Century Villa, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Inglewood, California.
- Location
- 301 Centinela Ave, Inglewood, California 90302
- CMS Provider Number
- 555368
- Inspections on file
- 26
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Century Villa, Inc during CMS and state inspections, most recent first.
An LPN gave medication cups to four residents without explaining what medications were being administered, and each resident swallowed the pills. The residents had diagnoses including DM, COPD, schizophrenia, bipolar disorder, anxiety, dementia, and HTN, and records showed varying capacity to understand and make decisions. During interview, the LPN stated residents should be told what medication they are receiving if they ask, and that they need to know in case they want to refuse.
Missing discharge notice and summary: A resident with cataract, HTN, and COPD was discharged to a lower level of care, but the medical record did not contain a Notice of Proposed Transfer or a discharge summary. The SSD stated the notice was used to inform the resident of the appeal process and to notify the Ombudsman, and the DON confirmed the discharge summary was absent. The facility P&P required written transfer/discharge notice with appeal rights and a discharge summary for community discharge.
A resident with unspecified dementia, schizophrenia, and depression did not have care plans for the mental health diagnoses. During record review, an LVN confirmed the care plans were missing and stated they should be in place so staff would know the interventions if behavioral issues occurred. The MDS nurse stated care plan initiation was a team effort and should be checked during quarterly MDS updates; the facility policy required care plans to include measurable objectives and timeframes.
A resident with bipolar disorder, schizophrenia, and suicidal ideations had intact cognition and capacity to make decisions, but the facility failed to carry out physician orders for stool for occult blood, chest x-ray, abdominal ultrasound, colonoscopy, and a dental referral after an ENT note identified a right jaw lymph node. The SSD stated the dental referral was missed, and the DSD stated the ordered tests were not transcribed into the physician orders, so the resident did not receive the ordered lab work or testing.
A facility arbitration agreement incorrectly stated that it could not be rescinded within 30 days of signature, and this version was used for three residents. The residents had psychiatric diagnoses and varying documentation of capacity/cognition, and the SSD confirmed the same erroneous agreement had been signed over the past 3 years. The ADM stated the error had the potential to violate resident rights by not providing the 30-day rescission period.
The facility failed to ensure that a resident was protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with multiple psychiatric diagnoses was prescribed Depakote, an anticonvulsant, which was not properly coded as such in the MDS assessment under high-risk drug classes. The MDS nurse confirmed the medication should have been classified based on its pharmacological category, but this was not done, resulting in inaccurate data being reported to CMS.
A resident with significant medical needs and a POA had their personal funds retained by the facility after discharge due to the facility's failure to respond to a request for the account balance. The Business Office Manager did not provide the required information to the resident's representative, despite facility policy mandating timely written statements upon request.
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. One resident with an ankle monitor lacked a care plan for skin care, while another resident had no care plan for temporary leave with family, despite having orders for such absences. The absence of these care plans was acknowledged by staff, highlighting a failure to follow facility policies.
The facility failed to adhere to infection control protocols for two residents, leading to potential infection risks. One resident's nasal cannula and humidifier were not changed as per policy, and another resident's enteral nutrition container was not replaced within the recommended timeframe. These oversights could lead to microbial growth and respiratory or gastrointestinal infections.
A resident with COPD, depression, and schizophrenia had their call light placed out of reach, potentially delaying necessary care. Staff confirmed the call light should be within reach, as per facility policy.
A resident's privacy was compromised when a sign disclosing the need to keep a law enforcement device charged was posted above their bed. The resident, with conditions including COPD, epilepsy, and schizophrenia, was unable to express or understand ideas and was fully dependent on staff. Facility staff acknowledged the privacy breach, which violated the policy requiring discreet display of confidential information.
A facility failed to revise a resident's care plan to include specific instructions for oxygen therapy, despite the resident's diagnoses of COPD, respiratory failure, and chronic heart failure. The care plan lacked details on the frequency, route, and conditions for administering oxygen, which was necessary for managing the resident's shortness of breath. The MDS Nurse acknowledged the oversight, noting that the care plan should have been updated to guide staff on when to administer oxygen and change equipment.
The facility failed to correctly obtain orthostatic blood pressure readings for two residents, potentially delaying interventions for orthostatic hypotension. Blood pressure readings were taken in the wrong order and without sufficient time between position changes, contrary to facility policy.
A resident with a history of cerebrovascular accident, schizophrenia, and bipolar disorder was not properly supervised or equipped with a smoking apron during a smoking break, contrary to her care plan and smoking assessment. The resident was observed on the smoking patio without the required protective gear and with her back to the supervising staff, posing a safety hazard. Facility staff acknowledged the oversight, which was inconsistent with the facility's smoking policy.
A resident with cervicalgia and neuropathy did not receive prescribed tramadol for severe pain on two occasions, despite the medication being removed from the narcotic cart. The discrepancy between the controlled drug record and the eMAR was confirmed by staff, leading to increased pain and frustration for the resident.
A facility failed to assess and obtain a physician's order for siderail use for a resident with diagnoses of failure to thrive and encephalopathy. The resident was observed with siderails up, but no assessment or order was documented. Staff interviews confirmed the lack of an Interdisciplinary Team meeting to determine the appropriateness of siderail use, contrary to facility policy.
The facility failed to manage medications properly, as an expired cranberry extract and an unlabeled docusate sodium liquid were found in a medication cart. The Treatment Nurse confirmed the expired extract should have been disposed of, and the lack of an open date on the docusate liquid could lead to uncertainty about its effectiveness. This was contrary to the facility's policy on medication storage.
A facility failed to date and label food items stored in a resident's room, as required by their policy. Observations revealed that a liter of Coca-Cola, a bag of Ruffles potato chips, and a jar of Cheez Whiz were not dated or labeled. Staff interviews confirmed that the policy mandates dating and labeling of food items, which should be consumed within three days to prevent potential health issues. The resident involved was independent and had the capacity to make decisions.
A facility failed to maintain accurate medical records for a resident during a transfer to another facility. The transfer form contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. The resident had chronic kidney disease, schizophrenia, and anxiety disorder. Staff acknowledged the error, and the importance of accurate documentation was emphasized by the DON.
The facility failed to meet the minimum room size requirement of 80 square feet per resident in six rooms, each occupied by three residents. Despite having a waiver, the limited space potentially affected resident safety and environment, as confirmed by the Maintenance Supervisor and Administrator.
A facility failed to document medication administration within the ordered time for four residents with conditions like bipolar disorder and schizophrenia. Medications scheduled for 9:00 am were administered late by an LVN, who cited issues with a new electronic record system. Despite training, the LVN needed more support, which was not communicated to management. The facility's policy requires timely medication administration, which was not followed, potentially affecting therapeutic outcomes.
The facility did not complete annual competency checklists for the IP, two LVNs, and a CNA, as required by their policy. This was discovered during a review of employee files by the DSD, who could not provide evidence of completed evaluations. The DON confirmed that these evaluations are necessary to ensure staff competency and identify training needs.
Residents Were Not Informed of Medications Before Administration
Penalty
Summary
The facility failed to ensure licensed nursing staff informed four sampled residents of the medications before administering them. During observations on 4/9/2026, LVN 1 and LVN 3 were seen giving medication cups to Residents 11, 22, 23, and 51 without explaining what medications were being administered, and each resident then swallowed the pills. During an interview later that morning, LVN 1 stated that if residents ask what medication is being given, staff should tell them, and that residents need to know what medication they are receiving in case they want to refuse. Resident 11 had diagnoses including type 2 DM, HTN, and dementia, and records noted fluctuating capacity to understand and make decisions, though the MDS indicated the resident was usually able to understand and be understood by others. Resident 22 had COPD, schizophrenia, and bipolar disorder; the H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated the resident was usually able to understand and be understood by others. Resident 23 had HTN, schizophrenia, and anxiety, and the H&P stated the resident had the capacity to understand and make decisions. Resident 51 had COPD, paranoid schizophrenia, and anxiety, and the H&P stated the resident had fluctuating capacity to understand and make decisions; the MDS indicated the resident was usually able to understand and be understood by others.
Missing discharge notice and summary
Penalty
Summary
The facility failed to complete discharge documents for one sampled resident before discharge. Resident 84 was admitted with diagnoses including unspecified complicated cataract, hypertension, and COPD. The resident’s H&P dated 7/10/2025 indicated fluctuating capacity to understand and make decisions. On 3/19/2026, the MDS showed the resident was discharged to the home/community and would not return to the facility, and a physician order indicated the resident may discharge to an assisted living facility for lower-level care. Progress notes from the same date stated the resident was alert, oriented, stable for transfer to a lower level of care, and discharged at 10:20 a.m. with current medications, personal belongings, and necessary documents. During a concurrent interview and record review on 4/9/2026, the Social Services Director stated there was no Notice of Proposed Transfer or discharge summary in the medical record. The SSD stated nurses fill out the Notice of Proposed Transfer and oversee faxing the notice to the Ombudsman, and that the notice included information regarding the appeal process and informed the ombudsman of the transfer. During a concurrent interview and record review, the Director of Nursing also stated there was no discharge summary and that it was very important to document the discharge summary. The facility policy for Transfer and Discharge (Including AMA), dated 01/2026, stated that for non-emergency discharges initiated by the facility, the resident and representative must receive written notice at least 30 days before transfer or discharge, including the reason, effective date, location, and appeal rights, and that for a community discharge, a discharge summary and plan of care should be prepared.
Missing Care Plans for Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that Resident 9 had comprehensive care plans for schizophrenia and depression. Resident 9’s admission record showed an initial admission and a readmission to the facility, and the resident’s diagnoses included unspecified dementia, schizophrenia, and depression. The resident’s H&P dated 10/9/2025 indicated fluctuating capacity to understand and make decisions. The MDS dated 1/13/2026 indicated the resident was usually understood, could usually understand others, had moderately impaired cognition, and was independent with eating and oral hygiene. During a concurrent interview and record review on 4/9/2026, LVN 1 reviewed Resident 9’s care plans and stated there were no care plans for schizophrenia or depression, adding that such care plans should be present so staff would know the interventions if behavioral issues occurred. During an interview on 4/10/2026, the MDS Nurse stated that initiation of care plans was a team effort and should be checked during quarterly MDS updates, and that the purpose of the care plan was to ensure the resident’s goals and interventions were being met. The facility policy titled Comprehensive Care Plans stated the care plan would describe services to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being and include measurable objectives and timeframes.
Missed Physician Orders for Testing and Dental Referral
Penalty
Summary
The facility failed to ensure physician orders for lab work, medical procedures, a chest x-ray, and a dental referral were carried out for one sampled resident. Resident 26 was admitted and later readmitted to the facility with diagnoses including bipolar disorder, schizophrenia, and suicidal ideations. The resident’s MDS dated 1/29/2026 indicated cognition was intact and unimpaired, and the H&P dated 3/3/2026 indicated the resident had the capacity to understand and make decisions. An ENT consultation note dated 3/26/2026 identified a right jaw lymph node and included a referral to a dentist for further evaluation. During interview, the SSD stated the dental referral order was missed and the ENT note was placed in the logbook without alerting the dentist. A physician progress note dated 4/3/2026 documented the resident’s request for testing for pancreatic, colon cancer, and other cancers, and included orders for stool for occult blood, chest x-ray, abdominal ultrasound, and colonoscopy. The DSD stated these orders were not carried over into the resident’s physician orders, were missed and not transcribed, and the resident did not receive the lab work or testing ordered.
Arbitration Agreement Misstated Residents’ 30-Day Right to Rescind
Penalty
Summary
The facility failed to ensure its arbitration agreement accurately reflected residents’ right to rescind the agreement within 30 days for three sampled residents. The facility’s undated Resident-Facility Arbitration Agreement stated, “This agreement may not be rescinded by written notice within thirty (30) days of signature,” which conflicted with the residents’ right to refuse or withdraw from the agreement. During interview, the Social Services Director stated this typographical error had been in the agreement used for the last 3 years and that the agreements containing the error were signed by Resident 15, Resident 26, and Resident 41. Resident 15 had diagnoses including schizoaffective disorder bipolar type, DM, and COPD, with documentation showing fluctuating capacity in the H&P and intact cognition on the MDS. Resident 26 had diagnoses including bipolar disorder, schizophrenia, and suicidal ideations, with intact cognition on the MDS and capacity to understand and make decisions documented in the H&P. Resident 41 had diagnoses including schizophrenia, anxiety disorder, and depression, with fluctuating capacity in the H&P and intact cognition on the MDS. The Administrator stated the typographical error had the potential to violate resident rights by not providing the 30-day time period to rescind the agreement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Accurately Code Anticonvulsant Medication in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident by not properly coding Depakote, an anticonvulsant medication, under Section N0415 (High-Risk Drug Classes) as required. The resident in question had diagnoses including paranoid schizophrenia, bipolar disorder, and anxiety disorder, and was prescribed Depakote for bipolar disorder. Despite the medication's pharmacological classification as an anticonvulsant, it was not marked as such in the MDS assessment. The Minimum Data Set Nurse (MDSN) acknowledged during interview and record review that Depakote should have been coded as an anticonvulsant regardless of the reason for its prescription, as per the Resident Assessment Instrument (RAI) manual. The MDSN admitted to not coding Depakote as an anticonvulsant in previous assessments and stated that this error was not previously flagged. The facility's policy and procedure on conducting accurate resident assessments requires that all assessments reflect the resident's status at the time and be completed by qualified staff. The inaccurate MDS assessment resulted in incorrect data being transmitted to CMS, specifically related to medication classification and care screening.
Failure to Respond to Request for Resident Personal Funds Account Balance
Penalty
Summary
The facility failed to respond to a request for the account balance of personal funds for one resident after discharge, resulting in the facility retaining the resident's funds. The resident in question had a Durable Unlimited Power of Attorney (POA) appointing her son to act on her behalf for financial matters. The resident was admitted with multiple diagnoses, including anemia, chronic kidney disease, and gastrostomy status, and was dependent on staff for all activities of daily living. The Minimum Data Set (MDS) indicated the resident rarely had the ability to make herself understood or understand others. The POA requested the account balance while the Business Office Manager (BOM) was away from the facility, but as of the survey date, the BOM had not responded to the request. A review of the resident's Trust Transaction History showed a closing balance of $1,504.04. The facility's policy and procedures require that quarterly statements be provided in writing to the resident or their representative within 30 days after the end of the quarter and upon request. Despite this policy, the BOM confirmed that no response had been given to the POA regarding the resident's personal funds account balance, resulting in the facility retaining the funds after the resident's discharge.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents, leading to deficiencies in their care. Resident 44, who was admitted with an ankle monitor, did not have a care plan addressing skin care related to the device. Observations revealed that the ankle monitor was not properly managed, as there was no material between the device and the skin to prevent breakdown. The Director of Nursing acknowledged the absence of a care plan and the need for one to prevent skin issues, although no skin problems had been reported at the time. Resident 90, who had orders allowing temporary leave with family, also lacked a care plan addressing safety and documentation for such absences. The LVN and MDS Nurse confirmed the absence of a care plan for temporary leave, which would typically include goals and interventions to ensure the resident's safety while outside the facility. The facility's policy on temporary passes was not followed, as it required proper documentation and safety measures, which were not in place for Resident 90.
Infection Control Deficiencies in Oxygen and Enteral Nutrition Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures for two residents, leading to potential risks of infection. For one resident, the nasal cannula and humidifier used for oxygen therapy were not dated or labeled correctly. The humidifier was observed to be dated over a month prior, and the nasal cannula lacked any date or label. According to the facility's policy, these items should be changed weekly to prevent respiratory infections. Interviews with staff revealed inconsistencies in the understanding of the required frequency for changing these items, with some staff indicating a two-week interval and others stating a weekly change was necessary. Another resident was observed with an enteral nutrition container that had been hanging for more than 24 hours, contrary to the manufacturer's guidelines and the facility's policy, which require the formula to be changed daily. The container was dated two days prior, and there was no nurse's signature or initials to confirm it had been changed as per the physician's orders. This oversight in changing the enteral nutrition could lead to microbial growth, posing a risk of gastrointestinal issues for the resident. The facility's policies and procedures for oxygen administration and enteral nutrition were found to be lacking in specific infection control guidelines. The failure to adhere to these policies and ensure proper labeling and timely changes of medical equipment and nutrition containers could potentially lead to the transmission of infectious microorganisms and increase the risk of infection among residents.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light device was placed within reach for a resident, identified as Resident 56, which could result in a delay or inability to obtain necessary care and services. Resident 56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), depression, and schizophrenia, and had fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS) assessment indicated that Resident 56 required supervision or assistance for activities of daily living. During an observation, the call light was found hanging on the overhead light above the resident's bed, out of reach, which was confirmed by Certified Nursing Assistant (CNA) 1. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the call light should always be within reach of the resident to ensure they can call for help in an emergency. The facility's policy and procedure on answering the call light also indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. The failure to adhere to this policy was identified as a deficiency during the survey.
Violation of Resident Privacy Due to Inappropriate Signage
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical information by posting a sign above the resident's bed. The sign disclosed that a law enforcement device needed to be plugged in, which was visible to anyone entering the room. This action violated the resident's right to privacy, as the sign contained sensitive information indicating the resident's involvement with law enforcement. The resident, who was admitted to the facility with chronic obstructive pulmonary disease, epilepsy, and schizophrenia, was dependent on staff for all functional abilities and had limited ability to express ideas or understand others. During observations and interviews, staff members, including a CNA and an LVN, acknowledged the inappropriate placement of the sign and its implications for the resident's privacy. The Director of Nursing also recognized the privacy violation but noted that the sign had been in place since before her tenure and was believed to be court-ordered. The facility's policy on posting signs requires that confidential information be displayed discreetly or in restricted areas, which was not adhered to in this case.
Failure to Revise Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include specific instructions for oxygen therapy. The resident, who was diagnosed with chronic obstructive pulmonary disease, respiratory failure, and chronic heart failure, required continuous oxygen at two liters per minute for shortness of breath and wheezing. However, the care plan, dated several months prior, only indicated that oxygen should be available if ordered or as needed, without specifying the frequency, route, or conditions under which the oxygen should be administered. This lack of detailed instructions placed the resident at risk of not meeting the care plan goal of avoiding shortness of breath. During an interview and record review, the MDS Nurse acknowledged that the care plan should have been updated to include specific interventions such as when to administer oxygen based on the resident's oxygen saturation levels, and when to change the nasal cannula and humidifier. The facility's policy on reviewing and revising care plans stated that care plans should be updated with new or modified interventions when a resident experiences a status change. The failure to revise the care plan with complete interventions could affect the resident's ability to meet their care plan goals.
Improper Orthostatic Blood Pressure Monitoring
Penalty
Summary
The facility failed to properly obtain orthostatic blood pressure readings for two residents, which could potentially delay necessary interventions for orthostatic hypotension. Resident 3, who has a history of bipolar disorder, schizophrenia, and hypertension, had an order to monitor orthostatic blood pressure weekly. However, the blood pressure readings were not taken correctly, as the times recorded were only one minute apart, and the readings were taken in the wrong order, with sitting measurements taken before lying measurements. This incorrect method of obtaining orthostatic blood pressure readings was confirmed during an interview with a registered nurse. Similarly, Resident 52, who also has a diagnosis of schizophrenia and hypertension, had an order to monitor orthostatic blood pressure weekly. The blood pressure documentation for Resident 52 showed similar issues, with readings taken only one minute apart and in the incorrect order. The facility's policy on orthostatic hypotension requires blood pressure to be measured in three positions: lying, sitting, and standing, with adequate time between position changes. The failure to adhere to this policy and the incorrect method of obtaining readings were identified as deficiencies during the survey.
Failure to Supervise Resident During Smoking Break
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 32, was adequately supervised and wore a smoking apron during a smoking break. Resident 32, who has a history of cerebrovascular accident, schizophrenia, and bipolar disorder, was observed sitting in a wheelchair on the smoking patio without a smoking apron and with her back to the sliding glass door, contrary to her care plan and smoking assessment requirements. The Assistant Activities Director (AAD) and Activities Director (AD) both acknowledged that Resident 32 needed supervision and a smoking apron for safety, and that the resident's positioning and lack of protective gear posed a safety hazard. Interviews with the Director of Nursing (DON) and a review of the facility's policy on resident smoking confirmed that the facility's procedures were not followed. The DON stated that smoking assessments are used to determine if residents require supervision and protective gear while smoking. The facility's policy mandates supervision and the use of smoking aprons for residents who need them, as indicated in their care plans. The failure to adhere to these protocols resulted in a potential safety risk for Resident 32, as she was not properly supervised and did not have the necessary protective equipment while smoking.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to administer pain medication as needed to one of the sampled residents, identified as Resident 84. Resident 84 was admitted with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety, and was capable of understanding and making decisions. The Minimum Data Set (MDS) assessment indicated that Resident 84 experienced significant pain, rated seven out of ten, which had the potential to interfere with daily activities. Despite the physician's order to administer tramadol 50mg every six hours for severe pain, the medication was not given at the scheduled times on two occasions, as documented in the Electronic Medication Administration Record (eMAR). Interviews with Resident 84 and facility staff revealed that the medication was removed from the narcotic cart but not administered, leading to increased pain and frustration for the resident. The Licensed Vocational Nurse (LVN) and the Minimum Data Set (MDS) Nurse confirmed the discrepancy between the controlled drug record and the eMAR, indicating a failure to follow the facility's medication administration policy. This oversight resulted in Resident 84 experiencing worsened pain and emotional distress due to the delay in receiving her prescribed pain medication.
Failure to Assess and Order Siderails for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 39, had an assessment and physician's order for the use of siderails. During an observation, it was noted that Resident 39 was resting in bed with one siderail up on each side, yet there was no documented order for their use in the resident's records. The resident had been admitted with diagnoses including failure to thrive and encephalopathy, conditions that could affect their ability to safely use siderails. Interviews with facility staff, including a Registered Nurse and the Minimum Data Set Nurse, revealed that an Interdisciplinary Team (IDT) meeting is required to assess the appropriateness of siderail use for residents. It was confirmed that Resident 39 did not undergo such an assessment, nor was there an order for siderails. The facility's policy mandates an assessment and documentation of the need for siderails before their use, which was not adhered to in this case.
Medication Management Deficiency
Penalty
Summary
The facility failed to properly manage medications in accordance with accepted professional principles, as observed during a survey. Specifically, a bottle of expired cranberry extract was found in medication cart #3 at nurses station #3, and a bottle of opened docusate sodium liquid lacked an open date label. During an interview, the Treatment Nurse acknowledged that the expired cranberry extract should have been disposed of to prevent residents from receiving ineffective medication. Additionally, the absence of an open date on the docusate liquid could lead to uncertainty about its effectiveness. The facility's policy on medication storage, which requires the disposal of outdated drugs and maintaining medication areas in a clean and safe manner, was not adhered to, contributing to this deficiency.
Failure to Date and Label Food Items in Resident's Room
Penalty
Summary
The facility failed to ensure that food items stored in a resident's room were properly dated and labeled, as required by their policy. During an observation, it was noted that a liter of Coca-Cola, a large bag of opened Ruffles potato chips, and an open jar of Cheez Whiz in the resident's room were not dated or labeled. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that the facility's policy mandates that all food items brought in by family or visitors must be dated and labeled, and consumed within three days. The staff acknowledged that failing to adhere to this policy could potentially lead to stomach issues for the resident. The resident involved, identified as Resident 84, was admitted to the facility with diagnoses including cervicalgia, idiopathic neuropathy, and anxiety. The resident was assessed to have the capacity to understand and make decisions, and was independent with personal hygiene, dressing, and eating. The facility's policy on the use and storage of food brought in by family or visitors emphasizes the importance of labeling and dating food items to ensure resident safety. However, the failure to comply with this policy in the case of Resident 84 represents a deficiency in the facility's adherence to its own procedures.
Inaccurate Documentation During Resident Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident 22, which is not in accordance with accepted professional standards. Specifically, the facility did not document the correct information regarding the resident's transfer to a different facility. The transfer form for Resident 22, dated 2/3/25, contained outdated vital signs and incorrect transfer details, which were not updated to reflect the resident's condition on the day of transfer. This discrepancy was acknowledged by the Director of Staff Development (DSD) and Registered Nurse (RN) 2, who admitted to not updating the transfer form with the correct information. Resident 22, who had diagnoses including chronic kidney disease, schizophrenia, and anxiety disorder, was transferred to another facility on 2/3/25. The Director of Nursing (DON) emphasized the importance of accurate documentation to ensure the resident's condition is known and to facilitate proper care during transfers. The facility's policy on charting and documentation requires that all services and changes in a resident's condition be documented in the medical record, which was not adhered to in this case.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that six out of forty-seven rooms met the minimum requirement of 80 square feet per resident in multiple occupancy rooms. During observations and interviews, it was confirmed that rooms 22, 24, 26, 27, 28, and 29 did not meet this requirement, as they were each occupied by three residents but only provided approximately 225 to 229 square feet in total. This deficiency was acknowledged by the Maintenance Supervisor and the Administrator, who confirmed the room measurements and the occupancy levels. The Administrator stated that the facility had a room waiver for these rooms, which allowed for the variance in square footage. However, the waiver did not negate the fact that the residents in these rooms had less space, potentially affecting their safety and environment. The facility's policy and procedure indicated that shared rooms must provide at least 80 square feet per resident, which was not adhered to in these cases. The Administrator acknowledged that the limited space could increase the risk of accidents for the residents occupying these rooms.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to document medication administration within the ordered time for four sampled residents. Each resident had specific diagnoses, including bipolar disorder, schizophrenia, dementia, epilepsy, and neuropathy, which required timely medication administration to manage their conditions effectively. The medications for these residents were scheduled for 9:00 am on November 22, 2024, but were administered and documented at varying times outside the prescribed window by LVN 3. LVN 3, responsible for administering the medications, stated that the facility had recently transitioned to an electronic medical record system on October 8, 2024. Despite receiving training, LVN 3 admitted to being slow in documenting medication times and expressed a need for additional training, which was not communicated to management. The facility's policy requires medication to be administered within 60 minutes before or after the scheduled time, a guideline that was not adhered to in these instances. The Director of Nursing (DON) confirmed the transition to the electronic system and mentioned that staff had access to training resources. However, the DON could not provide documentation of these training sessions. The facility's documentation policy emphasizes timely entries after care is provided, which was not followed, leading to potential risks in therapeutic outcomes for the residents involved.
Failure to Complete Annual Competency Checklists for Nursing Staff
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP), two Licensed Vocational Nurses (LVN1 and LVN2), and one Certified Nursing Assistant (CNA2) had their annual competency checklists completed. This deficiency was identified during a review of employee files conducted by the Director of Staff Development (DSD) on August 13, 2024. The DSD was unable to provide evidence that the required annual competencies were completed for these staff members. The purpose of these annual competencies is to assess the nursing skills of the staff and ensure they are capable of performing their duties effectively. The Director of Nursing (DON) confirmed that the facility's policy requires staff to complete a competency checklist upon hire and annually thereafter. These checklists are intended to verify staff competency and identify any need for additional training. The facility's policy and procedure document, titled 'Competency Evaluation,' outlines that these evaluations are necessary to ensure staff have the appropriate skills to meet the needs of the residents. The failure to complete these evaluations could potentially result in staff providing substandard care due to a lack of verified competencies.
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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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