Cheviot Hills Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Los Angeles, California.
- Location
- 3533 Motor Avenue, Los Angeles, California 90034
- CMS Provider Number
- 056451
- Inspections on file
- 60
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Cheviot Hills Post Acute during CMS and state inspections, most recent first.
The facility failed to implement its transfer/discharge policy by not providing required orientation and caregiver training to a responsible party before a high fall-risk resident with HTN, DM, CHF, moderate cognitive impairment, and substantial/maximal ADL assistance needs was discharged home. OT and PT notes documented falls, poor safety awareness, and the need for precautions, with therapy staff stating the resident required minimal to moderate assistance and cueing for ambulation and transfers. Both therapy staff and the ADON confirmed that no caregiver training or orientation was provided or documented for the responsible party, despite policy requiring resident/representative notification, orientation, and documentation for discharges.
A resident with schizophrenia, HTN, and MDD with psychotic features, and documented severe cognitive impairment requiring substantial/maximal assistance with ADLs, was receiving Quetiapine (Seroquel) 100 mg PO daily without documented informed consent. The ADON reported that antipsychotic consents are required on admission and with new orders and must include the medication name, dose, route, and frequency, but confirmed there was no consent on file for this antipsychotic. Facility policy on informed consent for psychotropic drugs required disclosure of reasons for use, benefits, risks (including black box warnings), and alternatives to the resident or RP, yet this process was not completed for the resident’s Seroquel order.
A resident with schizophrenia, HTN, MDD with psychotic features, and severe cognitive impairment was receiving Quetiapine (Seroquel) for MDD with psychotic features manifested by inconsolable screaming, but the facility did not develop or implement a comprehensive, individualized care plan for either the antipsychotic medication or the monitoring of psychotic behaviors. Despite physician orders specifying Quetiapine dosing and the need for behavior monitoring, and facility policies requiring care plans for behavioral symptoms and medications, there was no behavior monitoring care plan and no medication care plan. As confirmed by the ADON, this resulted in the resident’s psychotic behaviors and potential adverse drug reactions going unmonitored.
A resident admitted with sequelae of cerebral infarction, DM, and heart failure was assessed on admission as having excessive dry skin to the face and BLE, but no individualized care plan was developed to address this skin abnormality. The ADON acknowledged that dry skin is a skin abnormality that must be care planned and confirmed that no such care plan existed. The DON stated that not accurately assessing the dry skin could have resulted in broken skin or infection. Review of facility P&P showed that the IDT is required to develop a comprehensive person-centered care plan with measurable objectives and timeframes for all identified needs, including skin problems, but this was not done for this resident’s dry skin.
A resident with a history of stroke, DM, and heart failure was admitted with excessive dry skin on the face and bilateral lower extremities, but nursing staff did not obtain treatment orders or develop a care plan for this condition. Although the admission assessment documented dry skin, subsequent weekly head‑to‑toe assessments by CNs and LVNs failed to record it, and the ADON later confirmed these assessments were inaccurate. Staff interviews showed that CNs are expected to report skin abnormalities to charge nurses, LVNs typically obtain A + D ointment orders for dry skin, and RNs are responsible for comprehensive assessments and care plans, yet these processes did not result in an accurate assessment or care plan for the resident’s dry skin, contrary to facility policy and scope‑of‑practice requirements.
A resident with significant medical needs was found to have excessive dry skin on the face and overgrown toenails, despite requiring substantial assistance with ADLs. Staff observations and interviews confirmed the hygiene issues, and the care plan did not address the resident's specific skin care needs. Facility policy required support for hygiene and grooming, but this was not consistently provided.
A resident with multiple complex medical conditions, including OSA and use of BiPAP, was not accurately assessed in the MDS, as both the diagnosis of OSA and the BiPAP treatment were omitted. The ADON confirmed these omissions during review, despite facility policy requiring comprehensive and consistent documentation.
A resident with multiple diagnoses, including OSA and a history of hypercapnic respiratory failure treated with BiPAP, did not have a care plan developed for OSA or BiPAP use. The absence of this care plan was confirmed during record review and interview with the ADON, despite facility policy requiring comprehensive care planning for all identified needs.
A resident with multiple chronic conditions and at risk for pressure injuries was admitted with a physician's order for left foot treatment, but the facility did not develop a care plan to address this need. The DON confirmed that interventions for the left foot were not care planned, despite facility policy requiring comprehensive care planning and regular updates based on resident condition.
A resident with multiple risk factors for pressure injuries did not receive consistent skin monitoring or timely reporting of changes, as required by physician orders and facility policy. Staff failed to apply prescribed ointment and did not report redness and a developing wound on the resident's left heel, despite the resident voicing concerns and preventive measures being in place.
The facility did not ensure dietary cooks followed the menu and used a recipe for lunch, leading to potential food preparation errors. Observations revealed missing or incorrectly dated food items and a lack of a written recipe for the meal being prepared. Interviews confirmed that cooks were memorizing recipes, contrary to facility policy requiring standardized recipes.
The facility failed to maintain safe food storage and preparation practices, risking foodborne illness for 89 residents. Observations revealed improperly labeled food in the refrigerator and a lack of recipes for meal preparation. Interviews indicated inadequate staff training and improper cooling methods for leftovers, contrary to facility policies.
A facility failed to promote dignity during meal assistance when a CNA was observed feeding a resident while standing, contrary to the policy requiring staff to be seated at eye level. The resident, with a history of metabolic encephalopathy and other conditions, was dependent on assistance for eating. The facility's policy emphasizes maintaining resident dignity and ensuring safe eating practices.
A facility failed to complete and submit the annual MDS assessment within the required timeframe for a resident with multiple diagnoses, including epilepsy and bipolar disorder. The resident was totally dependent on staff for all ADLs and had severely impaired cognition. The last MDS assessment was completed months before the due date, and the facility's policies and job descriptions required timely completion and submission of assessments.
A facility failed to conduct a PASRR Level 1 assessment for a resident with schizophrenia and major depression, leading to potential inappropriate placement and management. The resident was admitted with these diagnoses, and the PASRR letter indicated no need for Level II screening. However, the facility did not follow up on the necessary PASRR Level II evaluation. Interviews revealed staff lacked experience and training in PASRR procedures, contributing to the oversight.
The facility failed to complete and maintain PASRR Level I evaluations for three residents, impacting their psychiatric care. A resident with bipolar disorder and another with schizophrenia did not have their mental illnesses indicated in their PASRR Level I, preventing necessary Level II evaluations. Another resident qualified for a Level II evaluation, which was not conducted. The Admission Director admitted to errors due to insufficient training.
The facility failed to maintain proper narcotic disposal procedures, as the DON did not keep records of medications collected for disposal, potentially leading to diversion. Additionally, an incorrect PASRR Level 1 screening was submitted for a resident with schizophrenia and major depression due to inadequate training of the Admission Director. These deficiencies highlight issues in the facility's adherence to policies, impacting resident care.
A resident with multiple health issues, including fractures and mobility problems, missed a crucial orthopedic follow-up appointment due to the facility's failure to coordinate transportation and appointment scheduling. The case manager, responsible for these tasks, was absent, leading to the oversight. The facility's policy requires social services to manage such referrals and transportation, which was not followed.
The DON failed to properly store and discard medications, leaving them accessible in an unlocked container in his office. The medications were not dissolved as required, posing a risk for diversion. The facility's policy mandates secure storage and proper disposal methods, which were not followed.
A resident experienced a delay in receiving a substitute meal after expressing dissatisfaction with the breakfast served. Despite requesting an alternative at 7:15 am, the resident waited over two hours before receiving a substitute meal. Staff interviews indicated a delay in the kitchen's preparation of the substitute, contrary to the facility's policy on accommodating food preferences.
A resident was bitten by a spider due to the facility's failure to maintain a pest-free environment. Despite recent pest control measures, a CNA observed a spider near the resident's room. The Maintenance Supervisor confirmed scheduled fumigation, but the incident indicates a lapse in the pest control program's effectiveness.
A resident with a history of falls and cognitive impairments was left unattended by a CNA while sitting on the side of the bed, resulting in a fall and multiple rib fractures. The resident required substantial assistance with daily activities and was identified as a fall risk. Despite this, the CNA left the resident unsupervised, leading to the incident and subsequent hospital transfer.
A resident with a history of sepsis and diabetes, and an indwelling catheter, exhibited chills on two occasions, but the facility failed to notify the physician as required by the care plan. This led to the resident developing altered mental status and being transferred to a hospital, where she was diagnosed with sepsis and a UTI.
A resident with intact cognitive skills refused assistance from a specific CNA due to negative past interactions. Despite this, another CNA brought the refused CNA into the resident's room to assist with care, violating the resident's right to choose their caregiver. The facility's policies, which emphasize resident participation in care planning, were not followed.
The facility failed to protect a resident from abuse, resulting in one resident punching another, causing a cut to the lip. The incident involved a resident with dementia and another with major depressive disorder and anxiety. The investigation revealed a lack of behavioral monitoring and documentation for the resident with dementia, contributing to the incident.
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for a resident with dementia, leading to an altercation where another resident punched the first resident in the face. The lack of monitoring and documentation contributed to the incident, despite the facility's policy on behavior management.
Failure to Provide Caregiver Orientation Prior to Discharge of High Fall-Risk Resident
Penalty
Summary
The facility failed to follow its Transfer or Discharge policy by not providing required orientation and caregiver training to the responsible party of a resident discharged home. The resident had diagnoses including HTN, DM, and CHF, and an MDS showing moderate cognitive impairment and a need for substantial/maximal assistance with most ADLs such as toileting hygiene, bathing, dressing, and footwear. Therapy documentation from OT and PT noted a history of falls, poor safety awareness, and the need for precautions. A physician’s order directed discharge to home on the day after the resident’s last covered day. Interviews with therapy staff and the ADON confirmed that no caregiver training or orientation was provided to the resident’s responsible party before discharge. The COTA stated the resident required minimal to moderate staff assistance for walking to ensure safety and positioning and could fall without that level of assistance, and confirmed no caregiver training or orientation was given. The PTA reported the resident was impulsive, confused, and required verbal and tactile cueing, with transfer assistance needs ranging from minimal to moderate, and confirmed he was not asked to provide caregiver training. The ADON stated that a proper and safe discharge included caregiver education and confirmed there was no documented evidence of such training, despite the facility’s policy requiring resident/representative notification, orientation, and documentation in the medical record for transfers and discharges.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
Facility staff failed to ensure that a resident and/or the resident’s responsible party were informed in advance of the risks and benefits of the antipsychotic medication Quetiapine (Seroquel), thereby not obtaining informed consent prior to its use. The resident was admitted with diagnoses including schizophrenia, hypertension, and major depressive disorder with psychotic features, and had a physician’s order dated 3/11/2026 for Quetiapine Fumarate 100 mg by mouth once daily for major depressive disorder with psychotic features. The resident’s Minimum Data Set dated 3/6/2026 documented severe cognitive impairment and a need for substantial/maximal assistance with most ADLs, indicating that the resident was not independently managing daily tasks. During an interview and concurrent record review with the ADON, it was stated that consents for antipsychotic medications are to be completed upon admission and whenever there is a new order, and that such consents must include the medication name, dosage, route, and frequency. The ADON confirmed there was no consent on file for Seroquel 100 mg for this resident, despite the existing order. The facility’s policy and procedure titled “Informed Consent for Psychotropic Drugs,” reviewed 2/2026, defined informed consent as disclosure of material information, including reasons for use, benefits, risks (including black box warnings), and alternatives, to allow the resident or representative to accept, refuse, or revoke consent. The absence of a documented consent for Seroquel showed that this process was not followed for the resident.
Failure to Care Plan and Monitor Antipsychotic Therapy and Psychotic Behaviors
Penalty
Summary
The facility failed to develop and implement an individualized, comprehensive care plan with measurable objectives and timetables for a resident receiving Quetiapine (Seroquel) for major depressive disorder with psychotic features manifested by inconsolable screaming. The resident was admitted with diagnoses including schizophrenia, hypertension, and major depressive disorder, and had severe cognitive impairment requiring substantial to maximal assistance with most ADLs. Physician orders directed Quetiapine administration, including a dose increase associated with psychotic features manifested by inconsolable screaming, and the resident was to be monitored for psychotic behaviors. However, review of the resident’s care plans showed there was no care plan addressing the use of Seroquel or the monitoring of psychotic behaviors. During an interview and concurrent record review with the ADON, it was confirmed that care plans are required for residents being monitored for behavioral issues such as aggressive behaviors and yelling, and for medications so staff know what interventions to carry out. The ADON acknowledged that there was neither a behavior monitoring care plan nor a medication care plan for Seroquel for this resident. This omission occurred despite facility policies requiring an individualized comprehensive care plan with measurable objectives and timetables to meet residents’ medical, physical, mental, and psychosocial needs, and a behavior management policy requiring evaluation of behavioral symptoms, use of non-pharmacologic interventions as first-line approaches, and inclusion of behaviors and interventions in the care plan. As a result, the resident’s psychotic behaviors and potential adverse drug reactions were not monitored.
Failure to Care Plan for Resident with Documented Dry Skin
Penalty
Summary
Surveyors identified that the facility failed to develop and implement an individualized, person-centered care plan for a resident who was admitted with documented dry skin to the face and bilateral lower extremities. The resident’s admission assessment, completed in the evening on the date of admission, recorded excessive dry skin under the body check section. Despite this documented skin abnormality, a review of the resident’s care plans showed there was no care plan addressing dry skin. The facility’s Assistant Director of Nursing (ADON) stated in interview that dry skin is considered a skin abnormality that must be care planned and confirmed that the resident was admitted with dry skin to the face and both legs but had no corresponding care plan. The resident’s medical record indicated admission with diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure. The Director of Nursing (DON) stated that not accurately assessing the resident’s dry skin could have resulted in broken skin or infection. Review of the facility’s policy and procedure titled “CARE PLAN COMPREHENSIVE” showed that the Interdisciplinary Team, in coordination with the resident and/or representative, is required to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs from the comprehensive assessment, including incorporation of identified problem areas and associated risk factors. The failure to create a care plan for the resident’s dry skin was inconsistent with this policy and represented the cited deficiency.
Failure to Assess and Care Plan Dry Skin for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with documented dry skin was properly assessed and care planned by nursing staff with the appropriate competencies and within their scope of practice. On admission, Resident 2’s initial assessment documented excessive dry skin on the face and bilateral lower extremities. The resident had significant medical diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure, and the MDS later documented mild cognitive impairment and a need for assistance with multiple ADLs. Despite the documented dry skin at admission, there were no physician orders for skin ointments or protectants for dry skin in the resident’s record over several months. Review of Resident 2’s care plans showed there was no care plan addressing dry skin, even though the ADON stated that dry skin is considered a skin abnormality that must be care planned. The ADON confirmed that Resident 2 was admitted with dry skin to the face and both legs but that this condition was not reflected in the care plan. Additionally, weekly head‑to‑toe assessments completed by night shift charge nurses on multiple dates did not indicate the presence of dry skin, which the ADON acknowledged was inaccurate. This demonstrated that the ongoing assessments did not accurately capture the resident’s skin condition. Interviews with staff further clarified the facility’s assessment and reporting processes. An LVN stated that A + D ointment is typically ordered for residents with dry skin and that CNs report skin abnormalities to charge nurses, who then assess residents and report changes in condition to the RN Supervisor. The RN Supervisor stated that full body assessments are completed on admission, readmission, or change of condition. Facility job descriptions for LVNs and RNs emphasized providing nursing care within the scope of practice and ensuring baseline and periodic comprehensive assessments and care plans are completed. The facility’s care plan policy required that identified problem areas and risk factors be incorporated into comprehensive care plans and that assessments be ongoing with care plans reviewed and revised as new information emerges. The Board of Vocational Nursing and Psychiatric Technicians guidance indicated that LVNs cannot perform certain types of assessment, underscoring that a licensed nurse with the appropriate skill set did not complete or document an accurate assessment and care plan for Resident 2’s dry skin.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene and grooming for one resident with multiple medical conditions, including Type 2 Diabetes Mellitus, sequelae of cerebral infarction, and dysphagia. Upon admission, the resident was noted to have excessive dry skin on the face and both lower legs, and required substantial to maximal assistance with showers and baths. The resident's care plan addressed self-care performance deficits related to impaired balance and limited mobility, but did not include interventions for the excessive dry skin. Observations revealed the resident had visible dry, white/gray flakes of skin on the face and overgrown toenails. Staff interviews confirmed these findings, with a nurse acknowledging the condition was unacceptable and a CNA admitting the toenails should have been reported to the charge nurse. Further review indicated that although the resident was scheduled for a shower and had reportedly received one, the issues with dry skin and overgrown toenails persisted. The facility's policy required that residents unable to perform activities of daily living independently receive appropriate support for hygiene and grooming, but this was not consistently implemented for the resident in question. The lack of timely intervention and communication among staff contributed to the ongoing issues with the resident's personal hygiene and grooming.
Failure to Accurately Document Diagnoses and Treatments in MDS Assessment
Penalty
Summary
The facility failed to ensure an accurate assessment in the Minimum Data Set (MDS) for one resident. The resident was admitted with multiple diagnoses, including heart failure, cellulitis, muscle weakness, morbid obesity, hypertension, and obstructive sleep apnea (OSA). The resident's hospital history and physical also documented hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy. However, upon review of the resident's MDS, it was found that the diagnosis of OSA was not included in Section I - Active Diagnoses, and the use of BiPAP was not documented in Section O - Special Treatments, Procedures, and Programs. During an interview and record review, the Assistant Director of Nursing (ADON) confirmed that both the OSA diagnosis and BiPAP treatment were missed in the MDS assessment. The facility's policy and procedures require that comprehensive assessments reflect information from progress notes, care plans, and resident observations/interviews, but this was not followed in this case. This omission had the potential to affect the resident's plan of care and delivery of services.
Failure to Develop Care Plan for OSA and BiPAP Use
Penalty
Summary
The facility failed to develop a care plan addressing obstructive sleep apnea (OSA) for a resident who was admitted with multiple diagnoses, including OSA, heart failure, cellulitis, muscle weakness, morbid obesity, and hypertension. The resident's hospital history indicated she experienced hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome and OSA, which was treated with BiPAP therapy, resulting in improvement. Despite these significant medical issues, a review of the resident's care plans confirmed that no care plan was created for OSA or the use of BiPAP. The resident was assessed as having intact cognition but required staff assistance for bed mobility, bathing, dressing, personal hygiene, and supervision for eating and oral hygiene. During an interview and record review, the ADON verified the absence of a care plan for OSA or BiPAP and acknowledged that this could impact the resident's overall health. The facility's own policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to address all identified needs, but this was not done for the resident's OSA.
Failure to Develop Care Plan for Left Foot Treatment
Penalty
Summary
The facility failed to develop a care plan addressing left foot treatments for a male resident admitted with multiple diagnoses, including peripheral vascular disease, Type 2 diabetes mellitus, atherosclerosis, and other chronic conditions. The resident was identified as being at risk for developing a pressure injury and was dependent on staff for activities such as toileting, personal hygiene, and transfers. Despite a physician's order to apply A&D ointment to the resident's left foot and toes for excessive dryness and to monitor for skin breakdown, no care plan was created to address these specific needs. During an interview and record review, the DON confirmed that the left foot treatment order should have been care planned, especially given the resident's risk factors for pressure injuries. The facility's own policies required comprehensive, interdisciplinary care planning for prevention and wound treatments, as well as regular review and updates to care plans based on changes in resident condition. However, the care plan for this resident did not include interventions for the left foot, and the omission was acknowledged by facility leadership.
Failure to Monitor and Report Skin Changes Leading to Pressure Injury Risk
Penalty
Summary
A deficiency occurred when staff failed to monitor and report changes in a resident's skin condition, specifically redness on the left heel, to the attending physician. The resident, an older male with significant medical history including peripheral vascular disease, diabetes, atherosclerosis, and a partial foot amputation, was identified as being at risk for pressure injuries and was dependent on staff for most activities of daily living. Despite physician orders to apply A&D ointment to the left foot for excessive dryness and to monitor for skin breakdown every shift, staff inconsistently applied the ointment and did not consistently monitor or report changes in the skin condition. The resident reported concerns about developing a pressure ulcer on the heels to both facility staff and the physician, but felt these concerns were not addressed. Observations revealed that heel protector boots, intended as a preventive measure, were not consistently used as ordered. Staff interviews confirmed that the ointment was not applied on the day of observation and that the CNA did not notice or report any redness. When the LVN finally assessed the left heel, a reddened area with a black scab was found, and the resident exhibited pain upon palpation. Facility policy required staff to observe for signs of potential or active pressure injury daily and to notify the physician of any significant changes. However, the lack of timely reporting and intervention for the observed skin changes on the resident's left heel constituted a failure to follow these protocols, resulting in a deficiency related to pressure ulcer prevention and care.
Failure to Follow Menu and Recipe in Food Preparation
Penalty
Summary
The facility failed to ensure that dietary cooks followed the menu and used a recipe for lunch on a specific date. During an initial kitchen observation, it was noted that several food items in the walk-in refrigerator were either not labeled with a date or were dated incorrectly. Additionally, during an observation of the food recipe binder, it was found that there was no recipe for the lunch being prepared, which was chicken noodle casserole. The Dietary Supervisor admitted that the menu was in their office and that the cooks were memorizing the recipe instead of following a written one. Interviews with the Dietary Supervisor and a dietary cook revealed that the lack of a written recipe could lead to food being prepared incorrectly, potentially making residents sick. The facility's policy and procedures, reviewed prior to the incident, stated that menus should meet the nutritional needs of residents and that standardized recipes should be developed and used in food preparation. However, these policies were not followed, as evidenced by the absence of a recipe for the meal being prepared.
Deficiency in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, which had the potential to result in harmful bacteria growth and foodborne illness for all 89 medically compromised residents. During an initial kitchen observation, several containers of cooked food in the walk-in refrigerator were noted to be improperly labeled or unlabeled, with some items not having a date. Additionally, the food recipe binder lacked a recipe for the chicken noodle casserole being prepared, and the Dietary Supervisor admitted that the menu was not available to the cooks, who were instead relying on memorization. Interviews with dietary staff revealed further issues, including a lack of recent skills competency assessments for the cooks and improper cooling methods for leftover food. The night shift cook did not follow the cooling down method for food cooked the previous day, and the leftover food was already stored in the refrigerator without proper cooling. The Registered Dietician confirmed that storing leftover cooked foods improperly could lead to foodborne illnesses. The facility's policy and procedures emphasized the importance of adhering to safe food handling practices, including rapid cooling of potentially hazardous foods, which was not followed in this instance.
Failure to Promote Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that staff promoted dignity while assisting a resident during meals. Specifically, a Certified Nursing Assistant (CNA) was observed feeding a resident while standing, rather than sitting at eye level as required by the facility's policy. This practice was noted during a meal observation, where the CNA was standing to the right side of the resident while feeding them. The CNA acknowledged that she was supposed to be seated beside the resident to assist with feeding, which is in line with the facility's policy to maintain resident dignity and ensure safe eating practices. The resident involved had a medical history that included metabolic encephalopathy, paralytic syndrome following cerebral infarction, hypertension, and contractures of both knees. The resident was dependent on assistance for eating, oral hygiene, and dressing, among other personal care needs. The facility's policy on dignity emphasizes caring for residents in a manner that promotes their well-being and self-esteem. The Assistant Director of Nursing confirmed that CNAs are required to be seated at eye level when assisting residents with eating to ensure proper chewing and swallowing, as well as to uphold the resident's dignity.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete and submit the annual comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe for a resident. The resident was originally admitted on November 3, 2023, and readmitted on May 17, 2024, with diagnoses including epilepsy, bipolar disorder, hemiplegia, and hemiparesis. The resident was totally dependent on staff for all activities of daily living and had severely impaired cognition. The last MDS assessment for the resident was completed on July 30, 2024, and the annual assessment was overdue as it should have been completed by November 1, 2024. During a review with the MDS Coordinator, it was confirmed that the annual MDS assessment was overdue, and the coordinator acknowledged that the MDS is a complete record of the resident's care. The Director of Nursing also stated that the MDS should be completed and submitted according to CMS timeframes. The facility's policy and procedures, as well as the MDS/RAI Coordinator's job description, indicated that assessments should be completed and transmitted within required timeframes, which was not adhered to in this case.
Failure to Conduct PASRR Level 1 Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to conduct a Preadmission Screening and Resident Review (PASRR) Level 1 assessment for a resident diagnosed with mental illness, specifically schizophrenia and major depression. The resident was admitted with these diagnoses, and the PASRR letter indicated a negative result for Level I screening, suggesting no need for Level II screening. However, the facility did not follow up on the PASRR Level II for the resident, which was necessary given the resident's mental health conditions and medication regimen, including Trazadone, Risperdal, Aripiprazole, and Clozaril. Interviews with facility staff revealed a lack of experience and training in PASRR procedures. The Admission Director, who was responsible for ensuring PASRR Level 1 was received upon admission, had minimal training and relied on licensed nurses to review the PASRR Level 1. The Assistant Director of Nursing and the Director of Nursing acknowledged the oversight and the need for a PASRR Level II evaluation, which was not conducted. This oversight was attributed to a failure in the facility's process to ensure proper PASRR assessments were completed, potentially leading to inappropriate placement and management of the resident's mental health condition.
Failure to Complete PASRR Evaluations
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening Resident Review (PASRR) Level I was obtained and maintained in the residents' charts for three sampled residents. Resident 1 was readmitted with diagnoses including bipolar disorder, anxiety, and depression, yet the PASRR Level I did not indicate a diagnosis of mental illness, leading to a lack of a Level II evaluation. Similarly, Resident 2, who was readmitted with schizophrenia and major depression, also did not have a PASRR Level I indicating a mental illness, resulting in no Level II evaluation. Resident 74, admitted with schizophrenia and depression, qualified for a PASRR Level II evaluation, but it was not conducted upon admission. The Admission Director admitted to submitting incorrect PASRRs due to a lack of training, which was only received after the errors occurred. The Assistant Director of Nursing acknowledged that Resident 74 should have been rescreened for PASRR Level II upon admission. The Director of Nursing confirmed that incorrect completion of PASRRs could affect psychiatric treatment for residents. The facility's policy stated that the Admissions Director or Social Worker should ensure PASRR completion for all potential residents, but this was not adhered to, leading to the deficiency.
Deficiencies in Narcotic Disposal and PASRR Screening
Penalty
Summary
The facility failed to maintain proper procedures for the disposal of narcotics, as the Director of Nursing (DON) did not keep a log or records of medications collected for disposal by a medication waste management company. During an interview, the DON admitted to not knowing the process of preventing diversion once the medications are picked up, nor did he have an answer for preventing theft of narcotics from an unlocked bucket in his office. This lack of knowledge and procedure could potentially lead to the diversion of medications. Additionally, the facility submitted an incorrect Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who was admitted with diagnoses including schizophrenia and major depression. The Admission Director (AD) acknowledged submitting the incorrect PASRR and admitted to not receiving adequate training on completing and submitting PASRR Level 1 or Level 2. This error in the PASRR process could affect the necessary and required treatment for the resident. The facility's policies and procedures require the Director of Nursing to be knowledgeable and competent in their duties, including overseeing nursing practices and developing staff training programs. However, the DON's lack of knowledge regarding narcotic disposal and the AD's insufficient training on PASRR processes highlight deficiencies in the facility's adherence to these policies, potentially impacting the quality of care provided to residents.
Failure to Coordinate Orthopedic Follow-Up for Resident
Penalty
Summary
The facility failed to provide necessary social services to Resident 244 by not following up on an orthopedic evaluation appointment. Resident 244, who was admitted with multiple diagnoses including fractures, gout, hyperlipidemia, prostate cancer, and mobility issues, had an intact cognition and required varying levels of assistance with daily activities. Despite having a scheduled orthopedic follow-up appointment, it was canceled without informing the resident of the reason or who canceled it. This oversight was identified during an initial tour when the resident mentioned the missed appointment. The case manager, responsible for coordinating referrals and appointments, acknowledged the missed appointment, citing her absence as the reason. She explained her usual process of arranging transportation and negotiating costs for private pay residents like Resident 244, who lacked transportation insurance. The Director of Nursing emphasized the importance of follow-up appointments for assessing treatment progress and adjusting care plans. The facility's policy indicated that social services should coordinate referrals and transportation for medical services based on physician evaluations and orders, which was not adhered to in this case.
Improper Storage and Disposal of Medications
Penalty
Summary
The Director of Nursing (DON) failed to store and discard controlled and non-controlled medications according to the facility's policy and procedures. During an observation and interview, it was noted that medications were stored in a large blue and white bucket with an unlocked screw-on top in the DON's office, which was shared with the Assistant Director of Nursing (ADON). The medications were whole, intact, and retrievable, and were not mixed in any solution to dissolve them, making them easily accessible. The DON stated that the narcotics are disposed of with the pharmacist once a month, but there was no log for the medication waste management company to sign upon pickup, and the DON was unaware of the process to prevent diversion once the medications were picked up. The facility pharmacist confirmed that the medications should be destroyed by adding a solution called drug buster to dissolve them, but he never witnessed the DON using this solution. The pharmacist emphasized that the container should be closed and locked to prevent drug diversion. The facility's policy requires that all unused controlled substances be retained in a securely locked area until disposal, and staff should contact the provider pharmacy if unsure of proper disposal methods. The failure to follow these procedures posed a risk for medication diversion and potential harm to residents.
Failure to Provide Timely Meal Substitutes
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, resulting in a significant delay in meal service. Resident 294, who was admitted with medical diagnoses including hypertension and muscle weakness, was observed on the morning of December 9, 2024, with a breakfast tray containing oatmeal that appeared watery and unappetizing. The resident, whose cognition was intact and could make decisions regarding medical care, expressed dissatisfaction with the meal, stating it was not hot and tasted bad. After requesting a substitute meal at 7:15 am, the resident waited over two hours before receiving an alternative meal of two sausage patties at 9:15 am. Interviews with staff revealed that the delay was due to the kitchen not promptly preparing the substitute meal. A Certified Nursing Assistant confirmed the resident's request for a substitute and noted the prolonged wait time. The Dietary Supervisor acknowledged the delay and stated that typically, substitutes do not take two hours to prepare. The facility's policy requires the Dietary Manager to discuss food preferences with residents and provide suitable substitutes if preferred items are unavailable, which was not adhered to in this instance.
Pest Control Deficiency Leads to Resident Spider Bite
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a spider bite incident involving Resident 294. The resident, who was admitted with medical diagnoses including hypertension and muscle weakness, was bitten by a spider, highlighting the facility's inability to ensure a homelike environment free of pests. During an observation, a Certified Nursing Assistant (CNA) reported seeing a spider on the wall near the resident's room, although she mentioned not having seen other insects except for occasional gnats. The Maintenance Supervisor stated that the facility's pest control company was scheduled to fumigate soon and that the facility had been treated two weeks prior. Despite these measures, the presence of spiders persisted, indicating a lapse in the effectiveness of the pest control program. The facility's policy mandates an ongoing pest control program to keep the building free of insects and rodents, yet the incident with Resident 294 suggests a failure in implementation. The Administrator acknowledged the expectation of a pest-free environment and indicated that immediate action would be taken upon spotting pests.
Resident Left Unattended Leads to Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a known history of falls and cognitive impairments. On 11/5/2024, a Certified Nursing Assistant (CNA) left the resident unattended while sitting on the side of the bed, which led to the resident falling and sustaining multiple rib fractures. The resident was subsequently transferred to a General Acute Care Hospital for further evaluation and treatment. The resident had been identified as a fall risk due to impaired mobility and cognitive decline, requiring substantial assistance with activities of daily living. Despite these known risks, the CNA left the resident unsupervised, contrary to the facility's fall management policy, which mandates appropriate interventions for residents at risk of falls. Interviews with staff and family members confirmed the resident's fall risk status and the inappropriate action of leaving the resident unattended, which directly contributed to the incident.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to implement its policy and procedure by not ensuring prompt physician notification for a resident who exhibited symptoms of chills on two separate occasions. The resident, who had a history of sepsis and diabetes mellitus, was admitted with an indwelling catheter and a care plan that required monitoring and reporting of signs and symptoms of urinary infection, including chills. Despite this, the resident's physician was not notified when the resident was observed shaking and was only provided with blankets and hot packs. As a result of this oversight, the resident later developed altered mental status and was found to be hypotensive with low oxygen saturation. The resident was subsequently transferred to a General Acute Care Hospital, where she was diagnosed with sepsis and a urinary tract infection. The Assistant Director of Nursing confirmed that the physician should have been notified promptly, as chills were a symptom that should have been monitored according to the resident's care plan.
Violation of Resident's Right to Choose Caregiver
Penalty
Summary
The facility failed to respect a resident's right to make informed decisions regarding their care, specifically in choosing who provides that care. The resident, who had intact cognitive skills and the capacity to make medical decisions, explicitly refused assistance from a particular CNA due to previous negative interactions. Despite this, CNA 1 brought CNA 2 into the resident's room to assist with hygiene care, against the resident's wishes. The resident expressed dissatisfaction with CNA 2's presence and behavior, stating that CNA 2 was rude and irritating. The resident's care plan emphasized the importance of providing consistent and trusted caregivers, as well as seeking the resident's input to make their stay meaningful. The facility's policies also supported the resident's right to participate in care planning and treatment decisions. However, these policies were not adhered to in this instance, as CNA 1 involved CNA 2 in the resident's care despite the resident's clear refusal. This action violated the resident's rights and the facility's own policies, as confirmed by interviews with the resident, CNA 2, and the Director of Nursing.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, resulting in an incident where one resident punched another in the face, causing a cut to the lip. Resident 1, who has unspecified dementia and lacks the capacity to understand and make decisions, was found with redness on the right side of the face and a minor skin tear on the upper lip after being punched by Resident 2. Resident 2, who has major depressive disorder and anxiety disorder, claimed that Resident 1 was going through his personal belongings and scratched him, prompting Resident 2 to defend himself by punching Resident 1. The investigation revealed that Resident 1's care plan did not include specific timeframes, initiation dates, or revision dates, and there were no orders to monitor Resident 1's behavior despite his dementia diagnosis. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that there were no behavioral monitoring orders for Resident 1, and his behavior was not documented in his medical chart or electronic medical record (eMAR). The DON acknowledged the importance of monitoring residents with dementia to prevent such incidents and stated that the charge nurse could initiate a care plan without a doctor's order. The facility's policies and procedures for behavior management and abuse prevention were reviewed, indicating that the interdisciplinary team should identify underlying causes of residents' behavior and ensure appropriate treatment. However, the lack of monitoring and documentation for Resident 1's behavior contributed to the incident, highlighting a deficiency in the facility's ability to protect residents from abuse and ensure their safety.
Failure to Monitor Resident with Dementia Leads to Altercation
Penalty
Summary
The facility failed to obtain a physician's order for behavior monitoring and implement behavior monitoring for signs and symptoms of dementia for Resident 1. Resident 1, who was diagnosed with unspecified dementia and exhibited agitated and disruptive behavior, did not have a physician's order for behavior monitoring documented in their medical records. This lack of monitoring led to an incident where Resident 2, who had major depressive disorder and anxiety disorder, punched Resident 1 in the face, resulting in a cut to Resident 1's lip. Resident 1 was found on Resident 2's bed, which triggered the altercation. Resident 1's care plan indicated a goal to reduce behavioral problems but lacked specific timeframes, initiation dates, or revision dates. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that there were no orders to monitor Resident 1's behavior, and no documentation of Resident 1's behavior was found in the medical chart or electronic medical record (eMAR). The DON and LVN both acknowledged the importance of behavior monitoring for residents with dementia to ensure safety and prevent incidents like the one that occurred. Resident 2's records showed that they had a physician's order to monitor for episodes of agitation, screaming, and aggressive behaviors. However, the lack of similar monitoring for Resident 1, who had dementia and was prone to wandering and confusion, contributed to the altercation. The facility's policy on behavior management emphasized the need for appropriate treatment and services for residents diagnosed with mental disorders, but this was not adequately implemented for Resident 1, leading to the deficiency identified in the report.
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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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