimum Data Sets (MDS) assessments for six residents were completed within the required timeframe. The residents affected included those with various medical conditions such as cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), acute embolism, and hypothyroidism. The assessments were not completed within the 14-day period following the Assessment Reference Date (ARD), as mandated by the Centers for Medicare and Medicaid Services (CMS) guidelines. During interviews and record reviews, it was revealed that the MDS assessments for these residents were completed late, ranging from several days to weeks past the deadline. For instance, Resident 83's assessment was due by July 27, 2024, but was not completed until August 12, 2024. Similarly, Resident 42's assessment was due by July 29, 2024, but was also completed on August 12, 2024. These delays were acknowledged by the Registered Nurse (RN) involved, who stated that such delays could negatively impact the residents by failing to identify significant changes in their conditions in a timely manner. The Director of Nursing (DON) emphasized the importance of timely MDS assessments to ensure that residents' specific needs are addressed promptly and that care planning is influenced by the most current assessment data. The facility's policy, last reviewed in May 2024, outlined the responsibility of the MDS Nurse/Coordinator to maintain a master schedule for MDS assessment completion and to ensure regular review by the Interdisciplinary Team (IDT). Despite these policies, the facility did not adhere to the required timelines, resulting in the identified deficiencies.
Medication Transcription Error Leads to Incorrect Doses
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) accurately transcribed a physician's order and administered the correct dose of lisinopril-hydrochlorothiazide for a resident. The resident, who had a history of cerebral infarction, acute respiratory failure, hypertension, depression, and dementia, was given 13 incorrect doses of the medication over a period of time. The physician's order specified that the medication should only be administered if the resident's systolic blood pressure (SBP) was greater than 140/80 mmHg. However, the RN mistakenly transcribed the order using the less than symbol (<) instead of the greater than symbol (>), leading to the administration of the medication when the resident's blood pressure was below the specified threshold. The resident's Medication Administration Record (MAR) showed that the medication was administered on multiple occasions when the resident's blood pressure was below 140/80 mmHg. Specific instances included blood pressure readings such as 130/60, 129/66, and 106/74, among others. During an interview, the RN admitted to the transcription error and acknowledged that she should have used the greater than symbol as per the physician's order. The Director of Nursing (DON) confirmed that the correct process for receiving telephone orders involves reading back the order to the physician to ensure accuracy and that symbols should not be used in such orders. The facility's policy on physician's orders requires complete and accurate transcription of orders, including the resident's full name, date of the order, medication name, dosage, administration information, route of administration, and the physician's signature. The policy also mandates that staff verify the order with the physician for accuracy. The failure to follow these procedures resulted in the resident receiving incorrect doses of medication, placing them at risk for serious health complications.
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The facility failed for an extended period to ensure that a qualified RN served as a competent DON, instead allowing an ADON without an RN license to function as DON while inconsistently designating an RN supervisor as DON without clear documentation or training. Staff rosters, HR files, sign-in sheets, and interviews showed the ADON was widely regarded and compensated as the DON, while the RN supervisor lacked knowledge of QAPI processes, could not effectively navigate the EMR, and did not participate in required QAPI meetings. This confusion and lack of qualified leadership contributed to nursing staff failing to provide adequate mental health services to a resident following a suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator: A wet box of individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. The DS stated the cold cuts should have been removed from the box and placed on a pan, and the Admin confirmed the facility P&P required a drip pan under food being thawed so drippings do not contaminate other food.
Infection prevention and control practices were not maintained when a resident’s Foley drainage bag was observed touching the floor while the resident sat in a wheelchair in the dining room. The resident had diagnoses including UTI, bacteremia, and CKD, and the TN stated the bag should have been securely hung because it was an infection control issue. Infection control was also not maintained when an RN carried a pre-prepared IV Daptomycin bag in his scrub pocket before administering it through a PICC line to a resident with necrotizing fasciitis; the DON stated this was not acceptable and that the policy was not followed.
The facility failed to maintain complete and accurate records for controlled medications, including shipping manifests, Controlled Drug Records, and the Narcotic Take Back Log, for multiple residents. Staff described procedures for receiving, storing, transferring, and destroying narcotics, but record review showed missing nurse signatures, undated entries, and instances where a single nurse signed as both the nurse returning and the RN accepting discontinued controlled drugs. These documentation gaps involved various narcotic pain medications and conflicted with facility policies requiring detailed reconciliation of receipt, dispensing, and disposition of controlled substances, resulting in the potential for undetected loss and diversion.
Surveyors found that the facility failed to consistently develop and implement person-centered care plans for several residents. One resident at risk for pressure injuries had a care plan requiring heel offloading and Prevalon boots, yet was repeatedly observed in bed with heels on the mattress and no boots, and an LVN incorrectly believed offloading was unnecessary on a low air loss mattress. Another resident who primarily spoke a non-English language had no care plan addressing communication needs despite staff using a language-specific communication board. A cognitively intact resident with ESRD and mobility deficits had a care plan requiring two-person transfers with a Hoyer lift, but a single CNA attempted a manual transfer, resulting in a fall and bilateral distal femur fractures. Additional residents who refused flu or pneumonia vaccines had no corresponding care plans, and one resident on HD had outdated and inconsistent documentation of AV fistula location and BP restrictions, contrary to facility policy requiring accurate care plan documentation of shunt site and precautions.
Surveyors found that the facility failed to follow its infection prevention and control policies by not initiating Enhanced Barrier Precautions (EBP) for a re-admitted resident with surgical wounds and a PICC line, and by not ensuring staff wore required PPE during high-contact care for two other residents already on EBP. One resident with intact cognition and an active infection-related history was re-admitted with a PICC and surgical wound, yet no EBP signage or PPE cart was present outside the room, and leadership later confirmed EBP should have been initiated at re-admission. Another resident with a G-tube and severe cognitive impairment had active EBP orders and clear doorway signage, but a CNA performed incontinent brief care wearing only gloves and a mask, omitting the required gown. A third resident with Parkinson’s disease, dysphagia, and an open sacral coccyx wound was on EBP with posted signage and a PPE cart, yet a CNA fed the resident wearing only gloves. Staff interviews and policy review confirmed that EBP required gown and gloves for high-contact activities such as toileting, device care, and feeding, and that these requirements were not followed.
The facility failed to follow its OOP policy and to develop OOP care plans for three residents. One resident with epilepsy, COPD, and neutropenia had an OOP order limited to four hours, but the order did not state the reason for the pass and no Release of Responsibility form was completed. A second resident with HTN, type 2 DM, and chronic kidney disease had an OOP order for therapeutic purposes and a Release of Responsibility form that lacked the return time, a contact phone number, and the nurse’s signature. A third resident with epilepsy, CHF, and ESRD, whose capacity fluctuated, had an OOP order without a stated reason and an OOP form that omitted the return time, contact phone number, and nurse’s signature; this resident also reported never being asked to sign any OOP form. The DON and other staff confirmed that policy required complete OOP orders, fully completed Release of Responsibility forms, and OOP care plans, none of which were properly implemented for these residents.
Missing documentation for catheter care and APP mattress checks was identified for a resident with an indwelling urinary catheter and an APP mattress order. The TAR lacked evidence that the catheter was monitored, the catheter site was cleansed, and the mattress was checked on multiple evening shifts, and the TN confirmed the omissions. The resident reported catheter leakage, and the DON stated the care was not recorded as completed in the TAR.
A resident with a history of traumatic brain injury and multiple falls did not receive complete neurological checks, skin assessments, or shift‑by‑shift alert charting as required by facility policy after several falls, including events with head impact and documented abnormal pupil findings that were never reported to a physician. Documentation shows missed neuro‑check intervals, discontinued monitoring before the 72‑hour period ended, and no internal records of head and facial injuries later described in hospital records. In a separate incident, two cognitively intact residents involved in a resident‑to‑resident altercation, where one kicked the other’s knee, were placed on 72‑hour alert charting, but nursing staff failed to complete alert charting every shift as ordered. Interviews with nursing leadership and other staff confirmed that these monitoring and documentation expectations were not met and that required physician notification for neurological changes did not occur.
A resident with severe cognitive impairment and multiple neurologic diagnoses allegedly was forcibly pushed into a wheelchair by staff, as reported by the resident’s responsible party to an RN supervisor. The RN supervisor learned from an LVN that there had been an allegation of rough handling and pushing, recognized this as possible physical abuse, but did not report it to the administrator. As a result, the allegation was not reported within two hours to the state survey agency, law enforcement, or the Ombudsman, contrary to the facility’s abuse reporting policy, as later confirmed by the DON and assistant administrator.
Unqualified and Inconsistent Nursing Leadership Resulting in Inadequate Oversight
Penalty
Summary
The deficiency involves the facility’s failure over approximately 15 months to ensure that a qualified and competent DON, holding a valid RN license, provided oversight of nursing services. Despite a prior citation and a plan of correction stating the facility would hire an RN for the DON position, records and interviews showed that the Assistant Director of Nursing (ADON), who did not hold an RN license, continued to function as the DON. The employee roster listed the ADON as the DON, and the ADON received monthly payments labeled as “DON monthly bonus.” Multiple staff, including a CNA, an occupational therapy assistant, the operations assistant, and the Ombudsman, identified or had been introduced to the ADON as the DON. State nursing board records confirmed that the ADON did not have an RN license. At the same time, the facility inconsistently represented the role of the RN Supervisor (RNS/[DON]). The RNS/[DON] stated they had been the DON for the past two years, but their badge identified them only as an RN supervisor, and their HR file listed the ADON as their manager and as the DON. Staffing sign-in sheets and staffing ratio forms showed the ADON listed as DON on multiple dates, with one sheet showing both the ADON and RNS/[DON] as DON, and some dates showing no DON on duty at all. The pharmacist consultant stated that RNS/[DON] was not the DON, and the admission manager described the ADON and Director of Staff Development as the individuals who reviewed potential residents for appropriateness, with the RNS/[DON] only seeing resident information after admission. During the survey entrance, the operations assistant initially introduced the ADON as the DON, then corrected themselves. The RNS/[DON], who was presented during the survey as the DON, demonstrated a lack of competence in key DON responsibilities. During review of a resident’s record, RNS/[DON] could not independently locate or print past progress notes and care plans in the EMR and required assistance. In an interview, RNS/[DON] was unable to describe the facility’s QAPI process, could not define a QAPI plan, and was unaware of any current QAPI projects, despite facility policy requiring the DON to be part of the QAPI committee. QAPI sign-in sheets showed the ADON, not RNS/[DON], attending QAPI meetings. Regarding a resident who had attempted suicide, RNS/[DON] stated they had notified the DON but then clarified they themselves were the DON, and they claimed there had been an IDT meeting about the incident, which the attending physician later denied. The administrator stated they had hired and trained RNS/[DON] as the DON but could not provide supporting documentation and later indicated they would backdate documents when RNS/[DON] returned from vacation. This pattern of misassignment and lack of documentation resulted in unqualified nursing leadership and contributed to staff failing to provide adequate mental health services to the resident after the suicide attempt.
Improper Food Thawing and Storage in Walk-In Refrigerator
Penalty
Summary
The facility failed to maintain a sanitary kitchen when a wet box containing individually rapid cold cuts was found sitting on top of a thawing roast beef inside a plastic container in the walk-in refrigerator. During observation with the Dietary Supervisor, the wet box was lifted and a thawed roast beef was observed underneath it. The Dietary Supervisor stated that the box contained cold meat and that it should have been removed from the box and placed on a pan. During record review, the facility's policy and procedure titled Thawing of Meats stated to use a drip pan under food being thawed so drippings do not contaminate other food, and the Administrator stated the cold cut should have been taken out of the box and placed on a drip pan.
Infection Control Failures With Foley Bag Placement and IV Medication Handling
Penalty
Summary
Infection prevention and control practices were not maintained for a resident with a Foley catheter when the drainage bag was observed in the dining room touching the floor while the resident was seated in a wheelchair. The resident’s record showed diagnoses including urinary tract infection, bacteremia, and chronic kidney disease. During the observation, the urine in the catheter bag appeared yellow and cloudy, and the Treatment Nurse stated the bag was not supposed to be dragging on the floor and needed to be securely hung on the side of the wheelchair because it was an infection control issue. The facility’s Catheter Care, Urinary policy stated the catheter tubing and drainage bag are to be kept off the floor when identified, and the Administrator and DON stated the policy was not followed. Infection control was also not maintained during IV medication administration for a resident with necrotizing fasciitis who had an order for Daptomycin sodium chloride 660 mg daily through a PICC line. RN 1 was observed wearing PPE, then removing a pre-prepared 50 mL IV medication bag from his scrub pants pocket and priming the IV tubing before connecting it to the resident’s PICC line. RN 1 stated he usually brings pre-prepared medication in his pocket to all residents and that he brings the IV cart to the front of the resident’s room when he prepares the powdered medication form. The DON stated it was not acceptable to carry medication in a scrub pants pocket for administration and acknowledged the process was not followed.
Incomplete and Inaccurate Controlled Substance Accountability Records
Penalty
Summary
The facility failed to maintain a complete and accurate controlled medication record system for residents 1–11, involving documents such as pharmacy shipping manifests, Controlled Drug Records (CDRs), Medication Administration Records (MARs), and destruction logs (Narcotic Take Back Log). The Medical Records Director stated that shipping manifests and CDRs were scanned and retained electronically beginning 3/23, but surveyors found that the facility did not have complete or accurate records. A nurse (LVN 1) described receiving scheduled medications, signing the shipping manifest, placing medications in the cart, and filing the CDR at the cart, as well as transferring discontinued medications to the DON with both signing the CDR. The ADON described that unit nurses were to hand remaining medications and the CDR to the DON, document the amount transferred in the Narcotic Take Back Book, and have both the nurse and DON sign, with the DON and pharmacist later destroying the medications and signing the log. Record review with the ADON showed multiple deficiencies in documentation. For Resident 1, two CDRs with the same number for hydrocodone/APAP 5/325 mg tablets lacked the nurse’s signature, date, and number of doses received in the designated spaces. Review of the Narcotic Take Back Log (pages 6–22, total 137 line items) revealed 21 entries where one nurse signed as both the nurse giving back and the accepting RN for various residents’ controlled medications, and 79 entries were incomplete due to missing the “LN giving” signature. The ADON acknowledged these missing and improper signatures. The facility’s written policies on controlled substances and discarding/destroying medications required a system of reconciling receipt, dispensing, and disposition of controlled substances, including records of personnel access and usage, and required accountability records for discontinued controlled substances to be kept with the unused supply until destruction, in sufficient detail to enable accurate reconciliation. The report states these failures resulted in the potential for undetected loss and diversion (theft).
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement comprehensive, person-centered care plans for multiple residents in accordance with their assessed needs and existing orders. For one resident with gastrostomy, malnutrition, generalized muscle weakness, impaired cognition, and documented risk for pressure injuries, the care plan identified the resident as at risk for skin breakdown and required use of Prevalon boots and offloading/floating of both heels while in bed. On two separate observations, the resident was found in bed with both heels resting on the mattress and without Prevalon boots. A CNA acknowledged that the heels were supposed to be elevated and that the resident was supposed to have Prevalon boots, while an LVN stated that because the resident was on a low air loss mattress, offloading and Prevalon boots were not needed. The DON later confirmed that the resident remained at risk for skin breakdown and that the care plan interventions for heel offloading and Prevalon boots should have been followed. Another deficiency involved a resident with atherosclerotic heart disease, metabolic encephalopathy, and dementia who had impaired cognition and lacked capacity for decision-making. During interview, the resident was unable to communicate in English and primarily spoke another language, and staff reported using a communication board written in the resident’s language. Review of the care plan showed there was no care plan addressing the resident’s communication needs related to the language barrier. The DON confirmed that the resident was at risk for impaired verbal communication due to the language barrier and that the facility communicated with the resident via a communication board, but there was no individualized, comprehensive care plan documenting these communication needs. A further deficiency occurred with a cognitively intact resident with DM, ESRD, and dependence on dialysis who used a wheelchair and required partial/moderate assistance for several mobility-related ADLs. The resident’s care plan for ADL self-care performance deficit, related to impaired mobility, generalized weakness, polyneuropathy, and wheelchair use, specified that transfers required total assistance, two staff participation, use of a Hoyer lift, and a specific sling. Despite this, on the morning of a documented fall, a single CNA attempted to transfer the resident from bed to wheelchair for dialysis without a second staff member or Hoyer lift. The resident slid from the bed to the floor, landing on both knees, reported significant knee pain, and was later found to have bilateral distal femur fractures on hospital x-rays. Multiple staff, including the DON, restorative nursing assistant, and DSD, confirmed that the care plan required two-person assistance with a Hoyer lift for transfers and that this care plan was not followed during the transfer when the fall occurred. Additional deficiencies involved another resident with ESRD on HD who had intact cognition and varying ADL assistance needs. This resident had refused the flu vaccine as documented on a vaccine consent form, but review of the care plan showed there was no care plan addressing the refusal of the flu vaccine. The IP nurse and DON acknowledged that the resident’s refusal of the flu vaccine was not care planned, despite the expectation that a care plan be developed when a resident refuses vaccines. The same resident also had complex HD access history, including a left upper arm AV fistula deemed permanently unusable, a right chest Permacath in use, and a new right upper arm AV fistula placed. Facility records and care plan entries were inconsistent and not updated to reflect the current AV fistula location and associated BP and venipuncture restrictions. Special instructions only referenced no BP on the left arm, and staff interviews confirmed that orders and the care plan had not been updated to include restrictions for the right arm with the AV fistula, contrary to facility policy requiring the care plan to document shunt site and related precautions. The report also identifies a resident originally admitted with epilepsy, cerebral infarction, and a gastrostomy, for whom the facility failed to develop a care plan addressing refusal of pneumonia vaccines. While the narrative for this resident is truncated, the stated deficiency includes the lack of a care plan for the resident’s refusal of pneumonia vaccines. Across these residents, surveyors found failures either to implement existing care plan interventions (such as heel offloading and two-person/Hoyer transfers) or to develop care plans for known needs and conditions (language communication preference, vaccine refusals, and current HD access site and precautions), as confirmed by interviews with the DON, IP nurse, MDS coordinator, and other staff.
Failure to Implement Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for multiple residents with conditions that required heightened infection control measures. One resident was originally admitted with a left femur fracture, a left artificial hip joint, and an infection following a surgical procedure, and was later re-admitted with surgical wounds and a PICC line. Review of the resident’s records showed intact cognition and capacity to make medical decisions. On two separate observations after this re-admission, there was no EBP signage or PPE cart outside the resident’s room. In interviews, the Infection Preventionist Nurse (IPN) acknowledged that this resident should have been on EBP due to the surgical wound and that she had not yet evaluated the resident for EBP since the re-admission. The Director of Nursing (DON) also stated that the resident should have been placed on EBP upon re-admission because of the surgical wounds and PICC line, and that nurses should have initiated EBP at admission. Another deficiency occurred with a resident who had been re-admitted with diagnoses including unspecified protein caloric malnutrition, muscle weakness, and essential hypertension, and who had severely impaired cognition and required maximum assistance with toileting, transferring, and mobility. The resident had an active order for EBP related to a gastrostomy tube. Observations outside the room showed a green dot sticker by the name plate and EBP signage instructing staff to wear a gown, mask, and gloves. During an observed incontinent brief change, a CNA wore gloves and a mask but did not wear a gown. In a subsequent interview, the CNA confirmed the resident was on EBP due to the G-tube, stated that a gown should have been worn for the incontinent brief change, and acknowledged that not wearing the gown was a failure to follow infection protocol. An LVN confirmed that the green dot and signage indicated EBP and that CNAs were required to wear PPE, including gowns, during incontinent care, and described the omission of the gown as unsafe infection control practice. The IPN also confirmed that EBP was indicated for residents with devices such as feeding tubes and that the CNA should have worn a gown for the incontinent brief change. A third deficiency involved a resident admitted with Parkinson’s disease, dysphagia, and hypothyroidism, who required moderate assistance with eating and had an open sacral coccyx wound. The resident’s orders and care plan documented EBP related to the sacral coccyx open wound. Observations showed an EBP sign posted at the doorway, a green dot sticker on the name plate, and a PPE cart near the room entrance. During an observation of a meal, a CNA was seen feeding the resident while wearing only gloves, despite acknowledging that the green dot indicated some type of precaution requiring PPE during care. A registered nurse later stated that staff had to wear PPE when assisting with ADLs such as changing diapers, feeding, and showering to avoid spread of infection and contamination. Review of a local health department document and the facility’s EBP policy showed that staff were to wear gown and gloves for high-contact resident care activities, including feeding, and the DON stated that the facility’s EBP policy, which required gown and gloves for such activities, was not followed. Across these three residents, surveyors found that the facility’s own policies and procedures for its Infection Prevention and Control Program and Enhanced Standard/Barrier Precautions required prompt recognition, initiation, and implementation of EBP, and the use of PPE (gown and gloves) during high-contact care activities such as changing briefs, assisting with toileting, device care (including feeding tubes), and feeding. However, the observations and staff interviews demonstrated that EBP was not initiated for one re-admitted resident with surgical wounds and a PICC line, and that staff did not consistently use required PPE (gowns) during high-contact care for two residents already on EBP. These actions and inactions constituted the identified infection control deficiencies.
Failure to Follow Out-on-Pass Procedures and Care Planning Requirements
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and procedure for residents going out on pass (OOP) and to develop OOP care plans for three residents. The facility’s policy required staff to obtain a physician’s order that included the reason for the pass (medical or social) and to complete a Release of Responsibility for Leave of Absence form with specific information. For one resident with epilepsy, COPD, and neutropenia, who had documented capacity and no cognitive impairment, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. The progress note documented that the resident left OOP on a specific date and time, but there was no completed Release of Responsibility for Leave of Absence form. For a second resident with HTN, type 2 DM, and chronic kidney disease, who also had capacity and no cognitive impairment and required partial to moderate assistance with ADLs, a physician’s order allowed OOP for therapeutic purposes. A Release of Responsibility for Leave of Absence form existed for this resident, but it was undated by year and incomplete: it documented the time the resident left and the date, but did not include the time of return, a phone number where the resident could be reached, or the nurse’s signature. For a third resident with epilepsy, CHF, and ESRD, whose H&P indicated fluctuating capacity but whose MDS showed no cognitive impairment and a need for partial to moderate assistance with ADLs, a physician’s order allowed OOP not to exceed four hours but did not state the reason for the pass. This third resident reported having gone OOP one or two times and believed nurses signed an OOP form at the nurse’s station, but stated that nurses had not asked the resident to sign or complete any form before going OOP. The Release of Responsibility for Leave of Absence form for this resident showed an OOP to a mobile phone store, but lacked the time of return, a contact phone number, and the nurse’s signature. Interviews with an RN, the MD, and the DON confirmed that facility practice and policy required a complete physician’s order specifying the reason and destination, completion of the Release of Responsibility form with detailed information (including times, destination, contact number, and signatures), and development of an OOP care plan addressing interventions and mental capacity. The DON acknowledged that one resident had no Release of Responsibility form completed at all, two residents’ forms were incomplete, and none of the three residents had an OOP care plan developed.
Missing Documentation for Catheter Care and APP Mattress Checks
Penalty
Summary
Resident 10, who was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, COPD, and acute respiratory failure with hypoxia, had physician orders for an indwelling urinary catheter to be checked every shift for intactness and function, and for catheter site cleansing with warm soap and water, rinsing, and patting dry every shift. The resident was observed in bed awake and alert with an indwelling urinary catheter in place, and during interview reported leakage from the catheter and stated he had previously told facility staff about the concern, but it had not been resolved. A review of the March 2026 TAR showed no documented evidence that the catheter monitoring order was completed on the evening shift for March 3, 4, 5, 10, 11, and 12, 2026. The same six evening shifts also had no documented evidence that catheter site cleansing was completed. The Treatment Nurse confirmed the missing documentation and stated the treatments should have been documented as completed. Resident 10 also had an order for an APP mattress to be set to the resident's weight and checked every shift for proper placement and function. The March 2026 TAR showed no documented evidence that the APP mattress check was completed on the same six evening shifts, and the Treatment Nurse confirmed those omissions as well. A later review of the April 2026 TAR showed missing documentation on the evening shift of April 9, 2026 for catheter monitoring, catheter site cleansing, and APP mattress checks. The DON reviewed the facility policy on physician orders and stated the policy was not followed because care was not recorded as completed in the TAR.
Failure to Complete Neuro Checks, Alert Charting, and Skin Assessments After Falls and Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and facility policies for post-fall and post-incident monitoring and documentation for multiple residents. Resident 4, admitted with multiple rib fractures, traumatic subdural hemorrhage, repeated falls, and later assessed as high fall risk, experienced several falls during his stay. Facility records, including SBAR forms, care plans, and IDT post-event notes, show that after these falls, staff were expected to complete neurological checks on a defined schedule (q15 minutes, q30 minutes, q1 hour, q4 hours, then q8 hours up to 72 hours), perform and document skin assessments, and complete alert charting every shift for 72 hours. However, the neurological check forms for multiple dates (1/10, 2/05, 3/12, 3/16, and 4/06) show missing assessments and vital signs at required intervals, and the 3/09 neurological checks were discontinued after the first hour despite the resident being within the 72‑hour monitoring window. Alert charting progress notes were also not completed every shift for the required 72 hours following several of his falls. In addition, Resident 4 had abnormal neurological findings that were not reported to a physician as required by policy and nursing standards. On 3/12 and again on 3/16, neurological check evaluations documented unequal pupils bilaterally, with specific measurements showing the right and left pupils of different sizes over multiple consecutive assessments. Despite these abnormal findings, there is no evidence in the eMAR or progress notes that the physician was notified of changes in the resident’s neurological status. The facility’s policies on Neurological Assessment and Resident Examination and Assessment require that changes in neurological status be reported to the physician, and interviews with licensed nurses and the administrator confirmed that unequal pupils should have triggered immediate physician notification and documentation, which did not occur. The facility also failed to complete required alert charting after a resident‑to‑resident abuse allegation involving Residents 1 and 2. Resident 1, cognitively intact and with COPD and major depressive disorder, was the victim of an altercation in which she was kicked in the left knee by another resident. Resident 2, also cognitively intact and with hemiplegia/hemiparesis and heart failure, was identified as the aggressor who kicked another resident’s knee. For both residents, IDT post-event notes and care plans documented that alert charting every shift for 72 hours was to be initiated following the incident. However, review of progress notes for both residents shows that alert charting entries were not completed every shift for the full 72‑hour period after the allegation. The Social Services Director and ADON confirmed that extra documentation and alert charting every shift for 72 hours were expected after any abuse allegation, and record review confirmed that this monitoring and documentation were not consistently performed. The record review further shows that for Resident 4, changes in skin condition following falls were not assessed, documented, or monitored as required. Despite documentation from an ED physician and a hospital critical care consult describing a scratch to the left temple and a left cheek abrasion, and an internal EMAR note referencing a bruise on the face from a prior fall, there is no evidence in the facility’s eMAR or progress notes of skin assessments or monitoring of these changes. The administrator and a licensed nurse acknowledged that the knot on the resident’s head after a fall and subsequent facial discoloration should have been documented as skin assessments or progress notes and monitored, but the facility was unable to provide such documentation. These omissions occurred despite facility policies on Charting and Documentation, Resident Examination and Assessment, Falls – Clinical Protocol, Safety, and Abuse, Neglect, and Exploitation, which require documentation of changes in condition, monitoring after falls, and increased supervision and monitoring after abuse allegations.
Failure to Timely Report Allegation of Physical Abuse to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy when an allegation of physical abuse involving a resident was not reported to required external agencies within the mandated two-hour timeframe. The resident, who had diagnoses including metabolic encephalopathy, dementia, and Alzheimer's disease, was assessed as severely cognitively impaired and required supervision or touching assistance for basic mobility tasks such as moving from lying to sitting, sitting to standing, and walking short distances. The resident’s responsible party reported that a visitor had informed her that an unidentified staff member forcibly pushed the resident into a wheelchair when the resident attempted to get up. The responsible party then informed the RN Supervisor of this allegation. During the resident’s readmission, the RN Supervisor was again informed by the responsible party about the concern that the resident had been pushed down into the wheelchair or roughly handled about a week earlier. The RN Supervisor acknowledged that, based on information from an LVN, there had been an allegation of rough handling and/or pushing the resident into the wheelchair, and that such conduct constituted a possible physical abuse allegation. However, the RN Supervisor did not report this allegation to the Administrator, and no report was made to the state survey agency, local law enforcement, or the Ombudsman within two hours as required by the facility’s Abuse Prevention and Prohibition Program policy. The DON and Assistant Administrator confirmed that staff are required to immediately report suspicions or allegations of abuse to the Administrator and to the three external entities within two hours, and that this did not occur in this case.
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