Grancell Village Of The Jewish Homes For The Aging
Inspection history, citations, penalties and survey trends for this long-term care facility in Reseda, California.
- Location
- 7150 Tampa Ave, Reseda, California 91335
- CMS Provider Number
- 555137
- Inspections on file
- 37
- Latest survey
- January 16, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grancell Village Of The Jewish Homes For The Aging during CMS and state inspections, most recent first.
The facility failed to inform cognitively intact residents about the existence and location of the most recent survey results, despite having survey binders posted near dining areas and a nursing station. Multiple residents with conditions such as HTN, osteoarthritis, hypotension, anemia, and muscle weakness, all assessed as capable of daily decision-making, reported during a resident council interview that they were unaware survey results were available or where they were kept. Review of resident council minutes showed no evidence that survey results were discussed, and the AD acknowledged not telling residents about the survey results or their location, while the DON confirmed residents should have been made aware of this information.
Surveyors found that staff failed to inform a cognitively intact resident about the names and purposes of multiple medications at the time of administration, despite facility policy and the resident’s right to make decisions about treatment. In a separate case, another cognitively intact resident had bed side rails in use without a properly completed informed consent form, which lacked the resident or representative signature, the clinical reason for rail use, and nurse verification, contrary to the facility’s bed rail policy requiring informed, voluntary consent before installation.
A resident with sepsis and Parkinson’s disease, who could communicate needs but required substantial assistance with ADLs, was observed seated in a wheelchair with an empty cup and gesturing for more while the call light remained on the bed and out of reach. A CNA acknowledged forgetting to place the call light within reach, despite facility policy and the DON’s expectation that call lights be accessible so residents can communicate needs such as requests for water.
A resident with DM and intact decision-making capacity had an order for daily Novolog insulin. Over multiple days, the resident refused the scheduled insulin doses, as documented on the MAR. However, review of progress notes showed no documentation that the physician was notified of these repeated refusals, despite facility policy requiring notification of the DON and physician when two consecutive doses are refused or withheld. The DON and an LVN acknowledged that the physician should have been informed and that the policy was not followed, resulting in a deficiency for failure to notify the physician of repeated insulin refusals.
Surveyors found that a medication cart computer was left unattended with an open eMAR displaying a resident’s information between a nursing station and dining room. An RN later approached, saw the visible PHI, minimized the screen, and reported the incident to the charge nurse. The LVN responsible admitted she had left the screen open and acknowledged it could expose residents’ personal information, while the DON confirmed this was a HIPAA-related privacy and confidentiality concern. Facility policies on medication administration and protected health information require MARs and electronic screens to be closed or covered and not left open and unattended.
The facility failed to create comprehensive care plans for three residents regarding bed side rail use and one resident for opioid medication management. Despite assessments indicating the need for such plans, they were not developed, posing potential risks to resident safety and care. The Clinical Manager and MDS Nurse acknowledged these deficiencies, highlighting the importance of adhering to facility policies for individualized care planning.
The facility failed to act on a consultant pharmacist's recommendations for two residents. One resident did not receive a timely lipid panel blood draw despite having hyperlipidemia and being on Lipitor. Another resident continued to receive Seroquel without a clear indication or measurable target behavior, as the facility did not clarify the behavior manifestation for its use. These oversights were acknowledged by the facility's staff, highlighting deficiencies in medication management.
A resident with intact cognition and requiring assistance with daily activities was found to have their call light out of reach, potentially delaying needed services. The facility's policy mandates that call lights be within easy reach to ensure residents' needs are met, which was not adhered to in this instance.
A facility failed to transmit the MDS for a resident to CMS within the required timeframe. The resident, admitted with hydronephrosis, acute kidney failure, and depression, was discharged without the completion and submission of the MDS assessment. The MDSN and DON acknowledged the oversight, which had the potential to delay services and payment.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident, specifically addressing pain management. The resident, admitted with chronic obstructive pulmonary disease and gastro-esophageal reflux disease, had physician's orders for pain medications but lacked a care plan detailing goals and interventions for pain management. The Clinical Manager confirmed the omission, which was against the facility's policy requiring a baseline care plan to be completed within 48 hours of admission.
The facility failed to update the care plan for a resident with edema, not reflecting her refusal to elevate her legs and omitting a physician's order for ace wraps. Another resident's family was not informed about the need for non-skid socks, despite the resident's fall prevention care plan. Both cases highlight a lack of adherence to care plan policies, potentially compromising resident care.
A resident's discharge from an LTC facility was mishandled due to failure to develop and review a discharge plan with the resident and family, and incomplete documentation of discharge progress notes. The resident, with a history of falling and muscle weakness, was discharged without proper documentation of the discharge plan meeting, including participants and final plans. Facility staff interviews revealed miscommunication and errors in documentation, contrary to the facility's policies.
A facility failed to implement a Bladder and Bowel Retraining Program for a resident, despite being identified as a good candidate, leading to the development of a Stage 1 pressure ulcer. The resident, admitted with conditions including hypertension and COPD, was incontinent and showed willingness to participate in retraining. The facility's policies required immediate placement on a retraining program, but this was not done, increasing the risk of skin tissue damage.
A facility failed to prevent complications of enteral feeding when an LVN did not check the residual volume in a resident's stomach before administering medication via G-tube. The resident, with severe cognitive impairment and total dependence on staff, had a care plan to minimize infection risk at the G-tube site. Despite an order to check tube placement and residual every shift, the LVN only confirmed tube placement and flushed it with water, neglecting to aspirate stomach contents. The DON acknowledged the oversight, which risked feeding intolerance.
A facility failed to clarify a physician's order for Norco 10/325 mg, leading to inadequate pain management for a resident with chronic pain syndrome. The order lacked a specified pain scale, resulting in inconsistent documentation and administration of the medication. The resident's MAR showed instances where the drug was given without a documented pain assessment, contrary to the facility's pain management policy. The Clinical Manager recognized the need for order clarification to prevent adverse effects.
A resident was prescribed Seroquel for mood disorder manifested by agitation without a clear indication or specific behavior to monitor, leading to a lack of proper documentation and monitoring. The Clinical Manager failed to act on the Consultant Pharmacist's recommendation to review the diagnosis and behavior manifestation, and the Director of Nursing confirmed the absence of specific measurable behaviors for monitoring. This resulted in the resident receiving Seroquel without proper oversight.
The facility failed to follow its Enhanced Barrier Precautions policy when an LVN did not wear a gown while administering medication via G-tube to a resident, increasing the risk of infection. Additionally, a resident's nasal cannula oxygen tubing was observed touching the floor, posing a contamination risk. These lapses in infection control practices were confirmed by facility staff.
A resident was not permitted to return to their LTC facility after hospitalization, despite a bed hold being in place. The facility declined the hospital's referral, citing the resident's need for acute psychiatric management, even though the hospital's physician cleared the resident for discharge. This led to the resident being discharged to a different facility, violating their rights and resulting in displacement.
A resident with intact cognition and multiple diagnoses reported being hit by a nurse, but the LTC facility failed to report the allegation to the SSA within the required two-hour timeframe. The delay was due to the late communication of the incident to the facility's administrator, resulting in a postponed inspection and potential risk to other residents.
Failure to Inform Cognitively Intact Residents of Survey Results and Their Location
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were notified of the existence and location of the most recent standard survey results, as required by 42 CFR 483.10(g)(10)-(11). Ten cognitively intact residents, each with various medical diagnoses such as hypertension, osteoarthritis, hypotension, anemia, and generalized muscle weakness, were identified as not being informed about the survey results. These residents had documented decision-making capacity on their MDS assessments, indicating they were capable of understanding and using such information. Review of resident council meeting minutes for multiple dates showed no documentation that residents were informed about the survey results or where they could be found. During a resident council interview, ten of eleven participating residents stated they were not aware that survey results were available for them to review and did not know where the survey results were located. They also reported that no one had told them about the survey results. Surveyors observed that survey result binders containing the most recent recertification survey were posted in holders near dining room entrances and a nursing station on various floors, indicating that the physical posting requirement had been met. However, during interviews, the Activities Director acknowledged that she had not informed residents during resident council meetings about the existence or location of these survey results, despite recognizing the importance of residents knowing about them. The DON similarly stated that residents should be made aware of the previous year’s survey results and their location, confirming that residents’ rights to examine survey results and receive related information had not been fully implemented in practice.
Plan Of Correction
F-577 Corrective Action for Affected Residents: The Administrator or designee met with Resident 189, Resident 30, Resident 51, Resident 59, Resident 62, Resident 65, Resident 83, Resident 203, Resident 219, and Resident 2, during resident council or individually to inform them of the existence of the most recent survey results, the location of the survey results binder on each floor near the dining room entrance and next to the consumer board in JEK, and their right to review these results at any time. The Administrator or designee provided each resident with written information documenting the location of the survey results on their respective floors. Identifying other Residents having the Potential to be Affected: The Administrator or designee met with residents during resident council meeting on 3/19/26 and informed them of the existence and location of the most recent survey results. The Director of Activities made announcements in all main dining rooms to inform them of the existence of the survey results dated, the location of the survey results binder on their floor, and their right to review the results. Measures put into place or Systemic Changes: The Administrator or designee will notify residents of the existence and location of survey results during the resident council meetings at least quarterly. The Activities Director (AD) or designee added a standing agenda item to resident council meetings to inform residents of the existence and location of survey results, ensuring this information is communicated at least quarterly. The AD or designee will document this notification in the resident council meeting minutes. Plan to Monitor Performance: Beginning 4/6/26, Director of Activities or designee will ask residents during resident council and during randomly to verify they are aware of location and existence of survey findings. The Director of Activities or designee will report audit results, including any identified deficiencies and corrective actions taken, to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Inform Residents About Medications and Obtain Informed Consent for Bed Rails
Penalty
Summary
The deficiency involves failure to uphold residents' rights to be informed of and participate in their treatment decisions, specifically regarding medication administration and use of bed side rails. For one resident with chronic respiratory failure and age-related osteoporosis, whose MDS documented intact cognitive skills and partial/moderate assistance needs for ADLs, a nurse administered multiple medications, including midodrine, Senokot-S, Trelegy Ellipta, Miralax, Tylenol, and Systane eye drops, without informing the resident of the name and indication of each medication at the time of administration. When questioned, the nurse stated she was not aware that providing this information was required by facility policy. The DON confirmed that residents have the right to be informed about their care, including medications, and that not providing this information restricted the resident from exercising this right. The facility’s administrative manual stated that residents have the right to make decisions about their medical condition and to accept or refuse proposed treatment. The deficiency also includes failure to obtain informed consent for the use of bed side rails for another resident with hypertension and dysphagia, whose MDS also showed intact cognitive skills and partial/moderate assistance needs for ADLs. Review of the resident’s "Informed Consent for Bed Rail Use" form showed it was incomplete, lacking the resident’s or representative’s signature, the reason for side rail use, and the licensed nurse’s signature verifying that consent was obtained. The DON acknowledged that consent had not been obtained and no explanation was provided regarding the reason for side rail use. The facility’s bed rail policy required that, when the IDT determines bed rails are appropriate, the "Informed Consent for Bed Rail Use" form must be used prior to installation, with information presented in an understandable manner and consent given voluntarily and free from coercion.
Plan Of Correction
Joyce Eisenberg - Keefer Medical Center makes every effort to operate in substantial compliance with Federal and State laws and regulations. Nothing in this Plan of Correction is an admission otherwise. Joyce Eisenberg - Keefer Medical Center is submitting this Plan of Correction in compliance with its regulatory obligations and does not waive any objections it may have as to the merit or form of any allegations contained herein. Please note that the facility may contest the merits or form of any of the alleged deficient findings and may take reasonable steps to appeal them. This Plan of Correction constitutes Joyce Eisenberg - Keefer Medical Center's written credible allegation of compliance for the deficiencies noted. F-552 Corrective Action for Affected Residents: The Director of Nursing (DON) met with LVN involved to provide 1:1 education regarding requirement. LVN reviewed Resident 59's current medication regimen and ensured that Resident 59 received information regarding the name of each medication, its indication, and the right to refuse medications and resident confirmed she is aware of medications as above. RN Unit Manager completed a comprehensive review of Resident 101's bed rail use and obtained informed consent from Resident 101, including explanation of the reason for bed rail use, risks, benefits, and alternatives. The DON or designee ensured that the Informed Consent for Bed Rail Use form was completed with appropriate signatures including Resident 101 and the licensed nurse verifying that consent was obtained. 3/17/26 Identifying other Residents having the Potential to be Affected: As most residents have medications, DON or designee provided education to licensed nurses on the requirement to provide information regarding the name of each medication, its indication, and the right to refuse medications as applicable. DON educated residents during the 3/19/26 Resident Council meeting regarding their right to be informed on their medications.The Medical Records Manager conducted an audit of other residents currently utilizing bed rails. The RN Unit Managers reviewed the Informed Consent for Bed Rail Use forms to ensure that informed consent was obtained, forms are completed in their entirety including resident or resident representative signature, reason for use, and licensed nurse signature. For residents with incomplete consent forms, the RN Unit Managers or designee obtained proper informed consent including explanation of risks, benefits, and alternatives. Measures put into place or Systemic Changes: The DON or designee in-serviced LVNs and RNs on the requirement to inform residents of medication names and indications prior to administration, the resident's right to be informed of and participate in treatment decisions, and the resident's right to refuse medications. The in-service included review of the facility's Administrative Manual regarding resident rights to make decisions about medical treatment and to accept or refuse proposed treatment.The DON or designee in-serviced LVNs and RNs on the facility's Bed Rails policy and procedure, including the requirement to obtain informed consent prior to bed rail installation, proper completion of the Informed Consent for Bed Rail Use form including resident or resident representative signature, documentation of the reason for bed rail use, explanation of risks, benefits, and alternatives, and licensed nurse signature verifying consent was obtained. Plan to Monitor Performance: RN Unit Manager or designee will begin conducting medication administration observations for a sample of residents with intact cognitive skills for daily decision making. The observations will verify that nursing staff inform residents of medication names and indications prior to administration. These observations will be conducted weekly for four weeks, then monthly for three months. Medical Records department will begin auditing Informed Consent for Bed Rail Use forms for residents utilizing bed rails to ensure forms are completed in their entirety including resident or resident representative signature, reason for bed rail use, and licensed nurse signature. The audits will be conducted weekly. The "Stand Up Meeting Routine Questionnaire" form was updated to include verification of consent for bed rails. Medical Records Manager or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident’s call light was within reach, as required for reasonable accommodation of resident needs and preferences. The resident had been admitted with diagnoses including unspecified severe sepsis and Parkinson’s disease. According to the History and Physical, the resident was able to speak in full sentences, make her own needs known, and make simple medical decisions. The MDS documented that the resident usually made herself understood, usually understood others, and required substantial assistance with upper and lower body dressing, personal hygiene, and putting on and taking off shoes. During an observation in the resident’s room, the resident was seated in a wheelchair with a bedside table in front, positioned between the bed and the entrance door. The resident lifted an empty cup and gestured for more, but the call light, located on the bed, was out of reach. In a concurrent interview, the CNA assigned to the resident stated she had forgotten to place the call light next to the resident and acknowledged that the call light should be within reach so the resident could communicate with staff, including to request water. The DON later stated that all call lights should be within each resident’s reach so staff can attend to their needs timely, and the facility’s “Answering the Call Light” policy indicated staff must ensure the call light is accessible to the resident.
Plan Of Correction
F-558 Corrective Action for Affected Residents: On 3/10/2026, Certified Nursing Assistant (CNA 1) immediately placed Resident 72's call light within reach. Identifying other Residents having the Potential to be Affected: RN Unit Managers conducted facility-wide room checks of current residents to ensure that call-lights were within reach and accessible to residents based on their individual needs and preferences. Out of 62 residents with limited mobility while in their room, 3 were found to not have the call light within reach. Any residents found with call lights out of reach had immediate corrective action taken to place call lights within reach by education to the responsible nurse 3/31/26. Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced Licensed nurses and Certified Nursing Assistants on the facility policy and procedure titled "Answering the Call Light," with emphasis on ensuring call lights remain within reach and accessible to residents at all times, including when residents are repositioned, moved to wheelchairs, or transitioned between locations. The in-service included education on assessing individual resident needs and preferences for call light placement based on physical limitations, mobility status, and cognitive abilities. Attendance records and lesson plans were maintained. Plan to Monitor Performance: Beginning 4/6/2026, the RN Unit Manager or designee will conduct random room audits of a minimum of 5 rooms per floor per week for four consecutive weeks, to verify that call lights are within reach and accessible to residents based on their individual needs and positioning. If deficiencies are identified during audits, immediate corrective action will be taken and the responsible staff member will receive re-education and supervisory intervention as appropriate. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when a resident repeatedly refused ordered insulin injections, contrary to federal requirements for notification of significant changes and the facility’s own policy. The resident, who had diabetes mellitus with diabetic polyneuropathy and peripheral vascular disease, was originally admitted in 2023 and re-admitted in 2025. A History and Physical dated 2/27/2026 documented that the resident had decision-making capacity and an HbA1c of 8.9%, above the stated goal of less than 8%. The resident’s MDS indicated intact cognition for daily decision-making. The physician’s order, effective since 3/21/2025, directed administration of Novolog 8 units subcutaneously once daily at 7:30 a.m. for diabetes management, with instructions to hold the dose if blood sugar was less than 100 mg/dL. Review of the MAR for 3/1/2026 to 3/10/2026 showed that the resident refused the scheduled Novolog injections on multiple mornings: 3/1, 3/4, 3/5, 3/6, 3/7, and 3/9. The DON confirmed that the order required daily administration and acknowledged that the resident had a tendency to refuse insulin injections. Review of progress notes for the same period, conducted with the DON and later with an LVN, revealed no documented evidence that the physician was informed of the repeated insulin refusals. Both the DON and LVN stated that licensed nurses should have notified the physician of these refusals, particularly when they occurred on consecutive days. The facility’s “Medication Administration” policy, revised 4/16/2025, specified that the DON and attending physician must be notified when two consecutive doses of medication are refused or withheld. The DON confirmed that this policy was not followed in the resident’s case, resulting in the cited deficiency for failure to notify the physician of repeated insulin refusals.
Plan Of Correction
Corrective Action for Affected Residents: On 3/12/2026, the RN Unit Manager notified Resident 94's physician of the multiple insulin refusals that occurred on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. On 3/12/2026, the RN Unit Manager obtained physician orders for Resident 94 regarding the management of insulin refusals and alternative diabetes management strategies. Identifying other Residents having the Potential to be Affected: On 3/25/26, the Medical Records Manager conducted an audit of the Medication Administration Records (MARs) for residents receiving insulin for the period of 3/1/2026 through 3/25/2026 to identify instances where residents refused two or more consecutive doses. No other residents in the facility were identified as refusing insulin. Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced licensed nurses on the "Medication Administration" policy, with emphasis on the requirement to notify physicians of two consecutive medication refusals, particularly insulin and other critical medications, and the importance of timely documentation of physician notification in the resident's progress notes. Plan to Monitor Performance: Beginning 4/6/2028, the contracted Medical Records Consultant will conduct random audits during scheduled monthly visits of the MARs and corresponding progress notes for residents receiving insulin or other critical medications to verify that licensed nurses are notifying physicians when residents refuse two consecutive doses and documenting such notifications appropriately. The audits will include a sample size of at least ten percent of residents receiving insulin or other critical medications. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Unattended eMAR Screen Compromises Resident Privacy
Penalty
Summary
Surveyors identified a deficiency related to resident privacy and confidentiality when a medication cart computer screen was left open and unattended, displaying a resident’s electronic Medication Administration Record (eMAR). During an observation on the second floor between the nursing station and main dining room, Team B’s medication cart (Medication Cart 3) was found unattended with the computer screen open to a resident’s eMAR. A registered nurse approached the cart, observed the open screen with resident information visible, minimized the window to remove the eMAR from view, and then left the cart to notify the charge nurse of the incident. In subsequent interviews, the RN who discovered the open screen stated that leaving the window open allowed residents’ information to be seen by others and referenced HIPAA concerns. The LVN responsible for the cart acknowledged that she had left the computer screen open and stated that she should not have done so because it could expose residents’ personal information and leave their privacy unprotected. The DON confirmed that leaving a computer screen open to a resident’s medical record is a HIPAA concern and compromises privacy and confidentiality. Review of facility policies on Medication Administration and Patient Protected Health Information showed that the MAR should be closed or covered when unattended and that employees using electronic devices must not leave them open and unattended, and should close documents and sign out of software programs, with screens not left open and unattended.
Plan Of Correction
F-583 Corrective Action for Affected Residents: On 3/9/2026, the medication cart computer screen was immediately closed by Registered Nurse (RN) 6 to prevent further unauthorized viewing of resident information. Only the surveyor saw the open computer screen. The LVN realized she left it open and returned to close it but the RN had already closed it. Identifying other Residents having the Potential to be Affected: No additional residents were identified as having their personal health information left viewable on unattended computer screens during follow up rounds. Measures put into place or Systemic Changes: RN Unit Manager (RN 6) met with Licensed Vocational Nurse (LVN) 8 to provide supervisory intervention regarding the importance of closing computer screens displaying resident information when stepping away from medication carts to prevent unauthorized disclosure of protected health information. The DON and/or Director of Education in-serviced licensed nursing staff (Registered Nurses and Licensed Vocational Nurses) on the facility's policies and procedures titled "Medication Administration" and "Patient Protected Health Information" with emphasis on: 1) closing or covering the Medication Administration Record when not attended to protect resident confidentiality; 2) closing documents and signing out of software programs when temporarily distracted by another duty; 3) ensuring computer screens are not left open and unattended; and 4) the HIPAA privacy implications of leaving resident information visible on unattended devices. Plan to Monitor Performance: Beginning 4/6/26, the RN Unit Manager or designee will conduct random observations of medication carts during medication passes weekly to ensure computer screens are closed when medication carts are unattended. The audit tool will document the date, time, medication cart number, whether the computer screen was closed when unattended, and any corrective action needed. If non-compliance is identified, the DON or designee will provide immediate re-education and supervisory intervention to the responsible licensed nurse. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
Failure to Develop Comprehensive Care Plans for Bed Rails and Opioid Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents regarding the use of bed side rails. Resident 26, who was admitted with pulmonary hypertension and heart failure, did not have a care plan addressing the potential risk of bed side rail entrapment, despite having an intact cognitive ability and requiring assistance with activities of daily living. Similarly, Resident 50, with chronic obstructive pulmonary disease and chronic pain syndrome, and Resident 171, with dysphagia and chronic obstructive pulmonary disease, also lacked care plans for bed side rail use, even though assessments were completed. The Clinical Manager acknowledged that the Interdisciplinary Team should have developed these care plans to ensure resident safety and prevent injuries. Additionally, the facility failed to develop a care plan for Resident 44, who was receiving Hydrocodone-Acetaminophen for pain management. Resident 44, with a history of a displaced fracture of the left femur and type 2 diabetes, had mildly impaired cognitive skills and required significant assistance with daily activities. Despite a physician's order for opioid medication, there was no care plan to address the risks and side effects associated with its use. The MDS Nurse confirmed the absence of a care plan and highlighted the potential for overlooking medication side effects. The facility's policies and procedures, reviewed in October 2024, emphasized the need for individualized comprehensive care plans that include measurable objectives and timetables to meet residents' needs. However, the facility did not adhere to these policies, resulting in the lack of care plans for the use of bed side rails and opioid medication management. The Director of Nursing acknowledged the deficiency, noting the importance of developing care plans to address residents' problems and identified needs.
Failure to Act on Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for two residents, leading to deficiencies in medication management. For one resident, the facility did not conduct a lipid panel blood draw as recommended by the consultant pharmacist. The resident, who was admitted with hyperlipidemia, had a medication regimen that included Lipitor, a drug used to treat high cholesterol. Despite the pharmacist's recommendation on 10/29/2024 to obtain a fasting lipid panel, the facility did not include this test in the physician's orders until 1/01/2025, resulting in a delay of over two months. This oversight was acknowledged by the Director of Nursing, who noted that the process should have been completed within one to two weeks of receiving the recommendation. For another resident, the facility failed to clarify the behavior manifestation for the use of Seroquel, a psychoactive medication. The resident, diagnosed with Alzheimer's disease and depression, was prescribed Seroquel for mood disorder manifested by agitation. However, the consultant pharmacist noted that the diagnosis and behavior were not appropriately documented, and the behavior of agitation was too subjective. Despite the recommendation to review and clarify the use of Seroquel, the facility did not act upon this advice. The Clinical Manager admitted to forgetting to follow up on the recommendation, resulting in the continued administration of Seroquel without a clear indication or measurable target behavior. The facility's policies and procedures require that psychotropic medications have an appropriate diagnosis and measurable target behaviors for monitoring. However, in the case of the second resident, the physician's order to monitor behavior was discontinued and not reactivated, leading to a lack of monitoring and documentation. The Director of Nursing acknowledged that the oversight in acting upon the consultant pharmacist's recommendation could impact the resident's quality of life, as the effectiveness of the medication could not be measured without specific behaviors to monitor.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident 171, which could potentially delay the provision of services and result in unmet needs. Resident 171 was admitted with diagnoses including dysphagia and chronic obstructive pulmonary disease, and required substantial assistance with daily activities such as toileting hygiene, showering, dressing, and moderate assistance with personal hygiene. During an observation, it was noted that the call light cord was hanging on the bed siderail with the call button at the bottom of the bed, out of the resident's reach. Resident 171 expressed a need for assistance and was unaware of the call light's location. A registered nurse confirmed the observation that the call light button was positioned below the bed and stated that it should be within the resident's reach to call for assistance. The Director of Nursing also confirmed that the facility's policy requires call lights to be within easy reach of residents to ensure their needs are met. The facility's policy, last reviewed in October 2024, emphasizes the importance of having call lights accessible to residents to prevent frustration and potential falls or injuries.
Failure to Transmit MDS Timely for a Resident
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) for a resident, identified as Resident 22, to the Centers for Medicare and Medicaid Services (CMS) system. Resident 22 was admitted with diagnoses including hydronephrosis, acute kidney failure, and depression. The resident had intact cognition and the capacity to understand and make decisions. The MDS assessment for Resident 22, dated 8/25/2024, was not submitted to CMS within the required timeframe. The resident was discharged on 9/7/2024, but the discharge MDS assessment was not completed or submitted as required. During interviews, the Minimum Data Set Nurse (MDSN) and the Director of Nursing (DON) acknowledged the oversight. The MDSN confirmed that the discharge assessment was not completed, and the DON stated that the assessment should have been submitted within 14 days of discharge. The facility's failure to transmit the MDS data timely had the potential to delay services and payment for Resident 22. The facility's policy, as outlined in the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, mandates that all MDS assessments be submitted within 14 days of completion.
Failure to Develop Baseline Care Plan for Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, specifically addressing pain management. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease and gastro-esophageal reflux disease, required substantial assistance with daily activities and had intact cognition. Despite having physician's orders for pain management medications such as Meloxicam, Acetaminophen, and Tramadol, the baseline care plan did not include goals and interventions for the resident's pain management. During an interview and record review, the Clinical Manager acknowledged that the baseline care plan, which should have been completed within 48 hours of admission, was missing essential components related to the resident's pain management. The facility's policy mandates the development of a baseline care plan to provide effective and person-centered care, including addressing health and safety concerns immediately upon admission. The absence of a care plan for pain management was identified as a deficiency, potentially leading to ineffective management of the resident's pain.
Failure to Update Care Plans and Engage Family Members
Penalty
Summary
The facility failed to update and revise the care plan for Resident 2, who was diagnosed with conditions including unspecified dementia, edema, and cellulitis. The resident was prescribed Lasix for bilateral lower extremity edema, which required specific interventions such as elevating the legs to manage fluid volume deficit and electrolyte imbalance. However, observations revealed that Resident 2's legs were not elevated as per the care plan, and the resident expressed refusal to have her legs elevated. Despite this refusal, the care plan was not updated to reflect the resident's current condition and preferences, nor did it include the physician's order to apply ace wrap to the resident's legs. This oversight was acknowledged by the MDS Nurse and the Director of Nursing, who confirmed that the care plan had not been revised to incorporate these critical elements. The facility also failed to engage Family Member 2 (FM2) in the care planning process for Resident 34, who had severe cognitive impairment and was dependent on staff for various activities of daily living. Resident 34's care plan included an intervention to wear non-skid socks to prevent falls, but observations showed the resident wearing regular socks brought in by a family member. There was no documentation indicating that FM2 was informed about the necessity of non-skid socks, which was a crucial part of the fall prevention strategy. The Director of Nursing emphasized the importance of involving family members in the care planning process to prevent incidents like falls. The facility's policy and procedure on care plans require that they be reviewed and revised quarterly or as changes in the resident's condition dictate. However, in both cases, the care plans were not updated to reflect the residents' current needs and conditions. This failure to adhere to the facility's policy and procedure potentially compromised the quality of care and supervision provided to the residents, as acknowledged by the Director of Nursing.
Failure in Discharge Planning and Documentation
Penalty
Summary
The facility failed to adhere to its policy and procedure for discharge planning for a resident, identified as Resident 21, who was investigated under a closed record review. The deficiency involved the lack of a developed discharge plan that was reviewed with the resident and/or his family at least 24 hours before discharge. Additionally, there was incomplete documentation of the resident's discharge progress notes, which placed the resident at risk of not receiving necessary care and services related to his discharge goals and needs. Resident 21 was admitted to the facility with a displaced trimalleolar fracture, a history of falling, and muscle weakness. The resident's cognitive skills for daily decision-making were intact, and he required substantial assistance for various activities of daily living. The discharge plan initially indicated that the resident might go home with his wife, but there was a lack of documentation regarding the discharge plan meeting, including the participants and the final discharge plan. The discharge instructions were completed on the day of discharge, contrary to the facility's policy of completing them 24 hours prior. Interviews with facility staff revealed confusion and miscommunication regarding the discharge process. The Medical Record Director mistakenly documented that the resident was discharged to an assisted living facility, while the Social Worker failed to note changes in the discharge plan. The Director of Nursing confirmed that the discharge notes were incomplete, lacking essential information such as the discharge address and mode of transportation. The facility's policies required thorough documentation to ensure effective discharge planning, which was not followed in this case.
Failure to Implement Bladder and Bowel Retraining Program
Penalty
Summary
The facility failed to implement a Bladder and Bowel Retraining Program for a resident, identified as a good candidate for the program, to prevent the development of skin impairment. The resident, admitted with diagnoses including hypertension and chronic obstructive pulmonary disease, was assessed as incontinent of bowel and urine since admission. Despite being oriented and aware, the resident showed willingness to participate in retraining, scoring a four on the Bowel & Bladder Admission assessment, indicating suitability for retraining. The Clinical Manager acknowledged that the resident's incontinence could lead to pressure ulcers and skin breakdown, and that retraining could have prevented the development of a Stage 1 pressure ulcer on the resident's left buttock. The pressure ulcer was identified on a safety event report dated shortly after admission. The facility's policy required immediate placement on a retraining program for residents identified as good candidates, but this was not done, leading to the resident's increased risk of skin tissue damage. Interviews with staff and the resident revealed that the resident could feel the urge to urinate or move her bowels but was not assisted to the bathroom in time, resulting in incontinence. The facility's policies on wound and skin management and bowel and bladder programs emphasized the importance of preventative measures and individualized care plans to maintain skin integrity and prevent complications. However, these policies were not followed, contributing to the deficiency.
Failure to Check Residual Volume Before G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy tube (G-tube). The deficiency was identified when a Licensed Vocational Nurse (LVN) did not check the residual volume in the resident's stomach before administering medication through the G-tube. This oversight was observed during a medication administration task, where the LVN confirmed the G-tube placement and flushed it with water but neglected to aspirate the stomach contents to check for residual volume, which is a necessary step to ensure the therapeutic effect of the medication. The resident involved had a history of Parkinson's disease, depression, and severely impaired cognition, making them totally dependent on staff for all activities of daily living. The resident's care plan included a goal to minimize the risk of infection at the G-tube site, and there was an existing order to check tube placement and residual every shift before administering medications and starting feeding. The facility's policy on enteral feeding tube drug administration also required the nurse to follow procedures for proper care and monitoring, including checking residual volume. The Director of Nursing confirmed that the LVN should have followed the procedure, and the failure to do so placed the resident at risk for feeding intolerance.
Inadequate Pain Management Due to Unclear Physician's Order
Penalty
Summary
The facility failed to ensure proper clarification of a physician's order for Hydrocodone-Acetaminophen (Norco 10/325 mg) for a resident, which led to inadequate pain management. The physician's order did not specify the pain scale rating required for administering the medication, resulting in inconsistent documentation and administration of the drug. On several occasions, the medication was given without a documented pain assessment, and the reasons for administration were not aligned with the facility's pain management policy. This oversight was identified during a review of the resident's Medication Administration Record (MAR) and physician's orders. The resident involved had a history of chronic obstructive pulmonary disease and chronic pain syndrome, requiring substantial assistance with daily activities. The facility's Nursing Policy and Procedure on Pain Management emphasized the need for accurate pain assessment using a numerical pain scale. However, the lack of a specified pain scale in the physician's order led to potential risks of adverse drug effects, such as constipation and respiratory depression. The Clinical Manager acknowledged the need for clarification of the physician's order to prevent confusion and ensure effective pain management for the resident.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary use of psychotropic medications, specifically Seroquel, by not monitoring specific, measurable target behaviors related to its use. The resident, who was admitted with diagnoses including Alzheimer's disease, depression, and unspecified mood affective disorder, was prescribed Seroquel for mood disorder manifested by agitation. However, the facility did not have a clear indication or specific behavior to monitor, which is required for the administration of psychotropic medications. The Clinical Manager (CM) acknowledged that the order for Seroquel did not include a clear indication and specific behavior to be monitored, and that agitation is considered a subjective behavior. The CM admitted that the order to monitor the resident's behavior was discontinued and not reactivated, leading to a lack of monitoring and documentation of the resident's behavior. The Consultant Pharmacist had recommended reviewing the diagnosis and behavior manifestation to ensure appropriate use of Seroquel, but the CM failed to act upon this recommendation. The Director of Nursing (DON) confirmed that the physician's order for Seroquel lacked a specific measurable behavior to be monitored, and that the behavior of agitation did not describe the resident's specific behaviors related to the use of Seroquel. The facility's policies and procedures require that all psychotropic medications have an appropriate diagnosis, a specific and clear indication for use, and measurable target behaviors for monitoring. The failure to adhere to these policies resulted in the resident receiving Seroquel without proper monitoring of its effectiveness or potential side effects.
Infection Control Lapses in G-Tube Medication Administration and Oxygen Tubing Management
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which is designed to reduce the spread of multidrug-resistant organisms (MDROs). During a medication administration task, a Licensed Vocational Nurse (LVN) did not don a gown while administering medication via a gastrostomy tube (G-tube) to a resident. This resident, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was at increased risk of infection due to the presence of a G-tube. The facility's policy required staff to wear gowns and gloves during high-contact care activities, such as administering medication via G-tube, to prevent the spread of MDROs. In another instance, the facility failed to ensure that a resident's nasal cannula oxygen tubing was not touching the floor. The resident, who required supplemental oxygen due to pulmonary hypertension and heart failure, was observed with oxygen tubing that was in contact with the floor. This practice posed a risk of contamination and potential infection, as the floor can harbor bacteria and other microorganisms. The facility's staff acknowledged that the tubing should not touch the floor to prevent contamination and subsequent infection. Both deficiencies highlight lapses in infection control practices within the facility. The failure to adhere to established protocols for gowning during high-contact activities and ensuring that medical equipment does not come into contact with contaminated surfaces increased the risk of infection for the residents involved. These observations were confirmed through interviews with facility staff, including the Infection Prevention Nurse and the Director of Nursing, who reiterated the importance of following the facility's infection control policies.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the resident's rights and resulting in their displacement to an unfamiliar facility. The resident, who had been admitted to the facility with diagnoses including depression and COPD, was transferred to a general acute care hospital due to behavioral disturbances. The facility had a bed hold policy in place, and the resident's bed was held from 12/20/2024 to 1/2/2025, with an extended hold authorized by a family member. Despite the bed hold, the facility declined the hospital's referral to return the resident, citing the resident's need for acute psychiatric management. The hospital's physician cleared the resident for discharge, but the facility maintained that the resident was not stable enough to return. This decision was based on inquiries received from the hospital, which indicated the resident's mood was still labile. The facility planned to accept the resident once they were psychiatrically stable. The facility's actions led to the resident being discharged to a different skilled nursing facility, 19 miles away, which was a locked facility. The facility's administrator stated that there was a miscommunication, and the resident ended up at the other facility. The facility's policy indicated that residents discharged to the hospital should be given priority in readmission, but this was not followed, resulting in the resident's unnecessary prolonged hospitalization and displacement.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically an allegation of physical abuse, in accordance with Section 1150B of the Act. The incident involved a resident who claimed to have been hit by a nurse when attempting to go to bed. The facility did not report this allegation to the State Survey Agency (SSA) within the required two-hour timeframe, instead reporting it approximately 4 hours and 53 minutes after the incident was reported to them. This delay in reporting resulted in a postponed onsite inspection by the SSA, which was necessary to ensure the safety of other residents and could have led to unidentified abuse. The resident involved was admitted to the facility with diagnoses including paroxysmal atrial fibrillation, generalized muscle weakness, and the presence of artificial shoulder joints. The resident's cognition was intact, and they required varying levels of assistance with daily activities. The incident was initially reported by the resident to a Licensed Vocational Nurse (LVN), who then informed a Registered Nurse (RN). However, the facility's administrator was not informed until two hours later, which contributed to the delay in reporting to the SSA. The facility's policy, last reviewed in 2023, mandates that any allegations of abuse or serious bodily injury be reported to the SSA within two hours, a requirement that was not met in this case.
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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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