Camellia Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, California.
- Location
- 1920 N. Fair Oaks Avenue, Pasadena, California 91103
- CMS Provider Number
- 056316
- Inspections on file
- 49
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Camellia Gardens Care Center during CMS and state inspections, most recent first.
Incorrect Low Air Loss Mattress Settings: Two residents with significant care needs and pressure ulcer concerns had LALMs set at the wrong weight-based settings. One resident with dementia and dependence for most ADLs had a mattress set at 50 lbs. despite a 90-lb weight, and another resident with encephalopathy, ESRD, DM, and a stage 4 coccyx PU had a mattress set at 120 lbs. despite a 103-lb weight. Staff and the DON confirmed the settings were incorrect and that the mattress should be adjusted to the resident’s weight per the order, facility P&P, and user manual.
Improper Glove Use and Food Handling During Tray Line Assembly: A cook handled cooked food directly with gloved hands during tray line assembly, placing a fish fillet, beef patty, and baked potato onto a resident’s plate and continuing to scoop food without changing gloves. The DTS stated serving utensils such as tongs should have been used to avoid cross-contamination, and the facility’s Food: Preparation policy required proper handwashing, glove use, and appropriate use of serving utensils.
Psychotropic medications were not tied to specific target behaviors for two residents. One resident with dementia, depression, anxiety, epilepsy, and impaired decision-making had Depakote and clonazepam orders for irritability and restlessness, but staff said the behaviors were not specifically monitored and the care plan was not resident specific. Another resident with LBD, depression, anxiety, and epilepsy had a Fluoxetine order for depression, but the order did not identify a specific manifested behavior for staff to monitor.
Failure to Develop Care Plan for Indwelling Catheter: A resident with hemiplegia/hemiparesis after cerebral infarction, type 2 DM, seizures, and severe cognitive impairment had an indwelling catheter order requiring daily monitoring of the drainage bag for color, output, odor, and hematuria. During record review, staff could not find a care plan addressing the Foley catheter, and the DON stated a resident-centered catheter care plan is required to support individualized care and help prevent, reduce, or manage CAUTI.
Inaccurate Monitoring and Documentation of Catheter Sediment: A resident with an indwelling urinary catheter, quadriplegia, and a history of acute pyelonephritis had cloudy urine with sediment observed by surveyors, but the TAR documented no sediment during the shifts reviewed. The order required catheter monitoring every shift and MD notification for sediment, yet the DON stated there was no documented evidence the MD was notified when sediment was noted, and the documentation was inconsistent with the observed findings and later CoC.
A resident with LBD, depression, anxiety, and epilepsy did not receive the required monthly MRR. The MRR binder and pharmacy summary did not show the resident was reviewed, despite orders for apixaban, fluoxetine, lorazepam, quetiapine, and oxcarbazepine. The DON and PHC confirmed there was no documentation that the resident’s medications were included in the monthly review.
Failure to monitor antiseizure medication use: A resident with epilepsy, LBD, depression, and anxiety was ordered oxcarbazepine for seizures, but the record did not show monitoring for ASM side effects or seizure episodes. The care plan directed staff to give seizure meds as ordered and monitor/document side effects and effectiveness, and the facility policy required periodic documentation of seizure activity and monitoring for antiepileptic complications, but the MDS nurse stated these monitoring steps were not followed.
Failure to Follow Infection Control Practices During Resident Care: An LVN did not wear a gown while providing care to a resident on contact precautions, an RN supervisor did not wear a gown while flushing a foley catheter in an EBP room, two RNs performed wound care without gowns and placed a trash bag with soiled dressing materials on a resident's bed, and an LVN failed to change gloves after touching a curtain before checking G-tube residual and giving medications. The IPN and staff acknowledged the PPE and glove-use expectations during these care tasks.
A resident with COPD, neuropathy, back muscle spasms, and dependence for all ADLs, who received both scheduled and PRN pain meds, reported severe pain rated 10/10 and was observed searching for a call light and then yelling for a nurse. Surveyors found the call light placed on the side rail behind a trash bag, out of the resident’s reach, despite care plan directives to anticipate and promptly respond to pain and a facility policy requiring call lights to be within easy reach when a resident is in bed or a chair. The RN Supervisor and DON both acknowledged that the call light should not have been behind the trash bag and should have been accessible to the resident.
A resident with COPD, neuropathy, and back muscle spasms was cognitively independent but dependent on staff for all ADLs, including toileting and personal hygiene. The resident’s care plans for MASD risk and UTI required staff to keep the skin clean and dry, check for incontinence at least every two hours, and wash, rinse, and dry soiled areas. A CNA reported the resident’s last brief change was at 8 a.m., found the brief wet late in the morning, and delayed changing the resident until after lunch, with the RN Supervisor later confirming the resident was changed at 1 p.m. The RN Supervisor acknowledged that the care plan directives for two-hour incontinence checks and maintaining cleanliness and dryness were not followed, despite facility policy and the DON’s statement that such care plan instructions should be implemented by staff.
CNAs did not complete required Stop and Watch Early Warning Tool forms when a resident with COPD, acute respiratory distress, dysphagia, and severe cognitive impairment exhibited congestion, coughing, phlegm, difficulty swallowing, fever-like warmth to touch, and diarrhea over multiple shifts. Facility policy and staff interviews confirmed that such symptoms represent an acute condition change and that CNAs are expected to document these changes on Stop and Watch forms and provide them to nursing and the DSD, yet review of the Stop and Watch binder showed no forms were completed for this resident.
A resident with severe cognitive impairment, ventilator dependence, and a tracheostomy developed dark purple discoloration and later greenish-yellow bruising with a linear red mark around one eye, with no known cause. Multiple staff, including an RN supervisor, TN, LVN, and CNA, observed the eye discoloration and described it as redness, light purple discoloration, and a “black eye,” but the TN only notified the physician and responsible party and did not initiate abuse reporting. The DON and ADM confirmed that, under facility policy, this unexplained bruise met the definition of an injury of unknown origin and should have been treated as potential abuse and reported to CDPH, law enforcement, and the Ombudsman within two hours, which did not occur, resulting in a delayed investigation.
A resident with severe cognitive impairment and requiring contact isolation for Candida auris was not admitted to the first available bed after a hospital stay, despite meeting all readmission criteria and the facility having an open bed. The Admissions Coordinator did not communicate the resident's status or bed needs to nursing leadership, resulting in a lack of internal coordination and a delayed return to the facility.
A resident remained in a room with an active ceiling leak and no safety signage or relocation, despite being at risk for falls and requiring assistance with daily activities. Additionally, a Hoyer lift and shower chair were left in a hallway for several hours, creating trip hazards for residents and staff. Staff and the DON confirmed these practices did not follow facility safety policies.
A resident with multiple pressure ulcers experienced significant changes in wound size and condition that were not documented or communicated using the SBAR tool as required by facility policy. Staff interviews confirmed that these changes were not reported or acted upon according to established procedures, resulting in a failure to provide care consistent with professional standards of practice.
Two residents with IV access did not receive appropriate monitoring or dressing changes as required by facility policy. One resident had a visibly soiled and blood-stained peripheral IV dressing that was not changed, and there was no documentation of IV site assessment or care for several days. Another resident was left with an unused peripheral IV line without monitoring or a physician's order for removal, and no documentation of IV site assessment was found. Facility policy requiring regular assessment and documentation of IV sites and dressings was not followed.
A resident with hemiplegia and cognitive impairments was not provided adequate ADL care in a LTC facility. The resident was found soaked in urine, indicating a failure to follow the care plan for incontinence checks every two hours. Additionally, a physician-ordered tongue scraping was not documented or performed, as it was not transcribed into the MAR. The DON confirmed the need for proper documentation and adherence to care plans.
The facility failed to provide a safe, clean, and homelike environment for two residents, leading to unsanitary conditions with used gloves on the floor and an overflowing trashcan with gowns. Both residents were severely impaired and dependent on staff for care. Interviews confirmed the inappropriate conditions, and the facility's policies for cleanliness and infection control were not followed.
Two residents in an LTC facility were not properly monitored for the use of physical restraints, as required by physician orders. The facility failed to document the release and monitoring of hand mittens and a soft elbow splint every two hours, leading to a deficiency in care. Incomplete informed consent and lack of adherence to facility policies contributed to the issue.
A facility failed to accurately document a resident's use of restraints in the MDS, despite physician orders for a left-hand mitten and soft elbow splint to prevent removal of invasive lines. The MDS Nurse acknowledged the omission, and the DON highlighted the importance of accurate MDS for care planning.
The facility failed to maintain proper hygiene and grooming for three residents, all of whom were dependent on staff for personal care. These residents, with conditions such as traumatic brain injury and quadriplegia, were found with long, untrimmed fingernails, posing risks of infection and skin breakdown. Staff acknowledged the need for regular nail care, which was not provided, contrary to the facility's policy on supporting activities of daily living (ADLs).
The facility failed to follow infection control practices, including improper handling of a foley catheter drainage bag, inadequate glove changes, and hand hygiene during medication administration for several residents. Additionally, a feeding pump was found unclean, increasing infection risks.
A resident with severe impairments was left exposed during a sponge bath due to a CNA's failure to close the privacy curtain, violating the facility's dignity policy. The resident's privacy was compromised as they were visible to their roommate and through an open door.
A facility failed to provide a resident with adequate notice regarding the termination of Medicare Part A coverage. The resident, with conditions including dementia and muscle weakness, did not receive a signed Notice of Medicare Non-coverage, and the Skilled Nursing Facility Advance Beneficiary Notice lacked an estimated cost for non-covered services. The Business Office Manager was unaware of the requirement to include cost estimates, and the facility's policy of notifying residents in writing was not followed.
A resident's medical records were left exposed on an unattended computer screen, violating confidentiality policies. The resident, who was alert and oriented, had diagnoses including sepsis and hypertension. Staff interviews confirmed the breach and the facility's policy on safeguarding records.
A resident with hearing loss and cognitive impairment did not have a comprehensive care plan addressing communication needs. Despite staff using effective methods like writing and speaking louder, these were not documented in the care plan, leading to potential delays in care.
A facility failed to properly implement pressure ulcer prevention for a resident with a Stage 4 ulcer. The resident's LAL mattress was not set to the correct pressure according to their weight, as required by the care plan and physician's orders. Observations showed the mattress was set incorrectly, which could worsen the resident's condition. A nurse confirmed the settings were wrong, indicating a failure to follow the facility's policy for pressure ulcer management.
A resident with hemiplegia and limited ROM did not receive necessary RNA services after readmission from a hospital. The facility failed to evaluate and continue RNA services, leading to a lapse in care for three weeks. Staff acknowledged the oversight, which was against the facility's policy to maintain or improve mobility.
A resident was not properly informed about a binding arbitration agreement they signed, which included giving up the right to a court trial. The resident, who was cognitively intact, was left with documents to sign without a thorough explanation or knowledge of their right to rescind the agreement within 30 days. The Admission Coordinator admitted the facility's responsibility to explain the agreement, which was not fulfilled.
The facility failed to complete antibiotic stewardship protocols for two residents, leading to a deficiency. One resident with chronic conditions was prescribed Ciprofloxacin for pneumonia without complete infection surveillance documentation. Another resident with hemiplegia and other conditions was prescribed Amoxicillin-Pot Clavulanate, also without complete documentation. The Infection Preventive Nurse confirmed the oversight, which could lead to inappropriate antibiotic use.
The facility failed to provide timely care for two residents dependent on staff for ADLs. One resident was found with a soiled towel and pad, while another had a soiled incontinence brief. Both residents had severe cognitive impairments and were always incontinent. The facility's protocol required regular rounds for cleaning, but care was delayed, violating the policy to maintain resident hygiene.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as prescribed due to a disconnection of the T-bar from the oxygen tubing, which was found on the floor. The contaminated tubing was improperly handled and reconnected, violating infection control protocols. Staff interviews confirmed the failure to follow facility protocols for oxygen administration and infection prevention.
A resident with multiple health issues experienced delayed dental services due to the facility's failure to follow up on a dental referral. The resident was dependent on staff for oral care, and a dental exam indicated the need for a deep cleaning. However, the referral was not communicated or acted upon in a timely manner, resulting in a deficiency.
A resident with hemiplegia and hemiparesis experienced a delay in receiving PT and OT services after physician orders, resulting in a decline in joint mobility. The services were approved to start but were delayed due to the rehab department's uncertainty about session authorization, contrary to facility policy.
The facility failed to label opened packages of ground coffee with the date of opening and did not discard expired food items in the walk-in refrigerator. During inspections, three unlabeled coffee packages and several expired items, including apple cider vinegar, oatmeal cookies, and fried beans, were found. The DM and DON confirmed that these practices do not comply with safe food handling standards.
A CNA entered a contact isolation room without PPE, violating the facility's infection control policy. Two residents, one with cerebral infarction and metabolic encephalopathy, and another with hemiplegia, were under contact isolation for unspecified dermatitis. Despite clear signage and policy requirements, the CNA failed to wear gloves and a gown, as confirmed by staff interviews. The facility's policy mandates PPE to prevent infection spread.
A facility failed to ensure a safe and homelike environment for a resident by placing two pillows and a wedge between the mattress and bedframe, causing discomfort and safety risks. The resident had severe cognitive impairments and was dependent on staff for daily living activities. No assessments or interdisciplinary team meetings were documented regarding the use of the pillows and wedge.
A resident with severe cognitive and physical impairments was found in bed with unpadded siderails and improper mattress setup, contrary to care plan and doctor's orders. The facility's failure to follow safety precautions and hazardous equipment policies put the resident at risk for physical harm and injury.
Incorrect Low Air Loss Mattress Settings
Penalty
Summary
The facility failed to ensure low air loss mattresses were set at the correct weight-based settings for two residents who were reviewed for pressure ulcers. Resident 13 was admitted with diagnoses including dementia, arthritis, and a right femur fracture, and the MDS indicated the resident had no intact cognitive ability and was dependent for multiple activities of daily living, including bed mobility and transfers. During observation, Resident 13’s low air loss mattress was set at 50 lbs. even though the resident’s weight summary showed 90 lbs., and the order summary indicated the mattress may have been set to the resident’s weight for skin management. Resident 81 was admitted with diagnoses including encephalopathy, ESRD, DM, and a stage 4 coccyx pressure ulcer. The MDS indicated severely impaired cognitive skills, dependence for multiple ADLs, risk for pressure ulcers, and use of pressure relieving devices for bed. The physician’s order directed that the low air loss mattress be set per the resident’s comfort/preference or weight every shift, and the resident’s weight was documented as 103 lbs. However, during observation the mattress was set at 120 lbs., and staff confirmed the setting was incorrect and should have matched the resident’s weight. The DON stated the low air loss mattress is used to prevent pressure ulcers by redistributing pressure and that if it is not set correctly it may promote skin breakdown instead of preventing it. The facility’s policy and procedure and the mattress user manual both indicated that redistributing support surfaces and the mattress dial should be adjusted to correspond to the patient’s appropriate weight setting. Resident 81 also stated that the mattress felt too hard and hurt the buttocks when it was set at the higher setting.
Improper Glove Use and Food Handling During Tray Line Assembly
Penalty
Summary
Kitchen staff failed to follow the facility’s food preparation policy during lunch tray line assembly on 4/22/2026. During an observation in the kitchen at 12:12 PM, Cook 3 touched and picked up a cooked fish fillet from a baking tray with a gloved hand and placed it on a resident’s serving plate, then used the same gloves to scoop the vegetable entree from the serving tray on the tray line assembly. During additional observations at 12:15 PM and 12:19 PM, Cook 3 continued handling food with the same gloves, picking up a beef patty and half a slice of baked potato from the serving trays and placing them on a resident’s serving plate without changing gloves. The Dietary Supervisor stated that Cook 3 should not handle food directly with gloved hands and should use tongs to pick up items such as beef patties because this can cause cross-contamination and result in residents becoming ill. Cook 3 stated she should not have touched the beef patty with her gloved hand because it could contaminate the food, and the facility’s Food: Preparation policy required proper handwashing, glove use, and appropriate use of serving utensils to prevent cross-contamination.
Psychotropic Medications Lacked Specific Behavior Monitoring
Penalty
Summary
The facility failed to ensure that psychotropic medications were monitored for specific target behaviors in two sampled residents. Resident 12 had diagnoses including metabolic encephalopathy, major depressive disorder, generalized anxiety disorder, epilepsy, and dementia, and the MDS indicated severely impaired cognitive skills for daily decision making. The physician’s order for Depakote 125 mg three times daily was written for mood disorder manifested by being easily irritable, but the MDS nurse stated there was no order or documentation showing that this specific behavior was monitored. Resident 12 also had a physician’s order for Clonazepam 0.25 mg at bedtime for anxiety manifested by restlessness, along with an order to monitor episodes of anxiety manifested by restlessness and tally them each shift. The MDS nurse stated the order did not include a specific manifestation of restlessness and that every resident may exhibit restlessness differently. The nurse further stated that the care plan interventions for clonazepam were not adequate and were not resident specific. Resident 57 had diagnoses including Lewy body dementia, major depressive disorder, anxiety disorder, and epilepsy, and the MDS indicated moderately impaired cognitive skills for daily decision making. The physician’s order for Fluoxetine 20 mg daily was for depression, but the MDS nurse stated the order did not include a specific manifestation for depression, such as verbalizations of missing his spouse. The DON stated the fluoxetine order was incomplete because it did not include the resident’s manifested behavior for depression.
Failure to Develop Care Plan for Indwelling Catheter
Penalty
Summary
Facility staff did not develop a care plan to address the use of an indwelling catheter for one sampled resident. The resident was initially admitted to the facility and later re-admitted, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus without complications, and other seizures. The resident's MDS dated 2/6/2026 indicated severe impairment in cognitive skills for daily decision making and dependence for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and rolling left and right. A physician's order dated 1/30/2026 directed staff to monitor the indwelling catheter urinary drainage bag and document color, output, odor, and hematuria every dayshift. During record review and interview on 4/22/2026, the Medical Record staff could not find any care plan addressing the resident's Foley catheter use in the care plan report, and the DON stated nurses are supposed to develop a resident-centered care plan for the use of an indwelling catheter to prevent, reduce, or manage catheter-associated urinary tract infections and to provide individualized, safe, and consistent patient care while promoting efficient communication among healthcare teams.
Inaccurate Monitoring and Documentation of Catheter Sediment
Penalty
Summary
Resident 72, who was admitted with diagnoses including quadriplegia, cerebral infraction, and acute pyelonephritis, had an indwelling urinary catheter and was assessed as cognitively intact but dependent for most activities of daily living. The resident’s order summary required the catheter to be monitored every shift for sedimentation and for the MD to be notified if sediment was present. During observation on 4/20/2026, the catheter tubing was seen with cloudy urine and sedimentation, and on 4/22/2026 the catheter tubing was again observed with cloudy urine and sediment by RN 2. The TAR for 4/20/2026 and 4/22/2026 documented that the resident did not have sedimentation in the catheter urine during the shifts reviewed, which the DON stated was inconsistent with the observations and the later CoC entered on 4/22/2026 noting sediment in the catheter. The DON also stated there was no documented evidence that the MD was notified about the sediment noted on 4/20/2026, despite the facility policy requiring staff to observe for unusual urine appearance and report findings to the physician or supervisor immediately.
Failure to Complete Monthly MRR for Resident with Multiple Psychotropic and Anticonvulsant Medications
Penalty
Summary
The facility failed to complete a monthly Medication Regimen Review (MRR) for one sampled resident, Resident 57, in accordance with its policy. Resident 57 was admitted with diagnoses including Lewy body dementia, major depressive disorder, anxiety disorder, and epilepsy. The resident’s MDS dated 2/10/2026 indicated moderately impaired cognitive skills for daily decision making and partial/moderate assistance with several activities of daily living, including toileting hygiene, bathing, footwear, bed mobility, and transfers. A review of the physician’s orders dated 2/5/2026 to 2/13/2026 showed the resident was receiving apixaban, fluoxetine, lorazepam, quetiapine, and oxcarbazepine. Review of the facility’s Medication/Drug Regimen Review Binder from 2/2026 to 4/2026 did not include an MRR report for Resident 57. During interview and record review with the DON, there was no documentation that an MRR was completed for the resident from 2/2026 to 3/2026, although the DON stated it should be completed monthly for all residents. During interview with the Pharmacy Consultant, the MRR Summary dated 2/1/2026 to 3/30/2026 did not list Resident 57 among the residents reviewed, indicating the resident’s medications were not reviewed.
Failure to Monitor Antiseizure Medication Use
Penalty
Summary
The facility failed to monitor the use of antiseizure medications for one resident, identified in the report as Resident 57, by not monitoring for side effects and seizure episodes in accordance with the care plan and facility policy. Resident 57 was admitted with diagnoses including Lewy body dementia, major depressive disorder, anxiety disorder, and epilepsy. The resident’s MDS showed moderately impaired cognitive skills for daily decision making and partial/moderate assistance needs for several activities of daily living. During interview and record review, the resident had a physician’s order for oxcarbazepine 300 mg three times a day for seizures, but the MDS nurse stated there was no physician order for monitoring antiseizure medication side effects and that the medical record did not show monitoring for oxcarbazepine side effects or seizure episodes. The resident’s care plan for seizure disorder/epilepsy directed staff to give seizure medication as ordered and to monitor and document side effects and effectiveness, but the MDS nurse stated these interventions were not followed. The facility policy for seizures and epilepsy required periodic documentation of seizure activity and monitoring for complications related to antiepileptic medications, including dizziness, ataxia, somnolence, headache, diplopia, blurred vision, nausea, vomiting, rash, and drug interactions.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Standard infection prevention and control practices were not followed for four residents during observed care activities. Resident 3 had diagnoses including chronic respiratory failure, spastic quadriplegic cerebral palsy, and seizures, and was severely impaired in cognitive skills and dependent for multiple activities of daily living. During an observation, an LVN provided care to Resident 3 without wearing the PPE required by the contact precaution sign posted on the room door. The LVN later stated that proper PPE is very important when providing care to residents under contact precautions because it helps prevent the spread of infections. Resident 8 had diagnoses including hemiplegia, hemiparesis following cerebral infarction, type 2 diabetes mellitus, and seizures, and was severely impaired in cognitive skills and dependent for multiple activities of daily living. During an observation, an RN supervisor flushed Resident 8's foley catheter without wearing a gown while the room was posted for enhanced barrier precautions. The RN supervisor stated that PPE is very important when providing care to a resident under enhanced barrier precautions because it helps prevent the spread of infection. The Infection Preventionist Nurse stated that staff must wear PPE when caring for residents in rooms under contact isolation or enhanced barrier precautions to contain contamination within the resident's immediate environment. Resident 10 had muscle weakness and a stage 4 pressure ulcer to the sacrum, with the MDS showing intact cognitive skills but dependence for many activities of daily living. During wound care, an RN supervisor placed a trash bag on the resident's bed next to the resident's leg, cleaned the sacral pressure ulcer, and disposed of soiled gauze in the bag. The resident's leg was observed resting on top of the trash bag containing soiled dressing materials. The RN supervisor stated the trash bag should not have been there and that the resident's leg should not touch a bag containing dirty gauze from a dressing change. The RN supervisor and another RN were also observed performing the dressing change without gowns, and the RN supervisor stated she did not wear a gown because the resident was not on isolation precaution. The Infection Prevention Nurse stated it was not acceptable to place a trash bag containing soiled dressing-change materials on top of a resident's bed. Resident 44 had chronic respiratory failure, traumatic brain injury, and seizures, and was severely impaired in cognitive skills and dependent for multiple activities of daily living. During an observation, an LVN wearing gloves touched the privacy curtain and the resident's linens, then used the same gloves to check G-tube residual and administer medications through the G-tube without changing gloves. The LVN stated she should have changed her gloves before administering medications via the G-tube due to infection control requirements. The Infection Prevention Nurse stated licensed staff must change gloves when performing different tasks during medication administration and must use clean gloves to prevent cross-contamination and avoid introducing microorganisms into the resident's G-tube.
Failure to Keep Call Light Within Reach for Resident in Pain
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach so the resident could request assistance and pain medication. The resident had diagnoses including COPD, hereditary and idiopathic neuropathy, and back muscle spasms, and was dependent on staff for all ADLs such as eating, toileting hygiene, bathing, dressing, and personal hygiene. The resident’s MDS dated 3/13/2026 documented that she received both scheduled and PRN pain medications and had experienced moderate pain within the last five days. Her care plans for acute left arm/shoulder pain and for potential excessive weakness, tiredness, weight loss, pain, and depression directed staff to anticipate her need for pain relief, respond immediately to any complaint of pain, and provide pain medication as ordered. Physician orders dated 2/23/2026 included Tramadol 50 mg via PEG tube every six hours as needed for moderate to severe pain. On 3/4/2026 at 10:40 AM, during observation and interview in the resident’s room, the resident stated she was in a lot of pain with a pain level of 10/10 and was observed looking for her call light, stating she did not have one. The call light was then observed on the side rail behind a trash bag, out of the resident’s reach, and the resident was observed yelling for the nurse. In interviews, the RN Supervisor stated it was not acceptable for the call light to be hidden behind a trash bag because the resident would not be able to ask for assistance when needed and receive proper treatment for her pain. The DON stated the call light should be within the resident’s easy reach and not behind a trash bag, and confirmed that per the facility’s “Answering the Call Light” policy, revised 3/2021, when a resident is in bed or confined to a chair, the call light must be within easy reach.
Failure to Follow Resident-Centered Incontinence and Skin Integrity Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to follow an individualized, resident-centered care plan for a resident with multiple medical conditions, including COPD, hereditary and idiopathic neuropathy, and back muscle spasms. The resident’s MDS dated 3/13/2026 showed that the resident was cognitively independent for daily decision-making but dependent on staff for eating, oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s care plan for potential/actual impairment to perineal skin integrity related to MASD, initiated 11/20/2025, directed staff to keep the resident’s skin clean and dry. A separate care plan for a UTI, revised 2/14/2026, directed staff to check the resident for incontinence at least every two hours and to wash, rinse, and dry soiled areas. On 3/4/2026 at 11:45 a.m., a CNA reported that the resident’s last brief change had been at 8:00 a.m. and, upon checking, found the resident’s brief to be wet but stated the resident would be changed after the CNA’s lunch. The RN Supervisor later stated the resident was changed at 1:00 p.m., indicating the resident remained in a wet brief beyond the two-hour incontinence check interval specified in the care plan. During interviews and record review at 2:00 p.m., the RN Supervisor confirmed that, according to the resident’s care plans, staff were required to keep the resident clean and dry and to check for incontinence every two hours, and acknowledged that the care plan was not being followed. The facility’s policy on Comprehensive Person-Centered Care Plans, revised 3/2022, stated that the comprehensive care plan describes services to attain or maintain the resident’s highest practicable well-being. The DON stated residents should be changed every two hours and that if the care plan indicated to keep residents clean and dry and to check every two hours for incontinence, it should be implemented by staff.
Failure to Use Stop and Watch Tool for Resident Change in Condition
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to complete required Stop and Watch Early Warning Tool forms when a resident experienced observable changes in condition on two consecutive days. The resident had a history of COPD, acute respiratory distress, and dysphagia, and was severely cognitively impaired per the MDS dated 2/2/2026, requiring substantial to total assistance with most ADLs. On one morning shift, a CNA observed that the resident was congested, had a lot of phlegm, and was having difficulty swallowing food. On another shift that same day, a different CNA noted the resident was hot to the touch and had diarrhea. The resident’s responsible party also reported the resident felt hot to the touch that day. On the following day, another CNA observed the resident coughing and congested during the day shift. Facility policy and staff interviews established that when CNAs notice a change of condition, they are to complete a Stop and Watch form describing what they observe and provide copies to the licensed nurse and the Director of Staff Development, with the nurse acknowledging the form. The DON confirmed that symptoms such as congestion, significant phlegm, difficulty swallowing, and diarrhea constitute an acute condition change under the facility’s Acute Condition Changes policy, and that CNAs are expected to use the Stop and Watch tool to communicate such changes. Review of the Stop and Watch binder with the DSD revealed there were no Stop and Watch forms completed for this resident, despite the observed changes in condition and the expectation that such forms should be present even if the resident was discharged.
Failure to Timely Report Injury of Unknown Origin as Suspected Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin as potential abuse in accordance with its Abuse Investigation and Reporting policy. A resident with severe cognitive impairment, ventilator dependence, a history of nontraumatic intracerebral hemorrhage, and a tracheostomy was admitted with significant functional dependence for toileting hygiene, personal hygiene, and bed mobility. On 1/27/2026, a Change of Condition (COC) documented that the resident was noted with discoloration on the right eye, further described as dark purple discoloration with intact but discolored skin. The Director of Nursing (DON) later observed greenish to yellowish discoloration with a small linear red mark at the right corner of the eye and acknowledged that the cause of the bruise was unknown. Staff interviews showed that multiple staff members observed the discoloration but did not initiate or complete required abuse reporting. The Treatment Nurse (TN) stated he first saw the right eye discoloration on 1/27/2026 after being informed by the RN Supervisor (RNS), describing it as light purple discoloration. TN reported the discoloration only to the physician and responsible party and did not measure the area or report it as suspected abuse. The RNS reported seeing redness under the resident’s eyes on 1/27/2026 but was not informed of TN’s assessment of dark purple discoloration and stated that, had she been informed, it should have been reported to the Administrator and then to CDPH, police, and Ombudsman as suspected abuse. A CNA reported that on 1/28/2026 she entered the room, turned on the light, and saw what she described as a “black eye,” with purple discoloration under and to the right side of the eye. The Administrator and DON confirmed that the facility’s policies required that injuries of unknown source be treated as potential abuse and promptly reported to local, state, and federal agencies, including immediate notification of law enforcement, and that “promptly” meant within two hours of observing suspected abuse. The Administrator stated that, under the Investigating Resident Injuries policy, an injury of unknown source should trigger the abuse reporting and investigation protocols. The DON stated she was not informed of the resident’s right eye dark purple discoloration when it was first noted and that the injury met the definition of an injury of unknown origin that should have been reported within two hours. The LVN also acknowledged noticing discoloration on the right side of the resident’s eye on 1/27/2026 and not reporting it to CDPH, Ombudsman, or police. As a result, the injury of unknown origin was not reported to CDPH, local law enforcement, or the Ombudsman within the required two-hour timeframe, delaying the investigation.
Failure to Admit Resident to Available Bed Following Hospitalization
Penalty
Summary
The facility failed to admit a resident to the first available bed following a hospital stay, despite the resident meeting all criteria for readmission and an available bed being present. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, required contact isolation due to a positive test for Candida auris. The resident's discharge from the hospital was delayed from 12/18/2025 to 12/24/2025 because the facility did not facilitate timely readmission. Record review and interviews revealed that the hospital's case manager repeatedly contacted the facility's Admissions Coordinator (AC) regarding bed availability for the resident, but the AC consistently reported no available isolation bed. The AC did not communicate with the Director of Nursing (DON) or the Infection Preventionist Nurse (IPN) about the need for an isolation bed or the resident's readiness for discharge. Both the DON and IPN stated they were unaware of the situation and indicated that they could have arranged for an isolation bed by moving other residents if they had been informed. Further review of the facility's daily census reports confirmed that there were open beds available in a four-bed room during the relevant period. The facility's policy required priority readmission for residents returning from the hospital, and the job description for the AC included maintaining updated bed availability and communicating with nursing leadership. The failure to coordinate and communicate internally resulted in the resident remaining unnecessarily in the hospital despite the facility's ability to accommodate the resident's needs.
Failure to Maintain Safe Environment Due to Water Leak and Improper Equipment Storage
Penalty
Summary
The facility failed to provide a safe environment in accordance with its own policies and procedures in two specific instances. First, a resident with a history of hypotension and anxiety disorder, who was dependent on assistance for most activities of daily living but able to walk to the bathroom independently, remained in a room where water was leaking from the ceiling during heavy rain. The resident's roommate was moved out due to the leak, but the resident was not relocated. Staff interviews confirmed that a tall bucket was placed to catch the water, but no safety cones or hazard signs were present, and the resident could have slipped on the wet floor or tripped over the bucket. The Director of Nursing acknowledged that the resident should have been moved and that additional safety measures, such as floor mats and signage, were not implemented. Second, a Hoyer lift and a shower chair were left in the hallway outside a resident's room for several hours, with the Hoyer lift's legs expanded and facing the hallway and the shower chair placed directly across from it. Staff interviews indicated that these items should have been stored in designated areas, such as the rehabilitation department or shower room, to prevent them from becoming trip hazards. The Director of Nursing confirmed that leaving these items in the hallway created accident hazards for residents and staff. Facility policies reviewed indicated a requirement to maintain a safe environment and minimize accident hazards, which was not followed in these instances.
Failure to Document and Communicate Significant Pressure Ulcer Changes
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the worsening of pressure ulcers for one resident. Specifically, staff did not assess and document detailed observations using the SBAR (Situation, Background, Assessment, Recommendation) communication tool when there were significant changes in the resident's skin and wound conditions on the left trochanter and sacral areas on multiple occasions. These changes in wound size and condition were not communicated through the required SBAR process, as confirmed by interviews with the wound treatment nurse, registered nurse supervisor, infection preventionist nurse, and director of nursing. The facility's policy required that significant changes in a resident's condition, such as those observed in wound size and severity, be documented and communicated using SBAR to ensure timely interdisciplinary review and care plan revision. The resident involved was an 84-year-old female with a history of encephalopathy, essential hypertension, and pulmonary embolism, who was admitted with multiple pressure ulcers and altered mental status. The resident was assessed as being at risk for developing pressure ulcers and was dependent on staff for several activities of daily living. Despite documented changes in the size and severity of stage 4 pressure ulcers on the left trochanter and sacrococcyx, there was no evidence that these changes were communicated using the SBAR tool or that a change of condition form was initiated as required by facility policy. Interviews with facility staff revealed a lack of awareness and follow-through regarding the responsibility to initiate SBAR communication for significant wound changes. The wound treatment nurse, who was new to the position, was unaware of the resident's wounds and did not initiate SBAR documentation. The infection preventionist nurse and director of nursing both confirmed that the observed changes in wound size were significant and should have triggered SBAR communication and care plan review, but this did not occur. The facility's own policy outlined the need for detailed observation and communication for significant changes, which was not followed in this case.
Failure to Monitor and Maintain IV Sites and Dressings
Penalty
Summary
The facility failed to properly monitor and maintain intravenous (IV) sites and change heplock dressings for two residents, as required by facility policy. For one resident with a history of vancomycin-resistant enterococci (VRE) and diabetes mellitus, observations revealed a peripheral IV site with a visibly soiled, blood-stained dressing and dried blood on the tape. Multiple staff interviews confirmed that the IV site was not clean or well secured, and the dressing should have been changed due to visible soiling. Record reviews showed that there was no physician's order for IV site monitoring or dressing changes, and no documentation of IV site assessment or care in the medical record for several days. The resident's care plan also contained incorrect information, listing a PICC line instead of a peripheral IV, and lacked interventions for IV site monitoring. For the second resident, who had diagnoses including sepsis, pneumonia, and COPD, the facility did not have a physician's order for IV site monitoring or discontinuation of the IV site when it was no longer in use. Progress notes lacked documentation of IV site monitoring, and staff interviews revealed that the IV site was not assessed or monitored after IV medications were changed to oral. The resident was left with an unused peripheral IV line, and staff failed to obtain an order for monitoring or removal. The care plan did not address IV site care, and there was no documentation of assessment or intervention for the IV site during the relevant period. Facility policy required that IV dressings be changed if soiled or compromised and that peripheral IV sites be assessed at least every four hours, with more frequent checks for residents with cognitive impairment. The policy also required documentation of dressing changes and any complications. These requirements were not met for either resident, as evidenced by the lack of monitoring, documentation, and appropriate care of the IV sites.
Deficient ADL Care and Documentation in LTC Facility
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care assistance for a resident, leading to deficiencies in incontinence care and oral hygiene. The resident, who was admitted with conditions such as hemiplegia, hemiparesis, and cognitive impairments, was found soaking wet with urine, indicating a failure to adhere to the care plan that required checking every two hours for incontinence. The resident's care plan, revised on 3/25/2025, specified interventions for bowel and bladder incontinence, which were not followed as the resident was not checked for nearly four hours. Additionally, the facility failed to provide tongue scraping as ordered by the physician. The order for tongue scraping was not transcribed into the Medication Administration Record (MAR), and there was no documentation indicating that the procedure was performed. Interviews with nursing staff confirmed that the tongue scraping was not documented, suggesting it was not completed, despite the physician's order being in place since 3/12/2025. The Director of Nursing acknowledged that the physician's orders should have been documented in the MAR and signed once the treatment was completed. The facility's policy on supporting ADLs, revised in 3/2018, mandates appropriate care and services for residents unable to perform ADLs independently, which includes hygiene and elimination support. The failure to adhere to these policies and care plans resulted in deficient practices that compromised the resident's care.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents, resulting in unsanitary conditions that placed them at risk for infection and discomfort. Observations revealed that the room shared by the two residents had used gloves left on the floor and an overflowing trashcan filled with used disposable gowns. Both residents were severely impaired in cognitive skills for daily decision-making and were dependent on staff for personal care activities, including hygiene and dressing. Interviews with the Housekeeping Manager and the Infection Prevention Nurse confirmed that the conditions observed were inappropriate and posed a risk of spreading germs or bacteria. The facility's policies and procedures for cleaning and maintaining a homelike environment were not followed, as evidenced by the failure to properly dispose of personal protective equipment and maintain cleanliness in the residents' room. The facility's policy emphasized the importance of a clean, sanitary, and orderly environment, which was not upheld in this instance.
Failure to Monitor and Document Physical Restraints
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of physical restraints for two residents, leading to a deficiency in care. Resident 28, who was admitted with chronic respiratory failure, seizures, and quadriplegia, was ordered to have bilateral hand mittens to prevent pulling out invasive tubing. However, the facility did not document the monitoring of these mittens every two hours as required by the physician's orders. Additionally, the informed consent for the use of these mittens was incomplete, lacking necessary signatures and verification of consent, rendering it invalid. Similarly, Resident 49, who had chronic respiratory failure, anemia, and type 2 diabetes, was ordered to have a left hand mitten and a soft elbow splint to prevent pulling out life-sustaining tubes. The facility failed to document the release and monitoring of these restraints every two hours, as per the physician's orders. The care plan for Resident 49 included interventions to assess skin condition and circulation, but there was no documentation to confirm these actions were performed. Interviews with nursing staff and record reviews revealed that the facility's policy and procedures for the use of physical restraints were not followed. The lack of documentation in the Medication Administration Record (MAR) for both residents indicated that the required monitoring and release of restraints were not consistently performed. This deficiency in documentation and adherence to physician orders had the potential to compromise the residents' safety and well-being.
Inaccurate MDS Documentation of Restraints
Penalty
Summary
The facility failed to ensure the accurate documentation of a resident's assessment on the Minimum Data Set (MDS), specifically regarding the use of restraints. Resident 49, who was admitted with chronic respiratory failure, anemia, and type 2 diabetes mellitus, was observed with a left-hand mitten and a soft elbow splint to prevent the removal of invasive lines and a tracheostomy tube. However, the MDS assessment dated 2/4/2025 did not reflect the use of these restraints, which were ordered by a physician on 11/24/2024. This omission was confirmed during an interview with the MDS Nurse, who acknowledged the failure to include the restraints in the assessment. The Director of Nursing emphasized the importance of an accurate MDS as it forms the basis for the resident's plan of care. The facility's policy and procedure, as well as the MDS Coordinator's job description, require that the MDS and all supporting documentation accurately represent the resident and meet regulatory requirements. The inaccurate MDS assessment had the potential to negatively affect Resident 49's plan of care and the delivery of necessary services.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for three residents, specifically in maintaining good grooming and personal hygiene. Resident 27, who has contracted hands, was observed with long, untrimmed fingernails pressing into his palms. This resident was admitted with conditions including seizures, traumatic brain injury, and hypertension, and was assessed as severely impaired in cognitive skills and dependent on staff for personal care. Resident 36, who suffers from chronic respiratory failure and traumatic brain injury, was also found with long, untrimmed fingernails. This resident was similarly assessed as severely impaired in cognitive skills and dependent on staff for various ADLs, including personal hygiene. Observations on multiple occasions confirmed the lack of nail care, which was acknowledged by a Certified Nursing Assistant (CNA) who stated that nails should be trimmed every 2 to 3 weeks to prevent infection. Resident 37, diagnosed with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was found with long, untrimmed fingernails on contracted hands. The Treatment Nurse confirmed the necessity of keeping nails short to prevent self-injury and infection. The Infection Prevention Nurse emphasized the importance of maintaining short and clean nails, especially for residents with hand contractures, to prevent skin breakdown and infection. The facility's policy on ADLs, revised in 2019, mandates appropriate care and assistance for residents unable to perform ADLs independently, which was not adhered to in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to standard infection prevention control practices for several residents, leading to potential contamination and infection risks. Resident 57's foley catheter drainage bag was observed touching the floor, which is against the facility's policy and procedure for catheter care. This oversight was confirmed by the Registered Nurse Supervisor and the Infection Prevention Nurse, who acknowledged that such a practice could lead to contamination and nosocomial infections. In multiple instances, staff members failed to change gloves and perform hand hygiene between tasks during medication administration. Licensed Vocational Nurse 3 did not change gloves or perform hand hygiene after assisting Resident 122 with an oxygen cannula and before administering medications. Similarly, LVN 4 and Registered Nurse 1 did not change gloves or perform hand hygiene between tasks while administering medications to Residents 9 and 11, respectively. These actions were acknowledged by the staff involved, who admitted that they should have followed proper infection control procedures to prevent cross-contamination. Additionally, the facility did not ensure that Resident 120's feeding pump was clean, as it was observed with visible stains. The Certified Nursing Assistant confirmed the pump's unclean state, and the Infection Prevention Nurse emphasized the importance of cleaning and disinfecting medical equipment to prevent infection spread. The facility's policy on cleaning and disinfection of resident care equipment was not followed, contributing to the potential risk of infection for Resident 120.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident 37, during personal care. Resident 37, who was admitted with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was observed receiving a sponge bath from a Certified Nursing Assistant (CNA 3) while laying naked on the bed. The privacy curtain was not fully closed, leaving Resident 37 exposed to their roommate and the open door, which compromised their privacy and dignity. CNA 3 acknowledged forgetting to close the privacy curtain completely during the care session, which was against the facility's policy on dignity revised in February 2021. This policy mandates that staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. The oversight in closing the privacy curtain led to a deficiency in maintaining the resident's dignity and privacy as per the facility's established guidelines.
Failure to Provide Adequate Notice of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide adequate notice to a resident regarding the termination of Medicare Part A coverage, which is a requirement to ensure residents are informed about their potential financial liabilities. Specifically, Resident 12, who was admitted with conditions including muscle weakness, dementia, and hypothyroidism, did not receive a signed Notice of Medicare Non-coverage (NOMNC) indicating the end of coverage. The NOMNC, dated 11/29/2024, stated that coverage would end on 12/2/2024, but it lacked the signature of the resident or their representative, which is necessary to confirm receipt and understanding of the notice. Additionally, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for Resident 12, also dated 11/29/2024, was incomplete as it did not include an estimated cost for services that would not be covered after the termination of Medicare Part A benefits. The Business Office Manager (BOM) admitted to not knowing the requirement to include an estimated cost on the SNFABN. Furthermore, the facility's policy and procedure, as well as the adopted guidelines, were not followed, as they require the resident or their representative to be notified in writing about the potential liability for non-covered services, and the SNFABN should not be communicated via phone, which was done in this case according to the Social Services Director's documentation.
Breach of Resident's Medical Record Confidentiality
Penalty
Summary
The facility staff failed to maintain the privacy and confidentiality of a resident's medical records, specifically for Resident 219. On March 5, 2025, a computer at Nurse Station 1 was left unattended with Resident 219's medical information visible on the screen. This incident was observed by a Registered Nurse Supervisor, who was unable to identify who left the computer screen on. The facility's policy requires staff to log off or turn off the computer screen before leaving it unattended to prevent unauthorized access to residents' medical records. Resident 219 was admitted to the facility with diagnoses including sepsis, degeneration of the nervous system due to alcohol, and essential hypertension. The resident was alert, oriented, and able to communicate effectively. Interviews with facility staff, including the Minimum Data Set Nurse and the Director of Nursing, confirmed that the medical records are confidential and should not be accessible to unauthorized individuals. The facility's policy, revised in October 2017, emphasizes safeguarding the personal privacy and confidentiality of all resident records, limiting access to authorized personnel only.
Failure to Develop Comprehensive Communication Care Plan
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, identified as Resident 52, who had significant communication challenges due to hearing loss and cognitive impairment. The resident was admitted with diagnoses including dysphagia, cognitive communication deficit, and unspecified bilateral hearing loss. Despite these challenges, the care plan did not include specific interventions to effectively communicate with the resident, such as writing on paper or speaking louder, which were methods found to be effective by the staff. This lack of a detailed communication strategy in the care plan was identified during a review of the resident's records and interviews with facility staff. Observations and interviews revealed that the resident's hearing loss worsened after cancer treatment, and the staff had to adapt their communication methods accordingly. However, these adaptations were not documented in the care plan, which should have been resident-centered and comprehensive. The facility's policy requires that care plans include measurable objectives and timetables to meet residents' needs, but this was not adhered to in the case of Resident 52. The deficiency was noted during a survey, highlighting the potential for delayed or inadequate care due to the lack of a proper communication plan.
Failure to Implement Correct Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement appropriate pressure ulcer prevention and management for a resident with a Stage 4 pressure ulcer in the sacral region. The resident, who was admitted with chronic respiratory failure, quadriplegia, and a Stage 4 pressure ulcer, was at moderate risk for skin breakdown according to the Braden Scale. The resident's care plan included the use of a low air loss (LAL) mattress to manage skin integrity, with specific settings based on the resident's weight of 132 pounds. However, observations revealed that the LAL mattress was not consistently set to the correct pressure of 132 mmHg, as required by the resident's weight and physician's orders. During observations, the LAL mattress was found to be set at 120 mmHg and later at 80 mmHg, which was not in accordance with the facility's policy and procedure or the manufacturer's operating instructions. A Licensed Vocational Nurse confirmed that the incorrect settings could lead to worsening of the resident's pressure ulcers. The facility's policy required monitoring of pressure ulcer risk factors and appropriate interventions, which were not adequately followed, leading to the potential for the resident's condition to deteriorate.
Failure to Provide Restorative Nursing Services for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion (ROM) and mobility, as per the facility's policy and procedure. The resident, identified as Resident 218, was initially admitted with conditions including hemiplegia affecting the right dominant side, aphasia, and essential hypertension. The resident was assessed with functional limitations in ROM on both upper and lower extremities and was dependent on assistance for various daily activities. Upon readmission from a General Acute Care Hospital (GACH), Resident 218 did not receive the necessary Restorative Nursing Assistant (RNA) services for passive range of motion (PROM) exercises, which were previously ordered before hospitalization. Observations and interviews revealed that the resident had not been assisted with exercises since returning from the hospital, and the RNA services were on hold. The facility's staff, including the Restorative Nurse Assistant, Registered Nurse Supervisor, Director of Nursing, and Director of Rehabilitation, acknowledged that the resident should have been evaluated and continued with RNA services to prevent further decline in ROM and mobility. The facility's policy indicated that residents with limited ROM should receive treatment to prevent further decrease, and those with limited mobility should receive appropriate services to maintain or improve mobility. However, the resident was not screened by a physical therapist after readmission, and no active order for RNA services was in place, resulting in the resident not receiving RNA services for three weeks. This oversight placed the resident at risk for further decline in ROM and potential contractures.
Failure to Inform Resident of Arbitration Agreement Details
Penalty
Summary
The facility failed to ensure that a resident was properly informed and understood the binding arbitration agreement they were asked to sign. The resident, who was cognitively intact and required a walker or wheelchair for mobility, was admitted with conditions including hemiplegia, hemiparesis, and hyperlipidemia. During the admission process, the resident was left with a stack of papers to sign, including the arbitration agreement, without a thorough explanation of its contents or the resident's right to rescind the agreement within 30 days. The Admission Coordinator acknowledged that it was the facility's responsibility to explain the arbitration agreement to residents and inform them of their right to rescind. However, the resident reported that the arbitration agreement was not explained, and they were unaware of the 30-day rescission period. The facility's arbitration agreement form clearly stated that signing the contract meant giving up the right to a jury or court trial, and that the agreement could be rescinded within 30 days. This oversight had the potential to result in the resident unknowingly forfeiting their right to resolve disputes through a court of law.
Incomplete Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to complete the antibiotic stewardship program protocols for prescribing antibiotics for two residents, leading to a deficiency. Resident 6, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and muscle weakness, was prescribed Ciprofloxacin for pneumonia. However, the Surveillance Data Collection Form for Resident 6 was incomplete, as the McGeer Criteria for infection surveillance was not fully filled out, with symptoms left unchecked. Similarly, Resident 218, who had diagnoses including hemiplegia, hypertension, and hyperlipidemia, was prescribed Amoxicillin-Pot Clavulanate for pneumonia. The Surveillance Data Collection Form for Resident 218 also had the McGeer Criteria incomplete, with symptoms not documented. During an interview, the Infection Preventive Nurse confirmed that the McGeer Criteria was incomplete for both residents before they received antibiotics. The facility's policy on antibiotic stewardship, revised in December 2016, requires that antibiotics be prescribed and administered under the guidance of the stewardship program, with signs and symptoms documented when a nurse communicates a suspected infection to a physician. The failure to complete the McGeer Criteria could lead to inappropriate antibiotic use, potentially resulting in antibiotic-resistant organisms.
Failure to Provide Timely ADL Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents, who were dependent on staff for activities of daily living (ADLs), were kept clean and provided with appropriate care. Resident 1, who was admitted with diagnoses including benign prostatic hyperplasia, hemiplegia, and hemiparesis, was found to have severely impaired cognitive skills and was always incontinent of urine and bowel. The care plan indicated that Resident 1 was totally dependent on staff for personal hygiene, yet during an observation, Resident 1 was found with a wet towel and absorbent pad soiled with urine, indicating a lack of timely care. Similarly, Resident 2, who had severe cognitive impairments and was always incontinent, was observed with a soiled incontinence brief. The facility's protocol required staff to round every two hours for cleaning and repositioning, but CNA 1 admitted to delaying care due to arriving late to work. The facility's policy stated that residents unable to perform ADLs independently should receive necessary services to maintain hygiene, but this was not adhered to, resulting in delayed services for both residents.
Failure to Maintain Continuous Oxygen Therapy and Infection Control
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not administering the prescribed continuous oxygen therapy. The resident, who was admitted with chronic respiratory failure and other serious conditions, was supposed to receive continuous oxygen therapy at 2 liters per minute. However, during an observation, the resident's T-bar was found disconnected from the oxygen tubing, and the tubing was observed on the floor, indicating a lapse in the administration of the prescribed oxygen therapy. Additionally, the facility did not maintain infection control protocols when the oxygen tubing became contaminated. The tubing, after falling on the floor, was picked up by a CNA and placed in the resident's nightstand drawer instead of being discarded as per facility protocol. Later, the contaminated tubing was handed to an LVN for reconnection to the resident, which posed a risk of infection due to the resident's immunocompromised status. Interviews with facility staff, including the LVN, Respiratory Therapist, Infection Preventionist Nurse, and Director of Nursing, confirmed that the facility's protocol was not followed. The staff acknowledged that the contaminated tubing should have been replaced immediately to prevent infection and ensure the resident received the necessary continuous oxygen therapy. The facility's policies on cleaning and disinfection, as well as oxygen administration, were not adhered to, leading to this deficiency.
Delayed Dental Services Due to Lack of Follow-Up
Penalty
Summary
The facility failed to ensure timely dental services for a resident, resulting in delayed dental care. The resident, who was admitted with multiple diagnoses including GERD, hemiplegia, and hemiparesis, was dependent on staff for personal hygiene and oral care. A dental exam conducted by a Doctor of Dental Medicine indicated the need for a deep cleaning by the facility's in-house hygienist. However, the Licensed Vocational Nurse was unaware of this referral until a later date, indicating a lack of communication and follow-up on the dental services required. The Social Services Director (SSD) acknowledged the delay in following up on the dental exam and referral, which was not acted upon until a family member requested a dental exam. The SSD admitted to not sending the referral for the hygienist immediately after the exam, as per facility policy. The facility's policies on dental and ancillary services require coordination and documentation of such services, which were not adhered to in this case, leading to the deficiency.
Delay in Therapy Services for Resident
Penalty
Summary
The facility failed to provide timely physical therapy (PT) and occupational therapy (OT) services for a resident after these services were ordered by the physician. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, was approved to receive PT and OT services starting on November 12, 2024. However, the services did not commence until December 2, 2024, for PT and December 3, 2024, for OT, resulting in a delay. This delay occurred despite the facility's policy that therapeutic services should be provided upon the written order of the resident's attending physician. The resident's condition included severely impaired cognitive skills and dependence on assistance for daily activities. During the period of delay, the resident experienced a decline in joint mobility, with assessments indicating increased limitations in shoulder, hand, hip, and knee mobility. Interviews with facility staff revealed that the delay was due to the rehab department's uncertainty about the number of sessions authorized, which contradicted the facility's process of initiating rehab services immediately upon authorization. The facility's policies emphasized the importance of timely therapeutic services to prevent further decline in residents' range of motion and mobility.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling opened packages of ground coffee with the date they were opened. During an observation in the facility's kitchen, three 8-ounce packages of ground coffee were found on a rolling cart without any labels indicating when they were opened. The Dietary Manager (DM) confirmed that all opened items should be labeled with the date of opening to ensure they are safe for consumption. The absence of such labels creates uncertainty about the freshness and safety of the coffee. Additionally, the facility did not discard expired food items found in the walk-in refrigerator, which is against safe food handling practices. During an inspection, several expired items were identified, including a gallon of apple cider vinegar, two boxes of oatmeal cookies, and a container of fried beans, all past their used-by dates. The DM acknowledged that expired items should not be stored in the refrigerator as they could be mistakenly served to residents, potentially causing illness. The Director of Nursing (DON) reiterated the importance of discarding expired food and labeling items with open and used-by dates to prevent foodborne illnesses.
Infection Control Breach in Contact Isolation Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices as outlined in their policy and procedure, specifically in the case of two residents who were under contact isolation precautions. Certified Nursing Assistant 1 (CNA 1) entered the room of these residents without donning the required personal protective equipment (PPE), which includes gloves and a gown. This action was observed despite the presence of a contact isolation precautions sign outside the room, which clearly indicated the necessity for PPE to prevent the spread of infection. Resident 1 was admitted with diagnoses including cerebral infarction and metabolic encephalopathy, and was moderately impaired in cognitive skills for daily decision-making. Resident 2, also admitted with cerebral infarction and hemiplegia, was severely impaired in cognitive skills and dependent on assistance for most activities. Both residents were placed on contact isolation precautions due to unspecified dermatitis, yet there was no physician order for these precautions until after the incident was observed. Interviews with staff, including CNA 1, Licensed Vocational Nurse 1 (LVN 1), the Infection Preventionist (IP), and the Director of Nursing (DON), confirmed the expectation that PPE should be worn in contact isolation rooms. The facility's policy, revised in October 2018, mandates the use of gloves and gowns for staff and visitors entering such rooms. The failure to follow these protocols was identified during a survey, highlighting a lapse in infection control measures intended to protect residents and staff from the transmission of infections.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe and homelike environment for one of three sampled residents by placing two pillows and a wedge between the resident's mattress and bedframe. This setup was observed during multiple instances, including an observation with a Certified Nurse Assistant (CNA) and the Director of Nursing (DON). The DON confirmed that the pillows and wedge should not have been placed there as they caused an elevation of the feet, limiting the resident's movement and creating a safety risk. The DON also noted that this arrangement could be unsafe and uncomfortable for the resident. The resident involved had severe cognitive impairments and was dependent on staff for various activities of daily living. The facility's records showed no documented evidence of an assessment, interdisciplinary team meeting, or nursing assessments and monitoring related to the use of the pillows and wedge. The facility's policies on Resident's Rights and Homelike Environment were reviewed, indicating that residents should be treated with respect and provided with a safe and comfortable environment. However, these policies were not followed in this instance, leading to the deficiency.
Failure to Provide Safe Environment for Resident
Penalty
Summary
The facility failed to provide an environment free of accident hazards for a resident with severe cognitive and physical impairments. The resident, who has a history of seizures, Parkinson's disease, bipolar disorder, and schizophrenia, was observed in bed with unpadded bilateral upper siderails, contrary to the care plan and doctor's orders. The Director of Nursing (DON) confirmed the absence of padding, acknowledging that this oversight put the resident at risk for physical harm and injury due to potential head and limb injuries during a seizure or other movements. Additionally, the resident was found lying in bed with two pillows and a wedge cushion improperly placed between the mattress and bed frame. This setup was observed by both a Certified Nurse Assistant (CNA) and the DON, who confirmed that the pillows and wedge should not have been there for safety reasons. The Maintenance Director (MD) identified the mattress as a prime mattress from Mattress Company 1, and the manufacturer's manual indicated that improper use could result in damage or injury. The facility's policies on safety precautions and hazardous equipment were not followed, contributing to the unsafe environment. The resident's Minimum Data Set (MDS) and History & Physical (H&P) records indicated severe impairments in decision-making and physical abilities, requiring maximal assistance for daily activities. Despite these documented needs, the facility did not adhere to the prescribed safety measures, thereby failing to mitigate accident hazards and ensure the resident's safety as per the care plan and facility policies.
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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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