Cottonwood Canyon Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Cajon, California.
- Location
- 1391 Madison Avenue, El Cajon, California 92021
- CMS Provider Number
- 055064
- Inspections on file
- 49
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Cottonwood Canyon Healthcare Center during CMS and state inspections, most recent first.
A resident with Osteitis Deformans and hemiplegia/hemiparesis, care planned for Hoyer lift use with safety measures, fell to the floor during a transfer from a shower chair to a wheelchair when the mechanical lift tilted forward. The resident reported being strapped in the lift as a CNA attempted to move him over a wheelchair armrest, causing the lift to tilt and the resident to land on the floor, after which he complained of back pain and was sent to the hospital. Two CNAs involved stated they could not recall whether the lift base was opened wide, and one acknowledged not performing a safety check. The Maintenance Supervisor found no equipment defects and indicated that an inadequately opened base could cause tilting, while facility policy and manufacturer instructions required ensuring lift stability, checking sling and weight distribution, and keeping the base legs fully spread during use.
A resident with IDD, severe cognitive deficits, dysphagia, and a documented high fall risk was care-planned for 1:1 feeding assistance and identified as needing close supervision, yet staff left the resident alone with a meal tray and unsupervised in a wheelchair in the hallway. Multiple CNAs observed the resident as confused, unable to reliably use the call light, and engaging in unsafe behaviors such as sitting at the edge of the bed and attempting to stand or ambulate without assistance, but several staff reported they were never informed the resident was a fall risk. The fall care plan contained generic interventions like reminding the resident to use the call light, which leadership later acknowledged were not individualized to the resident’s cognitive and safety needs and did not include 1:1 supervision. The resident was later found face down on the floor in the room with a bleeding head wound and agonal or irregular respirations, and hospital evaluation revealed an L4 compression fracture, need for intubation and ICU care, and new-onset seizure activity, with no prior history of seizures or feeding tube dependence before this event.
A resident with IDD and severe cognitive deficits experienced a fall resulting in a head laceration, bleeding, abrasions to both UEs, agonal and slowed respirations, and unresponsiveness. Nursing notes documented these findings, including a closed head injury with altered consciousness and the need for cervical precautions. However, the MDS for that assessment period was not coded to reflect a major injury under Section J1900C, despite CMS RAI Manual criteria and facility policy requiring that MDS data match clinical documentation and resident observations.
A resident with IDD, severe cognitive deficits, and a known fall history was admitted with documented fall risk and severe swallowing impairment requiring 1:1 supervision and 1:1 feeding assistance. The care plan for fall risk contained only generic interventions such as reminding the resident to use the call light and keeping the call light within reach, despite the resident’s inability to reliably understand or use it. Staff interviews showed inconsistent communication of the resident’s fall-risk status and supervision needs: some CNAs and an LN were unaware the resident was a fall risk, while others knew but did not have the resident care-planned for 1:1 supervision or clearly assigned monitoring responsibilities. On the day of the incident, the resident was left unsupervised in a wheelchair in the hallway and later found on the floor with a bleeding head wound. Additionally, although the nutritional care plan and speech evaluation specified 1:1 feeding assistance due to severe swallowing deficits and aspiration risk, the assigned CNA provided a meal tray and allowed the resident to eat independently, indicating the feeding assistance plan was not implemented.
A resident with intellectual developmental disability and severe cognitive deficits was allowed to remain unsupervised in a wheelchair in a hallway, despite some staff being aware the resident was a fall risk and observing attempts to stand. After the resident was found on the floor with a bleeding head wound, minimally or non-responsive and exhibiting agonal or irregular breathing but with a pulse, nursing staff applied oxygen via a non-rebreather mask but did not assess chest rise, did not provide rescue breaths, and inaccurately documented chest compressions as performed. Leadership later confirmed that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that passive oxygen alone does not ensure ventilation.
A resident with intellectual developmental disability, severe cognitive impairment, high fall risk, and severe swallowing deficits required close supervision, 1:1 feeding assistance, and adherence to AHA BLS guidelines during emergencies. Staff left the resident unsupervised in a wheelchair despite known impulsive and unsafe behaviors, and the resident was later found on the floor in the room with a bleeding head wound, unresponsive or minimally responsive, and with irregular breathing. The responding nurse confirmed the resident had a pulse but did not assess chest rise, did not provide rescue breaths, and only applied oxygen via a non‑rebreather mask, while documentation inaccurately indicated chest compressions were performed. The resident’s care plan and feeder list identified 1:1 feeding assistance due to aspiration risk, yet the assigned CNA, who reported not being informed of the resident’s fall risk or feeding needs, placed a meal tray for the resident to eat independently in the hallway. Multiple CNAs and nurses stated they were not clearly informed of the resident’s high fall‑risk status or supervision requirements, demonstrating a failure to ensure staff were competent, informed, and trained to meet this resident’s safety and care needs.
A resident with severe cognitive deficits and a history of IDD was observed independently wheeling in the hallway and later found face down on the floor in his room with a bleeding head wound, unresponsive and with irregular or agonal respirations. Multiple CNAs and an LN reported that the resident had a pulse, that oxygen via non-rebreather was applied, and that no CPR or chest compressions were performed, only stimulation such as chest rubs. However, late-entry nursing notes by two LNs and an IDT fall note documented that chest compressions were initiated along with oxygen administration. One LN acknowledged that the documentation of chest compressions was inaccurate and should have reflected chest rubs only. The DSD and DON stated that documentation must be timely, accurate, complete, objective, and reflect only the care actually provided, and identified the notes documenting chest compressions as inaccurate.
A resident with severe dementia and no family or surrogate decision-maker was discharged to an assisted living facility without documented IDT meetings, conservatorship planning, or evidence that the discharge decision was appropriately authorized or that the new setting could meet the resident's care needs. The facility did not follow its policy requiring interdisciplinary involvement in discharge planning.
A resident with a pelvic fracture did not receive a shower for 11 days due to the facility's failure to reschedule or find a suitable shower time according to the resident's preferences. Staff did not document any attempts to notify the physician or family or offer alternatives after multiple refusals, resulting in compromised hygiene and a lack of adherence to facility policy.
A resident with heart failure was discharged without a required discharge care plan in place. Record review and staff interviews confirmed that the Social Service Director and DON did not develop or implement the individualized discharge plan as required by facility policy.
A resident with a diagnosis of malignant neoplasm in the digestive system did not receive prescribed medications for constipation management over a three-day period. Despite being at risk for bowel regimen complications, the facility failed to administer Magnesium Hydroxide, Bisacodyl Suppository, and Fleet enema as ordered. The DON confirmed the oversight, which had the potential to impact the resident's health and safety.
A resident admitted with a diagnosis of malignant neoplasm of the digestive system experienced a medication error when the facility failed to match the hospital's discharge medication list with the facility's admission list. The resident was prescribed Sennosides 17.2 mg by the hospital, but the facility's order indicated only 8.6 mg. The DON confirmed the error was due to incorrect transcription by a nurse, violating the facility's medication reconciliation policy.
A facility failed to maintain complete medical records and inventory documentation for a resident. An LN did not document a medication order change properly, omitting details such as the prescriber's name and method of communication. Additionally, the resident's inventory sheet was not signed upon discharge, leaving the facility unable to verify the belongings taken home. The DON acknowledged these documentation lapses, and the facility lacked a policy for residents' belongings accountability.
The facility failed to offer and document advance directives for several residents, resulting in incomplete POLST forms and a lack of clarity on residents' treatment preferences and legal healthcare agents. Despite having policies in place, the facility did not consistently follow procedures to ensure residents' wishes were documented and accessible.
The facility failed to label opened dressings with an open date and remove expired food from the walk-in refrigerator, as observed during an interview with the DDS. Undated gallons of mayonnaise and Asian artisan dressings, along with an expired tub of cottage cheese, were found. The DDS confirmed that staff should have labeled and used or discarded the food by the used-by date, as per facility policy. These failures risked residents acquiring foodborne illness.
The facility failed to maintain accurate medical records for four residents, including incomplete treatment records for dialysis monitoring and diabetic administration. A resident's post-dialysis note lacked reassessment documentation after a bleeding incident, while two residents had missing blood sugar results, hindering proper insulin management. The DON confirmed the importance of complete documentation to prevent care issues.
The facility failed to follow infection control practices by using expired disinfectant wipes during wound care and delaying the implementation of Enhanced Barrier Precautions (EBP) for a resident with a wound infection. The Treatment Nurse used wipes with expired or unreadable dates, and the resident was not placed on EBP until days after the wound was identified, risking the spread of infection.
The facility failed to respond to call lights in a timely manner, causing residents to experience frustration and a lack of dignity. Residents reported waiting up to an hour for assistance, including for medications, due to understaffing and simultaneous staff breaks. Interviews with staff confirmed ongoing issues despite efforts to address them, and facility policy requires immediate call light responses.
A facility failed to obtain proper informed consent for a resident's psychotropic medication. The resident, diagnosed with paranoid schizophrenia, was taking Buspirone and Olanzapine. While the resident consented to Buspirone, the consent for Olanzapine was given verbally by a sister-in-law, who was not an authorized representative. The facility's records were inconsistent regarding the resident's ability to make medical decisions, and no authorized representative was designated for health care decisions.
A resident was discharged from the facility without being offered an Advanced Beneficiary Notice (ABN), which is necessary to inform residents and their families of their options regarding discharge placement and care. The resident, who had primary hypertension and osteoarthritis, was discharged home with home health and durable medical equipment. Facility staff acknowledged the oversight, and the facility's policy lacked guidance on ABNs. The resident's daughter expressed concerns about managing care at home.
Two residents in an LTC facility did not receive appropriate care due to the lack of comprehensive care plans. One resident was not repositioned or provided with necessary nail care, while another resident's pressure ulcer was not addressed in a care plan. These deficiencies were confirmed through observations and staff interviews.
The facility failed to follow physician's orders for two residents, leading to potential medical risks. One resident did not receive the ordered elevation of feet, while another did not receive proper care for a jejunostomy tube site and had medications administered incorrectly. Staff interviews revealed communication and documentation lapses.
A resident in a facility did not receive an audiology appointment, resulting in a lack of access to hearing aids. Despite a physician's order for evaluation and treatment, the resident's appointments were canceled due to being bed-bound and the clinic's inability to accommodate a gurney. Staff interviews revealed a lack of follow-up and coordination, with the Social Service Director acknowledging the oversight and the ADON confirming the consult was not completed.
The facility failed to follow physician's orders for oxygen administration for two residents. One resident with COPD received more oxygen than prescribed, while another with chronic pulmonary edema used oxygen without a physician's order until it was documented later. Staff acknowledged the discrepancies, and the facility's policies on medication and treatment orders were not adhered to.
A facility failed to provide Trauma Informed Care for a resident with PTSD, as staff were unaware of the diagnosis and potential triggers. The resident had a history of traumatic events, and the facility lacked in-service training on trauma-informed care. The Kardex did not include the resident's PTSD information, and staff interviews revealed a lack of awareness and training, contrary to the facility's policy.
A facility failed to conduct a monthly Medication Regimen Review (MRR) for a resident with paranoid schizophrenia, as required by their policy. The absence of MRRs for two consecutive months was confirmed by both the Assistant Director of Nursing and the Pharmacy Consultant, leading to a potential for unnecessary medications and unattended medication irregularities.
A resident on Olanzapine for schizoaffective disorder was monitored for lack of motivation, despite not exhibiting this behavior. Staff interviews revealed the resident experienced hallucinations, which were not documented as target behaviors. The Pharmacy Consultant noted that behavior monitoring should reflect actual symptoms, such as hallucinations, per facility policy.
The facility failed to maintain adequate staffing levels based on payroll data for the fourth quarter of 2024, specifically from July to September. This deficiency was identified through a review of the facility's PBJ Staffing Data Report, which indicated excessively low weekend staffing. The issue was triggered by a single day of low staffing in July, acknowledged by the DON and HR/Payroll personnel, who noted heavy reliance on registry staff. The facility's corporate office submitted the quarterly staffing data, but it failed to meet CMS requirements.
A resident with severe cognitive impairment repeatedly refused essential medications for various conditions, including depression and seizures, without a comprehensive care plan in place. The facility's staff acknowledged the absence of a care plan, which hindered consistent care and potentially risked the resident's health. Despite frequent refusals, no interdisciplinary team meeting was conducted to address the issue.
Two residents experienced inadequate pain management due to delays in medication reordering and insufficient pain relief measures. One resident with diabetic polyneuropathy faced missed doses of morphine and dilaudid, while another with osteomyelitis reported severe pain and insufficient nighttime relief. Interviews with LNs highlighted issues in the medication ordering process, contributing to the deficiency.
A resident with Parkinson's disease was prescribed Lorazepam without documented changes in condition or behavioral symptoms. The medication was administered routinely due to incorrect transcription of the physician's order, and the involved LNs failed to document the necessary details as per facility policy.
Unsafe Mechanical Lift Transfer Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure the safe use of a mechanical lift (Hoyer lift) during a resident transfer, resulting in the resident landing on the floor. The resident had diagnoses including Osteitis Deformans and hemiplegia/hemiparesis, and his care plan directed staff to use a Hoyer lift with the appropriate sling for all transfers, lock brakes, position him safely, and monitor during transfers. During a transfer from a shower chair to a wheelchair, the resident reported that he was strapped into the Hoyer lift when a CNA attempted to move him over the wheelchair armrest, causing the lift to tilt, strike the CNA, and result in the resident landing on the floor. The resident stated he experienced back pain, staff responded, and 911 was called; paramedics applied a neck collar and transported him to a general acute care hospital for evaluation. In interviews, one CNA stated that during the transfer the Hoyer lift tilted forward and that she attempted to hold the resident while another CNA used the remote to lower him to the floor. Both CNAs reported they could not recall whether the base of the Hoyer lift had been opened wide, and one CNA acknowledged she should have performed a safety check before moving the resident. The Maintenance Supervisor reported that after the incident he inspected the Hoyer lift, found no defects, and stated that failure to open the base wide enough could cause the lift to tilt forward. Facility policy required staff to make sure the lift was stable and locked and to lift the resident slightly to check stability, sling fit, and weight distribution, while the manufacturer’s guidance required that the base legs be spread to the widest position, casters unlocked, and the patient kept centered over the base and facing the caregiver during lifting or lowering.
Failure to Provide Required 1:1 Feeding Assistance and Fall Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and provide adequate supervision and assistance for a high fall-risk resident with severe cognitive impairment and dysphagia. The resident was admitted with difficulty walking, muscle weakness, a history of falls, an Intellectual Developmental Disability, and dysphagia, and was documented as having decreased safety judgment and severe cognitive deficits. The resident’s MDS identified them as a fall risk with prior falls, and the admission fall risk assessment scored the resident as high risk. The nutritional care plan and speech evaluation specified that the resident required 1:1 feeding assistance due to severe swallowing impairment and aspiration risk, and the resident’s name appeared on the facility’s feeding list. Despite these assessments and care plan directives, staff left the resident alone with a meal tray and did not provide the required feeding assistance or supervision. On the day of the incident, a CNA reported seeing the resident independently wheeling in the hallway and provided a meal tray, observing the resident eat independently while seated in a wheelchair in the hallway without supervision until approximately 8 p.m. The CNA stated she was not informed that the resident was a fall risk and did not request another staff member to supervise the resident when she left the area to use the restroom. Other CNAs on the unit also reported they were not informed that the resident was a fall risk, although they observed the resident as confused, not fully oriented, and unable to reliably use the call light. One CNA described the resident as requiring maximum assistance for sit-to-stand and transfers, being wobbly and unstable, and needing prompt staff response to prevent unsafe attempts to stand. Another CNA reported that from admission, the resident frequently sat on the edge of the bed, attempted to stand or ambulate without assistance, had difficulty understanding how to use the call light, and was known to be a fall risk, and that these concerns had been reported to licensed nurses. Licensed nursing staff and leadership interviews further showed that the resident’s fall risk and supervision needs were not adequately assessed, care-planned, or communicated. The supervising nurse on duty acknowledged that the resident was a high fall risk who required close supervision and should have been on 1:1 supervision for safety, but there were no orders or care plan for 1:1 supervision. The nurse documented that the medication nurse had instructed CNAs to perform visual inspections every 30 minutes and to keep the resident under continuous supervision, including remaining in the room if the resident was alone, but this level of supervision was not consistently implemented. Another nurse stated she was not aware the resident was a fall risk prior to the incident, although she recognized that the resident’s IDD, confusion, and communication deficits warranted considering the resident a safety and fall risk. The Director of Staff Development and DON both stated that the resident’s fall risk care plan, which included generic interventions such as educating the resident to call for assistance and keeping the call light within reach, was not individualized to the resident’s cognitive and safety needs and did not effectively reduce fall risk for a resident who could not comprehend or appropriately use the call light. The incident culminated when staff found the resident lying face down on the floor in the room with a bleeding forehead laceration, unresponsive, and with agonal or irregular respirations. Staff applied oxygen via a non-rebreather mask, stabilized the cervical spine, and called emergency services. Hospital records documented that the resident sustained an L4 compression fracture with 30% height loss, required intubation, was transferred to the ICU, and experienced seizure activity. The hospital discharge summary indicated diagnoses including seizure disorder and dysphagia and stated it was presumed the resident suffered arrest from acute respiratory failure in the setting of recurrent aspiration, with MRI findings consistent with recent seizure activity. The records also showed that the resident had no documented history of seizure activity or feeding tube dependence prior to this facility-to-hospital transfer. The facility’s own policies on comprehensive person-centered care plans and managing falls and fall risk required individualized interventions based on assessment, but the resident’s care plan and supervision practices did not reflect the resident’s identified high fall risk, cognitive impairment, and need for 1:1 feeding assistance and close supervision.
Inaccurate MDS Coding of Major Injury After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) to reflect a resident’s true injury status following a fall. The resident, who had a history of Intellectual Developmental Disability and was assessed on the MDS as rarely or never understood with severe cognitive deficits, experienced a fall on a specified date. Nursing progress notes documented that when staff entered the room, the resident was lying face down with agonal respirations, had a bleeding laceration on the top left of the forehead, slowed respirations, and was fully unconscious. A subsequent late entry nursing note further described bleeding on the left side of the head, abrasions to both upper extremities, and that the resident was unresponsive at that time. Despite these documented clinical findings, the MDS dated for that assessment period was not coded to indicate a major injury under Section J1900C, which includes closed head injury with altered consciousness. During interview and record review, the MDS Coordinator acknowledged that the resident’s condition, including the need for cervical precautions, slowed respirations, head bleeding, and full unconsciousness, met the criteria for a major injury and should have been coded as such. The DON also stated that accurate MDS coding is essential to correctly reflect a resident’s clinical status and to guide care planning and clinical decision making. The facility’s own Resident Assessments policy required that information in MDS assessments consistently reflect information in progress notes, plans of care, and resident observations/interviews, which did not occur in this case.
Failure to Individualize and Implement Care Plan for Fall Prevention and Feeding Assistance
Penalty
Summary
The deficiency involves the facility’s failure to develop, revise, and implement an individualized, person-centered care plan addressing supervision, fall prevention, and feeding assistance for a high fall-risk resident with intellectual developmental disability and severe cognitive deficits. The resident’s MDS documented that he was rarely or never understood and had severe cognitive impairment, and he had a known history of falls prior to admission. Despite this, the fall-risk care plan initiated on 12/22/25 contained only generic interventions such as educating/reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view “as much as possible,” without tailoring these interventions to the resident’s inability to understand or reliably use the call light or recognize danger. The DSD stated that this care plan was not individualized or specific to the resident’s cognitive and safety needs and that relying on the call light alone was insufficient given his decreased safety awareness and limited understanding. On the day of the fall, multiple staff interviews showed that the resident’s high fall-risk status and need for close supervision were not consistently communicated or incorporated into his care plan. CNA 1, who was assigned to the resident, reported that she was not informed the resident was a fall risk and therefore did not arrange for supervision when she left the area to use the restroom. She stated she had observed the resident independently wheeling himself in the hallway and had provided a meal tray, watching him eat independently, and that he remained seated in his wheelchair unsupervised in the hallway until approximately 8 p.m., when he was later found on the floor with a bleeding head wound. CNA 2, who worked on the same unit but was not assigned to the resident, also stated she was not informed the resident was a fall risk, observed him sitting alone in his wheelchair appearing confused, and did not recognize the need for close supervision. In contrast, CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed him attempting to stand from his wheelchair, but she reported that CNA 1 did not instruct her to monitor or supervise the resident before leaving for the restroom. Licensed nursing staff interviews further demonstrated that the resident’s supervision needs were not translated into an updated, individualized care plan or clear staff assignments. LN 1, the nursing supervisor on duty, stated he had verbally directed CNAs on the hallway to closely monitor the resident because he was a high fall-risk, had repeatedly attempted to get out of his wheelchair, and required close supervision at all times, including 1:1 supervision for safety. However, he acknowledged that there were no physician orders for 1:1 supervision and that the resident was not care-planned for 1:1 supervision, even though he believed this should have been done. LN 2 stated she was not aware the resident was identified as a fall risk prior to the incident, but given his IDD, confusion, and communication deficits, he should have been considered a safety and fall risk and the care plan should have been updated with interventions such as 1:1 supervision. The DON stated her expectation that staff complete a comprehensive safety assessment, personalize safety needs based on cognitive impairment and decreased safety awareness, and implement structured monitoring with clearly assigned staff responsibility, and acknowledged that failure to clearly communicate the fall risk and lack of supervision resulted in inadequate monitoring and hospitalization. The deficiency also includes failure to implement the resident’s nutritional care plan for feeding assistance. The resident’s nutritional care plan, initiated on 12/22/25, specified 1:1 feeding assistance, and a speech evaluation from the same date documented severe swallowing abilities, prior 1:1 feeder treatment, and aspiration risk. The facility’s feeding list included the resident’s name, and CNA 5 stated that although the resident could physically feed himself, he was on her feeder list due to difficulty swallowing and to prevent choking hazards. Despite these documented needs, CNA 1 reported that she provided the resident with a meal tray and watched him eat independently, indicating that 1:1 feeding assistance as outlined in the care plan was not followed. The DSD stated that staff were required to communicate resident-specific risks and care needs, including feeding assistance, through shift handoff reports and nurse-led huddles before providing care, and that failure to communicate these risks could result in preventable injuries such as choking. The DON stated that assigned staff were required to provide direct assistance during feeding due to choking risk and not leave the resident unattended, and that failure of staff to understand and follow the resident’s specific risks and care needs placed him at risk for injury, further health decline, and death.
Failure to Provide Rescue Breathing and Supervision After Resident Fall With Abnormal Breathing
Penalty
Summary
The deficiency involved the facility’s failure to provide appropriate emergency respiratory interventions, including rescue breaths or assisted ventilation, to a resident who was found on the floor after a fall. The resident had a history of intellectual developmental disability and severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the day of the incident, a CNA reported that the resident had been independently wheeling himself in the hallway, was provided a meal tray, and ate independently. The CNA stated she was not informed the resident was a fall risk and that the resident remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and observed nursing staff with the resident lying face down on the floor with a bleeding head wound. Multiple CNAs and licensed nurses described the resident’s condition after the fall as minimally responsive, non-responsive, or having irregular or agonal breathing. One CNA reported that the resident had been seen earlier in the hallway sitting in his wheelchair, making random sounds, not fully verbal, and attempting to stand up from the wheelchair, and that she had been informed by licensed nurses that the resident was a fall risk. However, neither she nor another CNA were instructed to monitor or supervise the resident, including when the assigned CNA left the area to use the restroom. After the fall, staff observed the resident on the floor with a bleeding forehead, non-responsive, with irregular breathing and body twitching, and oxygen was applied via a non-rebreather mask. Licensed nursing staff interviews and record review confirmed that, following the fall, the resident had a pulse but was experiencing agonal or irregular breathing, and that staff did not assess chest rise and fall to determine effective breathing and did not provide rescue breaths. One nurse stated that the only intervention provided was oxygen via a non-rebreather mask and acknowledged that chest compressions were inaccurately documented as having been performed when they were not. Another nurse stated that the resident’s oxygen saturation was not registering on the pulse oximeter, that she did not check for chest rise, and that she did not provide rescue breaths despite uncertainty about the resident’s respiratory status. The Director of Staff Development and the DON stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing at a rate of one breath every six seconds for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation or ensure air movement into the lungs. The facility’s policy indicated staff are trained to follow current AHA guidelines for recognition of cardiac arrest, initiation of resuscitation, and opening the airway.
Failure to Ensure Staff Competence in Emergency Response, Fall Prevention, and Feeding Assistance for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff caring for a high fall‑risk resident were competent, informed, and trained to meet the resident’s safety and care needs. The resident had a history of intellectual developmental disability, severe cognitive deficits, and was rarely or never understood, with documentation indicating the resident did not have capacity to understand and make decisions. The resident’s fall risk assessment showed a high fall‑risk score, and hospital physical therapy records documented decreased awareness of the need for safety and assistance. Despite this, the resident’s fall care plan contained only general interventions such as reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view as much as possible, which the Director of Staff Development later acknowledged were not individualized to the resident’s cognitive and safety needs. On the day of the incident, multiple CNAs and nurses described that the resident was confused, impulsive, and had poor safety awareness, with a history of sitting on the edge of the bed, attempting to stand or ambulate without assistance, and not reliably using the call light. One nurse supervisor stated he had verbally instructed CNAs to closely monitor the resident, perform visual checks every 30 minutes, and keep the resident under continuous supervision, including staying in the room if the resident was alone. However, the assigned CNA reported she was not informed that the resident was a fall risk and did not ask another staff member to supervise the resident when she left the area to use the restroom. A registry CNA also reported she was not instructed to monitor the resident. Other CNAs on the unit stated they were not told the resident was a fall risk or that close supervision was required. During this period, the resident remained seated in a wheelchair in the hallway, unsupervised, and later was found in his room lying face down on the floor with a bleeding head wound, unresponsive or minimally responsive, and with irregular breathing. After the fall, several staff members described the resident as unresponsive or non‑responsive, with irregular or agonal breathing, twitching, and oxygen saturation not registering on the pulse oximeter. The nurse who responded confirmed the resident had a pulse but did not assess chest rise and fall to determine effective breathing and did not initiate rescue breaths, instead applying oxygen via a non‑rebreather mask and performing chest rubs. Multiple CNAs confirmed that no rescue breaths or chest compressions were provided, and the nurse later acknowledged that documentation indicating chest compressions had been done was inaccurate. The Director of Staff Development and the DON both stated that staff were expected to follow AHA BLS guidelines, which require rescue breathing for an unresponsive person with a pulse and abnormal or ineffective breathing, and that supplemental oxygen alone does not provide ventilation. In addition, the resident had a nutritional care plan and speech evaluation indicating severe swallowing impairment, aspiration risk, and a requirement for 1:1 feeding assistance, and the resident’s name appeared on the facility’s feeder list. Nonetheless, the assigned CNA reported she was unaware the resident required 1:1 feeding assistance and had placed the meal tray on a bedside table for the resident to eat independently while seated in a wheelchair in the hallway. The DSD and DON stated that staff were required to communicate resident‑specific risks, including fall risk and feeding assistance needs, through shift reports and huddles, and that failure to communicate these needs left staff unaware of the resident’s required level of care.
Inaccurate Emergency Event Documentation for Fall and Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and reliable medical records that reflected the actual care provided to a resident during an emergency event. The resident had a history of intellectual developmental disability and an MDS indicating severe cognitive deficits, was rarely or never understood, and was unable to make decisions. On the evening of the incident, a CNA reported that she began her shift and observed the resident independently wheeling himself in the hallway, provided him a meal tray, and saw him eat independently. She stated she was not informed the resident was a fall risk and that he remained unsupervised in his wheelchair in the hallway until approximately 8 p.m., when she returned from a bathroom break and found nursing staff with the resident lying face down on the floor with a bleeding head wound. She reported that oxygen was applied and that the resident was minimally responsive, moving only his hand, and that CPR or chest compressions were not initiated because the resident had a pulse. Multiple staff interviews consistently indicated that chest compressions were not performed, while the medical record documented that they were. LN 1 stated that the resident’s baseline was alert but not oriented x3 and non-verbal, and that during the event the resident had agonal breathing but a pulse. LN 1 reported that the only intervention provided was oxygen via non-rebreather and explicitly stated that what was documented in the medical record about chest compressions was not true. CNA 2 stated she assisted in placing the resident in a safe position, observed irregular breathing, and saw LN 2 administer oxygen via non-rebreather, confirming that CPR or chest compressions were not initiated because the resident had a pulse. CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed the resident in the hallway attempting to stand from his wheelchair and being impulsive and resistant to redirection. She reported that after the fall, oxygen via mask was applied and that she observed no rescue breaths or chest compressions, and that the resident did not regain consciousness and his body was twitching on the floor. In contrast to these accounts, the resident’s EHR contained nursing notes and an IDT fall note documenting that chest compressions were initiated. A nurse’s note by LN 1 at 20:55, entered as a late entry, described the resident lying face down with agonal respirations and a bleeding laceration, oxygen via non-rebreather being applied, and stated that, as per the medication nurse, the carotid pulse was too faint to be identifiable and that compressions were briefly initiated and then stopped after breathing stabilized and a carotid pulse was noted. A separate nurse’s note by LN 2 at 21:00, also a late entry, documented that the resident was found on the floor unresponsive, with bleeding to the head and abrasions, and stated that “the chest compression initiated and oxygen with a non re-breather mask was given” and that 911 was called. The IDT fall note likewise stated that the resident was unresponsive and that chest compressions and oxygen with a non-rebreather mask were given. LN 2 later acknowledged that documentation indicating chest compressions were performed was inaccurate and that it should have reflected chest rubs only. The DSD and DON both stated that nursing documentation must be accurate, complete, objective, and reflect exactly what care was provided, and that documenting interventions that did not occur, such as chest compressions in this case, was not acceptable and could misrepresent the resident’s clinical status and negatively impact continuity of care during hospital transfer.
Failure to Ensure Proper Discharge Planning for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident with severe cognitive impairment due to dementia and no family or surrogate decision-maker. The resident was admitted with dementia and had a BIMS score of 2, indicating severe cognitive impairment. The medical record showed that the resident was under a bioethics interdisciplinary team (IDT) and could not make medical decisions. Although a public resident representative met with the Social Service Director (SSD) to discuss criteria for a public representative, there was no documented evidence of a plan for conservatorship or that IDT meetings were conducted to address the resident's discharge needs, goals, or the appropriateness of the assisted living facility selected for discharge. The SSD documented the resident's discharge to an assisted living facility without evidence of how the decision was made, who authorized it, or whether the facility could meet the resident's dementia care needs. Interviews with the DON and SSD confirmed that no IDT meeting or third-party agency decision occurred prior to discharge, and the resident had no family member to assist in decision-making. The facility's policy required the care planning/interdisciplinary team to develop the discharge plan with the assistance of the resident and representative, but this process was not followed in this case.
Failure to Provide Timely Bathing and Accommodate Resident Preferences
Penalty
Summary
A resident admitted with a left ilium fracture did not receive a shower for 11 days, despite having a scheduled shower every Wednesday and Saturday. The resident preferred morning showers, but the facility's schedule placed the shower during the PM shift. Documentation showed that staff did not assist the resident with showering from 6/23/25 until 7/4/25. The resident had refused showers three times, but there was no evidence that staff attempted to reschedule the shower to accommodate the resident's preferences or find a suitable alternative time. Additionally, there was no documented communication with the resident's physician or family regarding the prolonged period without a shower or the resident's refusals. The Assistant Director of Nursing acknowledged that not showering for 11 days was excessive and that staff should have offered alternatives and notified the physician and family. The facility's policy emphasized the importance of bathing for cleanliness, comfort, and skin observation, but these procedures were not followed in this instance.
Failure to Develop Discharge Care Plan
Penalty
Summary
The facility failed to develop and implement a discharge care plan for one resident who was admitted with heart failure, as evidenced by a review of the resident's medical record showing no discharge care plan was created prior to the resident's discharge. Interviews with the Social Service Director and the Director of Nursing confirmed that the responsibility for creating the discharge care plan was missed, despite facility policy requiring an individualized discharge plan to be initiated at admission and included in the comprehensive care plan. The absence of a discharge care plan was identified during a record review and staff interviews, with both the Social Service Director and Director of Nursing acknowledging the oversight.
Failure to Implement Resident-Centered Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan for a resident who had no bowel movements for three days. The resident was admitted with a diagnosis of malignant neoplasm of ill-defined sites within the digestive system and was at risk for complications with bowel regimen due to decreased physical mobility, weakness, and medication use. The care plan included administering medications per physician order to manage constipation. However, the facility did not follow the physician's orders for administering Magnesium Hydroxide, Bisacodyl Suppository, and Fleet enema as needed. The Bowel Movement Report indicated that the resident had no bowel movements for three days, and the Medication and Treatment Administration Record showed no evidence that the medications were offered or given as ordered. During an interview, the Director of Nursing confirmed that the licensed nurse should have administered the medication to help with constipation but failed to do so. This oversight in following the care plan and physician's orders had the potential to affect the resident's health and safety.
Medication Reconciliation Error on Admission
Penalty
Summary
The facility failed to ensure that the discharge medication list from the hospital matched the facility's admission medication list for a resident, resulting in a significant medication error. The resident, who was admitted with a diagnosis of malignant neoplasm of ill-defined sites within the digestive system, was prescribed Sennosides 17.2 milligrams by the hospital. However, the facility's Order Summary indicated that the resident was to receive only 8.6 milligrams, one tablet orally at bedtime, instead of the two tablets required. There was no evidence of an order change from the physician, and the Licensed Nurse responsible for transcribing the order was unavailable for an interview. The Director of Nursing confirmed that the Licensed Nurse did not transcribe the order correctly, which was against the facility's policy and procedure for medication reconciliation on admission.
Incomplete Medical and Inventory Documentation
Penalty
Summary
The facility failed to maintain complete medical records for a resident, leading to an inability to verify a physician's order and incomplete documentation of the resident's belongings upon discharge. A licensed nurse (LN) did not document the details of a medication order change, including who authorized the change and how the order was received. This lack of documentation occurred after the resident expressed dissatisfaction with the medication regimen, which was initially prescribed as needed and later changed to routine. The nurse practitioner was contacted to change the order back to as needed, but the LN failed to record the prescriber's name, credentials, and the method of communication, as required by the facility's policy. Additionally, the facility did not ensure the completion of the resident's inventory sheet upon discharge. The inventory sheet, which should have been signed to confirm the resident's belongings were taken home, was left blank. The Director of Nursing acknowledged that the inventory should have been reviewed and signed before the resident's departure. The facility was unable to provide a policy and procedure for the accountability of residents' belongings, further highlighting the deficiency in maintaining accurate records.
Failure to Offer and Document Advance Directives
Penalty
Summary
The facility failed to offer and follow up on advance directives for seven out of twenty sampled residents, leading to a lack of documentation regarding residents' treatment preferences and legal healthcare agents. This deficiency was identified through observations, interviews, and record reviews. For instance, Resident 10, diagnosed with paranoid schizophrenia, had no evidence of being offered an advance directive, and the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete. Similarly, Resident 29, with a cerebral infarction diagnosis, also lacked documentation of an advance directive, despite having designated agents to manage care. Further findings revealed that Resident 77, responsible for himself, had no advance directive information on his POLST form, and there was no evidence of the facility offering or following up on this matter. The Assistant Director of Nursing (ADON) confirmed the absence of advance directive documentation for Residents 10, 29, and 77, emphasizing the importance of having such directives to honor residents' wishes when they can no longer make decisions. The facility's policy required staff to offer assistance in establishing advance directives and document the offer in medical records. Additional residents, including Resident 36 with chronic osteomyelitis, Resident 237 with chronic pulmonary edema, Resident 62 with acute respiratory failure, and Resident 61 with hemiplegia following a cerebral infarction, also had incomplete POLST forms with no advance directive information. Interviews with the ADON and the Director of Nursing (DON) highlighted the expectation for nursing staff to verify advance directives upon admission and ensure they are uploaded into medical records. The facility's policy outlined the responsibility of social services to inquire about and provide information on advance directives, but this was not consistently followed, resulting in the deficiency.
Failure to Label and Discard Expired Food in Kitchen
Penalty
Summary
The facility failed to ensure that opened dressings were labeled with an open date and that expired food was removed from the walk-in refrigerator in the kitchen. During an observation and interview with the Director of Dietary Services (DDS), it was noted that there were opened, undated gallons of mayonnaise and Asian artisan dressings, as well as an opened tub of cottage cheese with a 'USED BY' date that had already passed. The DDS acknowledged that the kitchen staff should have labeled the food with the date it was opened and should have used or discarded the food before the used-by date. The facility's policy on food receiving and storage requires that refrigerated foods be labeled, dated, and monitored to ensure they are used by their use-by date, frozen, or discarded. These failures placed residents at risk of acquiring foodborne illness.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, leading to potential risks in their care. Resident 66's treatment record was incomplete, as the monitoring of the dialysis site for bleeding and infection was not documented on several occasions. The Director of Nursing (DON) confirmed that the dialysis site should have been monitored per the physician's order, and the lack of documentation indicated that the monitoring was not performed. The facility was unable to provide a policy and procedure for Treatment Administration Records, further complicating the issue. Resident 23's post-dialysis note was incomplete, lacking documentation of reassessment after a bleeding incident at the dialysis site. The resident reported that after returning from dialysis, the AV shunt began to bleed, and the staff response was delayed. Although pressure was applied to stop the bleeding, the Licensed Nurse (LN) did not document all reassessments, which was confirmed by the DON and the Assistant Director of Nursing (ADON). The facility's policy required documentation of observations post-dialysis, which was not adhered to in this case. Residents 36 and 63 had incomplete Diabetic Administration Records (DAR), with missing blood sugar results on multiple occasions. This lack of documentation meant that staff and physicians could not accurately assess the residents' blood sugar levels or determine the need for insulin coverage. The DON acknowledged the importance of complete and accurate documentation to prevent glycemic reactions and to allow physicians to monitor and adjust medication as needed. The facility's policy required documentation of blood glucose levels and medication administration, which was not consistently followed.
Infection Control Deficiencies: Expired Disinfectant Wipes and Delayed EBP Implementation
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the use of expired disinfectant wipes by the Treatment Nurse (TN) during wound care procedures. The TN initially used wipes from a container with an expired date and then attempted to use another container with an unreadable expiration date. The Infection Preventionist (IP) confirmed that expired wipes should not be used to ensure efficacy and prevent the spread of germs, as per the facility's policy on cleaning and disinfection of environmental surfaces. Additionally, the facility did not timely implement Enhanced Barrier Precautions (EBP) for a resident with a wound infection. The resident, who was readmitted with diagnoses including muscle weakness and acute respiratory failure with hypoxia, was not placed on EBP until several days after the wound was identified. The IP and Assistant Director of Nursing (ADON) acknowledged the delay in implementing EBP and the failure to notify the resident's physician, which was crucial to prevent the spread of infection and protect the resident's health condition.
Delayed Call Light Response Leads to Resident Frustration
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, which resulted in residents experiencing a lack of dignity and expressing anger and frustration. During a confidential group meeting, three out of seven attendees reported complaints about the facility's call light response time, noting that it varied depending on the shift and staff availability. Residents reported waiting up to an hour for assistance, including for medications and pain relief, due to understaffing and staff taking breaks simultaneously. The Resident Council Minutes from September to November 2024 consistently documented ongoing concerns about call light response times. Interviews with facility staff, including the Activity Director (AD), Director of Staff Development (DSD), and Assistant Director of Nursing (ADON), confirmed the ongoing issues with call light response times. The AD stated that concerns were communicated to department leaders, but no improvements were observed. The DSD acknowledged receiving complaints and conducting in-services, but the issues persisted. The ADON emphasized the importance of timely responses, noting that delays could lead to resident agitation and increased risk of infection. The facility's policy on answering call lights mandates immediate responses to residents' requests and needs.
Failure to Obtain Proper Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident had an authorized responsible party to sign the informed consent for the use of psychotropic medication. Resident 10, who was admitted with a diagnosis of paranoid schizophrenia, was taking Buspirone Hydrochloride and Olanzapine. Although Resident 10 consented to the Buspirone, the consent for Olanzapine was given verbally by the resident's sister-in-law, who was not an authorized representative for health care decisions. The facility's records indicated that Resident 10 was responsible for herself, but conflicting information in the history and physical report suggested that she could not make medical decisions due to her schizophrenia. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that Resident 10 had five emergency contacts involved in her care, but none were designated as her representative for health care decisions. The facility's policy required informed consent to be obtained from the resident or an appropriate representative, which was not adhered to in this case. The DON acknowledged that informed consent should have been signed by the resident or a responsible party, highlighting a lapse in the facility's adherence to its own policies and procedures regarding psychotropic medication use.
Failure to Provide Advanced Beneficiary Notice for Discharge
Penalty
Summary
The facility failed to provide an Advanced Beneficiary Notice (ABN) to a resident, identified as Resident 39, who was discharged from the facility. Resident 39 was admitted with diagnoses including primary hypertension and osteoarthritis. The Physician's Order Summary indicated a discharge order for Resident 39 to return home with home health and durable medical equipment. However, the Business Office Manager and the Social Service Director both acknowledged that an ABN was not offered to Resident 39, which was necessary to inform the resident and her family of their options regarding discharge placement and care. Interviews with facility staff revealed that the responsibility for offering the ABN was not fulfilled, as the Social Service Director admitted to not providing the notice. The facility's policy on Admission, Transfer, and Discharge did not include guidance on ABNs. Additionally, the resident's daughter expressed concerns about the ability to care for Resident 39 at home, particularly regarding lifting and the use of durable medical equipment. The absence of an ABN potentially limited the resident's options for a safe discharge and care plan.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for two residents, leading to deficiencies in their care. Resident 29, who was at risk for skin breakdown due to impaired mobility and incontinence, was not assisted with repositioning while in bed, as observed multiple times throughout the day. Additionally, Resident 29's nail care was neglected, with long nails on the right hand causing discomfort. Despite the care plan indicating the need for regular repositioning and nail care, these interventions were not carried out, as confirmed by interviews with the CNA and nursing leadership. Resident 62, who had a pressure ulcer on the left foot, did not have a care plan addressing this wound, despite being on enhanced barrier precautions. The absence of a specific care plan for the wound was acknowledged by the ADON, who emphasized the importance of having such a plan for effective care. The DON also confirmed the expectation for individualized care plans to ensure proper care delivery. The facility's policies on care plans and repositioning were not adhered to, resulting in these deficiencies.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to potential risks for medical complications. For Resident 64, who was admitted with hemiplegia and hemiparesis following a stroke, the physician's order to elevate both feet with a pillow every shift was not followed. Observations over several days confirmed the absence of pillows under the resident's feet, despite the Medication Administration Record indicating compliance. Interviews with staff, including the Director of Staff Development and the Assistant Director of Nursing, revealed a lack of communication and responsibility in ensuring the physician's order was implemented. For Resident 286, who was admitted with morbid obesity and stomach cancer, the facility failed to follow the physician's order for the care of the jejunostomy tube site and the administration of medications. The resident reported that the treatment for the JT site was not performed, and medications were given orally instead of through the JT. Staff interviews confirmed the failure to transcribe and follow the physician's orders accurately. The facility's policy on administering medications through an enteral tube was not adhered to, as evidenced by the lack of proper documentation and execution of the treatment orders.
Failure to Arrange Audiology Appointment for Resident
Penalty
Summary
The facility failed to arrange an audiology appointment for a resident, resulting in the resident not having access to hearing aids. The resident, who was readmitted to the facility, had a moderately impaired mental cognition but was capable of understanding and making decisions. A physician's order for an audiology evaluation and treatment was issued, but there was no documentation indicating that the resident was seen by an audiologist. Scheduled audiology appointments were canceled due to the resident being bed-bound and the clinic's inability to accommodate a gurney. Interviews with facility staff revealed a lack of follow-up on the audiology consults. The Social Service Director acknowledged the oversight, and the Unit Clerk mentioned the clinic's limitations in accommodating the resident's needs. The Assistant Director of Nursing confirmed that the audiology consult was not completed and outlined the roles of staff in coordinating appointments and transportation. The facility's policy on referrals indicated that social services should coordinate resident referrals and document them in the medical record, which was not done in this case.
Failure to Follow Physician's Orders for Oxygen Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in providing respiratory care for two residents. Resident 16, who was admitted with chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at five liters per minute, contrary to the physician's order of four liters per minute. This discrepancy was noted during an observation and confirmed by LN 21, who acknowledged that the physician's order was not followed. The Assistant Director of Nursing (ADON) also confirmed the physician's order and emphasized the importance of adhering to it, especially given Resident 16's COPD diagnosis. Resident 237, admitted with chronic pulmonary edema, was using oxygen without a physician's order until one was obtained on 12/10/24. The Treatment Nurse (TN) was unaware of any existing order during an observation, and the ADON confirmed that the order was only documented after the resident had already been using oxygen. The Director of Nursing (DON) highlighted the necessity of having physician's orders to ensure continuity of care and proper administration of oxygen. The facility's policies on medication and treatment orders, as well as oxygen administration, were not followed, leading to these deficiencies.
Failure to Provide Trauma Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) for a resident diagnosed with PTSD and suicidal ideations. The resident, identified as Resident 9, was admitted with a history of traumatic events, including molestation at a young age. Despite this, the facility did not ensure that staff were aware of the resident's PTSD diagnosis or potential triggers that could lead to re-traumatization. Observations and interviews revealed that the resident experienced difficulty sleeping due to noise, and staff members, including CNAs, were unaware of the resident's PTSD diagnosis and its implications. The facility's Director of Staff Development confirmed the absence of in-service training on trauma-informed care or PTSD for staff. The Kardex, which should have contained information about the resident's PTSD, did not include this critical information. Interviews with various staff members, including CNAs and the Director of Nursing, highlighted a lack of awareness and training regarding the resident's PTSD, which is essential for providing appropriate care and minimizing triggers. The facility's policy on Trauma Informed Care and Culturally Competent Care, which mandates staff training and identification of triggers, was not effectively implemented.
Failure to Conduct Monthly Medication Regimen Review
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) was completed monthly for a resident, leading to a potential for unnecessary medications and unattended medication irregularities. The resident, who was admitted with a diagnosis of paranoid schizophrenia, did not have documented MRRs for October and November 2024. During a joint interview and record review, the Assistant Director of Nursing confirmed the absence of these reviews, acknowledging that they should have been conducted monthly. The Pharmacy Consultant also confirmed the lack of evidence for the MRRs during these months, despite the facility's policy requiring monthly reviews.
Inappropriate Behavior Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate behavior monitoring for a resident prescribed antipsychotic medication, specifically Olanzapine, for schizoaffective disorder. The resident, who was admitted with diagnoses including paranoid schizophrenia, was monitored for lack of motivation as a target behavior for the medication. However, interviews with staff, including CNAs and the Assistant Director of Nursing, revealed that the resident did not exhibit issues with lack of motivation but rather experienced hallucinations, such as hearing voices and seeing people who were not there. The Pharmacy Consultant confirmed that the behavior monitoring should align with the resident's actual experiences, such as auditory or visual hallucinations, rather than lack of motivation. The facility's policy on psychoactive/psychotropic medication use requires that symptoms and therapeutic goals be clearly identified and documented, which was not adhered to in this case. This oversight had the potential to result in the unnecessary use of psychotropic medication for the resident.
Failure to Maintain Adequate Weekend Staffing Levels
Penalty
Summary
The facility failed to maintain adequate staffing levels based on payroll data for the fourth quarter of 2024, specifically from July 1 to September 30. This deficiency was identified through a review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, which indicated excessively low weekend staffing. The issue was triggered by a single day of low staffing in July 2024. During an interview, the Director of Nursing (DON) and HR/Payroll personnel acknowledged the deficiency, noting that the facility had relied heavily on registry staff during that period. The facility's corporate office submitted the quarterly staffing data, but it failed to meet the Centers for Medicare & Medicaid Services (CMS) requirements due to the low staffing incident. The CMS policy manual emphasizes the importance of staffing in ensuring quality care in nursing homes, and the deficiency was noted as a failure to meet these standards.
Failure to Develop Care Plan for Medication Refusal
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident who repeatedly refused to take prescribed medications. This deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The resident, who had a severely impaired cognitive score, was prescribed several medications for conditions including depression, hypertension, chronic heart failure, chronic chest pain, and seizures. Despite the importance of these medications, the resident frequently refused them, and there was no documented care plan addressing these refusals. The Medication Administration Record revealed multiple instances where the resident refused medications, including Sertraline, Carvedilol, Sacubitril-Valsartan, Ranolazine, Depakote Sprinkles, and Levetiracetam. Additionally, the resident refused blood sugar checks on numerous occasions. Despite these refusals, there was no evidence of an interdisciplinary team meeting to address the issue, nor was there a care plan developed to manage the resident's refusal of medications. Interviews with facility staff, including a licensed nurse and the Director of Nursing, confirmed the absence of a care plan for the resident's medication refusals. The staff acknowledged that the lack of a care plan prevented them from consistently addressing the resident's needs and potentially put the resident at risk for worsening medical conditions. The facility's policies on care plans and refusal of care emphasize the importance of addressing underlying issues and reassessing care plans when significant changes in condition occur, which was not adhered to in this case.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide effective pain management services for two residents, resulting in psychological harm due to unrelieved pain. Resident 1, diagnosed with Type 2 diabetes and diabetic polyneuropathy, experienced delays in receiving pain medication due to issues with medication reordering and availability. The resident reported waiting up to three hours for pain medication and noted that nurses did not reorder medication in time, leading to missed doses of morphine and dilaudid. Additionally, the resident mentioned that warm showers helped alleviate pain, but they were not provided frequently enough. Resident 2, suffering from acute osteomyelitis and embolism, reported severe pain in her left arm, which was not adequately managed. Despite being prescribed Norco, the resident expressed a desire for additional pain relief at night to aid sleep, as the pain was rated at a 10 on a 1/10 scale. The resident also mentioned that over-the-counter Tylenol PM was taken away by staff, and no one inquired about managing her pain more effectively. Interviews with licensed nurses revealed inconsistencies in the medication reordering process, with delays attributed to the need for manual reordering and waiting for physician signatures. The Assistant Director of Nursing confirmed that missed doses of pain medication could lead to increased pain for residents and acknowledged the lack of documentation regarding physician notification or pain management referrals for Resident 1.
Failure to Document Change in Condition and Correctly Transcribe Medication Order
Penalty
Summary
The facility failed to document a change in a resident's condition before starting Lorazepam and ensure the correct transcription of the physician's order. Resident 1, diagnosed with Parkinson's disease, was prescribed Lorazepam 1 mg twice a day without any documented change in condition or behavioral symptoms. The medical record lacked documentation of the resident's behavior and the interventions attempted before the medication was ordered. The Lorazepam was administered routinely from 4/20/24 to 4/29/24 without proper documentation or monitoring of the resident's behavior. Licensed Nurse (LN) 1 and LN 2 were involved in the transcription and administration of the Lorazepam order. LN 1 transcribed the order based on a verbal communication from LN 2, who had received the order from the Nurse Practitioner (NP). However, LN 2 did not document the change in condition or the event leading to the medication order. The Assistant Director of Nursing (ADON) confirmed that the order was intended to be as needed, not routine, and that LN 1 had transcribed it incorrectly. The facility's policies on psychotropic medication use and documenting changes in resident condition were not followed, leading to the potential for unnecessary medication administration without proper monitoring.
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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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